The five organs that travel.

LAYER 01Anatomy

Learn the liver as a map of segments before you learn the operations: each of Couinaud's eight segments has its own independent inflow, outflow and biliary drainage, so the liver can be divided between segments into two working parts, a graft and the donor's remnant².

1. 01Anatomy, step 1 of 6: Position and relations

   The liver is the largest gland in the body and lies in the right upper quadrant beneath the right hemidiaphragm². Its coronary ligament, the largest of its ligaments, leaves a bare area on its back, and the ligament's posterior layer attaches the liver to the right kidney². At the hilum it is joined to the duodenum by the hepatoduodenal ligament, the right free edge of the lesser omentum, which carries the portal triad and forms the front wall of the epiploic (Winslow's) foramen².

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2. 02Anatomy, step 2 of 6: Lobes and Couinaud's segments. Show it on the plate.

   Cantlie's line runs from the gallbladder fundus to the suprahepatic inferior vena cava (IVC), in the plane of the middle hepatic vein, and divides the liver into right and left hemilivers; for decades the falciform ligament was believed to be the true division². In the Brisbane 2000 terminology, segments II and III form the left lateral section and segment IV, divided into IVa above and IVb below, the left medial section; V and VIII form the right anterior section and VI and VII the right posterior section^2,21. The portal branches run within the segments while the three major hepatic veins pass between them, and the caudate lobe, segment I, takes vessels and bile ducts from both the right and the left, and its veins drain directly into the IVC².

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3. 03Anatomy, step 3 of 6: Arterial supply and its variants. Show it on the plate.

   In the usual pattern, seen in 757 of 1000 donor livers, the common hepatic artery arises from the coeliac axis, gives off the gastroduodenal artery and continues as the proper hepatic artery, which divides into right and left hepatic arteries⁹. The commonest variants were a replaced or accessory right hepatic artery from the superior mesenteric artery (SMA), in 106 livers, and a replaced or accessory left hepatic artery from the left gastric artery, in 97; in 15 the whole common hepatic artery came from the SMA⁹. The right hepatic artery passes behind the common hepatic duct in 80 to 90% of people². Every variant artery has to be defined so that the whole graft is arterialised, and variant arterial anatomy is a risk factor for early hepatic artery thrombosis^9,11.

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4. 04Anatomy, step 4 of 6: Portal vein and hepatic veins. Show it on the plate.

   The portal vein, about 8 cm long and without valves, begins where the splenic vein joins the superior mesenteric vein in front of the IVC; at the hilum its left branch has a longer, more horizontal course outside the liver, and its right branch divides into anterior and posterior branches². Blood leaves by three major hepatic veins, right, middle and left: the middle and left share a trunk before the IVC in about 65 to 85% of people, and an accessory inferior right hepatic vein is present in 21 to 48%². In a right-lobe graft, inferior right hepatic veins wider than 5 mm are joined to the IVC, and when the graft is taken without the middle hepatic vein, that vein's segment V and VIII branches wider than 5 mm are rebuilt, because undrained segments congest^14,17.

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5. 05Anatomy, step 5 of 6: The bile duct and its blood. Show it on the plate.

   In the hepatoduodenal ligament the portal vein lies behind the common bile duct, which is slightly to its right, and the proper hepatic artery, which is slightly to its left². The duct depends on the artery: hepatic artery occlusion is a cause of bile duct necrosis, and early non-anastomotic strictures are typically ischaemic-type biliary lesions¹³. Biliary complications are the most common complications after liver transplantation, with an incidence of 10 to 32%¹³.

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6. 06Anatomy, step 6 of 6: What the team measures and watches

   Before a living donation the team estimates the graft's weight as a percentage of the recipient's body weight, the graft-to-recipient weight ratio (GRWR), and its volume against the recipient's standard liver volume; risk rises around a GRWR of 0.8% or a graft volume under 40% of the standard¹⁴. King Faisal Specialist Hospital and Research Centre (KFSHRC) offers its robotic recipient operation for right grafts under 900 g with an anticipated GRWR above 0.80%, and not when extra segment V or VIII veins would need joining⁴. After the transplant, Doppler ultrasound screens the hepatic artery, and magnetic resonance cholangiopancreatography (MRCP) is the gold standard for diagnosing biliary complications^11,13.

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LAYER 02The operation

The donor

1. 01The donor, step 1 of 4: The right lobe, for an adult. Show it on the plate.

   Segments V to VIII, the usual adult living-donor graft. In the first three fully robotic cases at King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh, the graft-to-recipient weight ratio was 0.81 to 1.10% (robotic recipients are chosen when it is expected to be above 0.80%), and the donors kept an estimated 32 to 42% of the liver⁴.

   Why

   An adult needs enough working liver. In 276 living-donor transplants, one-year actuarial graft survival in elective cases was 42% when the graft weighed less than 0.8% of the recipient's body weight, against 92% at 1 to 3%¹⁰, and a recent international consensus took a graft-to-recipient weight ratio (GRWR) of 0.8 as the safe limit for adults¹⁴. The right lobe is the usual adult graft: in one Taiwanese series of 380 donors, 93.4% gave a right hemi-liver¹⁶.

