Organ procurement (recovery surgery)

Organ procurement, also called organ recovery surgery, is the surgical operation by which transplantable organs are removed from a deceased donor.[1][2] In a typical deceased-donor case it is a multiorgan retrieval, heart, lungs, liver, pancreas, kidneys, and sometimes intestine are recovered in a single coordinated operation, performed by one or more visiting surgical teams after the donor has been authorized, evaluated, and physiologically optimized (see Donor management and optimization).[1][2] The defining technical step is the aortic cross-clamp and in-situ cold flush, which arrests the circulation and rapidly cools the organs to begin cold ischemic preservation before they are removed (see Organ preservation and machine perfusion).[1][2] The operation differs substantially depending on whether the donor is declared dead by neurologic criteria (DBD) or by circulatory criteria (DCD).[3]

Terminology

The neutral clinical terms are "recovery" and "procurement," used interchangeably; the older word "harvest" is now generally avoided as insensitive in donation contexts.[1] The visiting surgeons and assistants who perform the operation are referred to as the recovery team or procurement team; abdominal and thoracic organs are often recovered by separate teams traveling from the respective transplant centers, coordinated on site by the organ procurement organization (OPO).[1][2]

Preparation and the donor operation

In a standard DBD recovery, exposure is obtained through a long midline incision, typically extending from the suprasternal notch to the pubis, combined with a median sternotomy to open the chest.[1] The teams first explore and inspect the organs in situ, palpating and visually examining the heart, lungs, liver, and other organs to confirm suitability and exclude unsuspected disease or malignancy.[1][2] The surgeons then dissect and mobilize each organ, identifying and preserving the key vascular structures (the aorta, vena cava, portal vein, and organ-specific vessels) that will be divided last so that perfusion and removal can proceed quickly.[1] Once dissection is complete, the donor is systemically heparinized (commonly on the order of 20,000-25,000 IU intravenously) to prevent microvascular clotting during the low-flow period, and cannulas are placed in the distal aorta (and portal system for the liver) for cold perfusion.[1]

Cross-clamp and cold perfusion

The pivotal maneuver is the aortic cross-clamp: the aorta is clamped to isolate the organs from the systemic circulation, after which cold preservation solution is infused through the aortic cannula to flush blood out of the organs and cool them ("in-situ cold flush").[1][2] A typical abdominal flush uses a preservation solution such as histidine-tryptophan-ketoglutarate (HTK) or University of Wisconsin solution, on the order of 2 liters delivered over several minutes, with separate pulmonary and cardioplegia perfusion for the thoracic organs.[1] The heart and lungs are vented (for example, by incising the left atrial appendage or pulmonary artery) and the inferior vena cava is opened to drain blood and effluent.[1] Simultaneously, topical cooling with sterile ice slush is packed around the organs in the chest and abdomen to accelerate hypothermia and minimize metabolic injury.[1] From the cross-clamp onward the organs are in cold ischemia, and recovery proceeds with deliberate speed.[1][2]

Sequence of organ removal

Because the heart and lungs are adjacent and most time-sensitive, the thoracic organs are generally removed first, followed by the abdominal organs, typically the liver, then pancreas, then kidneys, with close coordination between the thoracic and abdominal teams so that each organ's shared vascular structures are divided to the benefit of all grafts.[1] This sequencing, and the division of shared vessels such as the suprahepatic vena cava and the aortic patch supplying the kidneys, is agreed upon among the teams before the operation begins.[1]

DBD versus DCD recovery

In DBD recovery the donor has a beating heart and intact circulation up to the moment of cross-clamp, so the organs are not exposed to warm ischemia and the dissection can be performed in a controlled, unhurried manner before clamping.[1][3]

In donation after circulatory death (DCD), life-sustaining treatment is withdrawn and the surgeon waits for circulatory arrest. Death is then declared on circulatory criteria, and recovery may begin only after a mandatory no-touch observation period to exclude spontaneous return of circulation (autoresuscitation).[3] In the United States, professional societies such as the American Society of Transplant Surgeons endorse a minimum observation interval of about five minutes; the interval varies internationally (from roughly two minutes to as long as twenty in some jurisdictions).[3][4] Because every minute between arrest and cold perfusion adds warm ischemia that injures the organs, DCD recovery often uses a "super-rapid" technique: a quick laparotomy and immediate aortic cannulation and cross-clamp with cold flush, with formal dissection deferred until after the organs are cooled.[2][3] An increasingly used alternative restores oxygenated circulation in situ after death declaration, normothermic regional perfusion, to limit warm ischemic injury and assess organ function before recovery; the practice is the subject of ongoing ethical debate (see Normothermic regional perfusion).[2]

Back-table preparation and packaging

After removal, each organ is taken to a sterile back table, where it is flushed again if needed, inspected, and trimmed; accessory vessels are reconstructed and donor iliac arteries and veins are recovered as conduits for later use.[1] The organ is then placed in sterile bags containing cold preservation solution and packed in an ice-filled container (or loaded onto a machine-perfusion device) for transport to the recipient's transplant center.[1] See Organ preservation and machine perfusion.

Multi-team coordination and the role of the OPO

A deceased-donor recovery frequently involves several surgical teams traveling from different transplant centers, each responsible for specific organs, all operating in one donor at one time.[1][2] The OPO coordinates the logistics, scheduling the operating room, sequencing the teams, arranging transport, and managing the timeline so that ischemic times for every organ are minimized.[1][2] This coordination function is part of the broader donation process described in The donation pathway.[2]

Outcomes and ischemia considerations

The quality of recovery directly affects transplant outcomes.[1] Cold ischemic time (from cross-clamp to reperfusion in the recipient) and, in DCD, warm ischemic time (around the period of circulatory arrest) are key determinants of graft injury, and minimizing them is a central goal of the operation and of preservation and transport.[1][2][3] Technical injury during procurement, for example, to a vascular structure, can render an organ untransplantable, which is why planning, inspection, and inter-team communication are emphasized.[1]

See also

• The donation pathway
• Donor management and optimization
• Donation after circulatory death (DCD)
• Normothermic regional perfusion (NRP)
• Organ preservation and machine perfusion

References

• Hwang HP, Kim JM, Shin S, et al. Organ procurement in a deceased donor. Korean J Transplant. 2020;34(3):134-150. doi:10.4285/kjt.2020.34.3.134. PMID: 35769061. PMCID: PMC9186815.
• Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant. 2023;28(2):139-144. doi:10.1097/MOT.0000000000001045. PMID: 36603197. PMCID: PMC9994842.
• Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. 2015;43(6):1291-1325. doi:10.1097/CCM.0000000000000958. PMID: 25978154.
• American Society of Transplant Surgeons. Position Statement on a 5-Minute Observation Period for Donation After Circulatory Death. https://www.asts.org/docs/default-source/position-statements/asts-position-statement-on-a-5-minute-observation-period.pdf