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CHAPTER 104: Pancreas Backtable Preparation

Juan Glinka; Ernesto P Molmenti

INTRODUCTION

  • It is essential to verify that the specific organ received is the correct one for the designated recipient.

  • all forms should be completed following regulatory requirements

  • Sterility is maintained at all times

  • During the back-table preparation, the organ is prepared for implantation

  • The reconstruction of the superior mesenteric and splenic arteries is undertaken with the donor iliac artery (“Y”) graft obtained at the time of procurement

  • The purpose of the back-table preparation is to enable or facilitate the subsequent implantation of the organ

  • The main task during the back-table preparation is the arterial reconstruction. This is usually achieved with the Y-shaped iliac artery obtained from the donor (external iliac artery to superior mesenteric artery; internal iliac artery to splenic artery)

  • In our experience, pancreas grafts rarely require elongation of the portal vein with donor iliac vein. However, some disagree with this view and routinely perform it.

FIGURE 104-1

Schematic representation of a pancreas graft ready for implantation after back table preparation.

An illustration shows a pancreas graft in the hands of a gloved surgeon. The donor duodenum adjoins the donor pancreas on the left side. The following arteries connect to the pancreas from the bottom: Donor superior mesenteric artery, donor external iliac artery, donor common iliac artery, Donor splenic artery, and donor internal iliac artery. The donor portal vein is labeled on the superior side of the donor pancreas. A surgical tool points toward the donor portal vein.
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PANCREAS BACK TABLE—PREPARATION OF ILIAC ARTERY GRAFT AND PANCREATICODUODENAL COMPLEX (FIGURES 104-2 AND 104-3)

FIGURE 104-2

The common, external, and internal iliac arteries of the donor are obtained at the time of the procurement. They will be used in the arterial reconstruction of the pancreas allograft. The iliac veins should also be procured for instances in which a venous graft is also required.

"Surgical tools are in contact with the common, external, and internal iliac arteries of the donor."
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FIGURE 104-3

Appearance of a pancreas allograft after procurement. Note that the duodenum and spleen have also been procured. We routinely remove the spleen during the back table preparation. The root of the small bowel mesentery has been stapled (arrow), and can be oversewn prior to implantation. Alternatively, the mesenteric vessels can be individually ligated (as shown in Figure 104-10).

A procured pancreas is held by the gloved hand of a person. The spleen and the duodenum are identified along with the pancreas.
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PANCREAS BACK TABLE—RECONSTRUCTION OF SPLENIC AND SUPERIOR MESENTERIC ARTERIES (FIGURES 104-4 TO 104-7)

FIGURE 104-4

The splenic artery (yellow arrow) and superior mesenteric artery (black arrow) are being prepared for reconstruction.

The donor pancreas is on the back table. 2 arrows point toward the cut ends of the splenic artery and the superior mesenteric artery.
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FIGURE 104-5

The splenic artery (yellow arrow) has been dissected along its course up to its first major branch, and is already anastomosed to the internal iliac artery graft. The superior mesenteric artery (black arrow) is being anstomosed to the external iliac graft.

A dissected splenic artery is grafted to the internal iliac artery graft. The cut-end of the superior mesenteric artery is identified.
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FIGURE 104-6

The anastomosis is constructed.

The procedure of anastomosis is performed. 2 sharp surgical tools and threads are identified at the construction site.
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FIGURE 104-7

The arterial reconstruction is finalized. The common iliac artery (pink arrow) of the arterial graft will subsequently be anastomosed onto the aorta at the time of implantation.

The thin long tubular structure of the common iliac artery pointed by an arrow with the arterial grafts is shown in the reconstruction site.
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