   Watch for

   Small-for-size syndrome, with cholestasis, coagulopathy and ascites, develops when a graft is too small for its portal flow and for the recipient's needs; the excess flow injures the sinusoids¹⁴. Segment V and VIII veins are branches of the middle hepatic vein: when the graft is taken without that vein, branches over 5 mm are rebuilt with grafts and smaller ones tied¹⁷.

   On the plate

   The right lobe washes: segments V to VIII, everything to the right of Cantlie's line, which on this front view is on your left.

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2. 02The donor, step 2 of 4: The left lobe, for a smaller adult. Show it on the plate.

   Segments II to IV. KFSHRC has reported its first two fully robotic left-graft living donor liver transplants⁶.

   Why

   A left lobe leaves the donor more of the liver: in that series, left-lobe donors kept a larger share of their total liver volume than right-lobe donors¹⁶. Recent studies have not shown an adverse impact of using left lobe grafts¹⁴.

   Watch for

   Its weak point is size: a left lobe graft may contain less functioning liver than a right lobe graft of the same volume¹⁴, and grafts under 0.8% of the recipient's weight did worse¹⁰.

   On the plate

   The left lobe washes: segments II to IV, to the left of Cantlie's line, which on this view is on your right.

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3. 03The donor, step 3 of 4: The left lateral section, for a child. Show it on the plate.

   Segments II and III, the left lateral section²¹.

   Why

   Segments II and III form one section, and each segment has its own inflow, outflow and biliary drainage, so the section can be taken whole^2,21. It is used for children, and for a small infant even this can be too big: it can be reduced further, into a hyperreduced graft, to prevent large-for-size complications¹⁵.

   Watch for

   Too large is a risk as well as too small: in Kiuchi's series, grafts of 3% or more of the recipient's weight had more vascular complications and acute rejection¹⁰. Children's arteries clot more often: early hepatic artery thrombosis was 8.3% in children against 2.9% in adults¹¹.

   On the plate

   The left lateral section washes, the far left of the liver, which on this view is the tip on the right of the plate.

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4. 04The donor, step 4 of 4: The division. Show it on the plate.

   The donor operation divides the liver along the planes drawn on the plate, so that each graft is a set of whole segments. KFSHRC reported in 2024 that it offers robotic donor hepatectomy to all its donors, after more than 1000 minimally invasive donor hepatectomies⁴.

   Why

   Each segment has its own independent inflow, outflow and biliary drainage, and the major hepatic veins run between segments, so a cut along those planes leaves both the graft and the donor's remnant working². The remnant then regrows: in 380 donors it regenerated to a volume similar to the whole liver before donation¹⁶.

   Watch for

   Donor safety comes first. A 2026 meta-analysis of 7 studies with more than 15,000 adult donors found fewer transfusions and less overall donor morbidity with robotic than with laparoscopic donor hepatectomy, and no difference in major complications or deaths¹⁸. The learning curve is steep, because liver tissue is fragile and bleeding needs experienced control¹⁹.

   On the plate

   The division planes appear as cut lines: one along Cantlie's line between the right and left lobes, and one between segment IV and the left lateral section.

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The back table

1. 01The back table, step 1 of 1: The back table: one wide outflow. Show it on the plate.

   On the back table, a right lobe taken with its middle hepatic vein has that vein joined to the right hepatic vein, to make one wide triangular opening¹⁷. In a right lobe taken without that vein, segment V and VIII branches over 5 mm are rebuilt with expanded polytetrafluoroethylene (ePTFE) grafts, which are then joined to the right hepatic vein as one opening, and smaller ones are tied; in both, inferior right hepatic veins over 5 mm are kept for their own join to the IVC¹⁷.

   Why

   Every part of the graft must drain: reconstruction of the hepatic venous outflow is essential to prevent graft congestion¹⁷, and undrained segments also impair the liver beside them¹⁴.

   Watch for

   The width of the opening matters: in that series of 52 grafts, an anastomotic diameter of 30 mm or less raised the risk of outflow complications (odds ratio 14.3), and one occlusion was fatal¹⁷. Each join was checked by Doppler ultrasound on the back table and again after reperfusion¹⁷.

   On the plate

   The right lobe washes again: its outflow is built at its top edge, where the hepatic veins leave it for the IVC.

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The recipient

1. 01The recipient, step 1 of 4: The outflow. Show it on the plate.

   A whole liver goes in by piggyback, which keeps the recipient's IVC and needs less bypass and transfusion, or by the conventional technique, which replaces the recipient's IVC and traditionally uses veno-venous bypass, a pump that carries blood from the legs and gut back to the heart while the IVC is clamped³. For a right-lobe living-donor graft, its right hepatic vein is joined to the IVC under a partial clamp⁴.

   Why

   The outflow is joined first, before any blood is let into the graft⁴. A graft that cannot drain congests, and undrained areas also impair the liver around them¹⁴. Piggyback keeps the recipient's IVC: in a network meta-analysis of 40 studies and 10,238 patients, piggyback methods shortened the operation and needed fewer transfusions than caval replacement, with similar results afterwards¹².

   Watch for

   A kinked or narrow outflow obstructs the graft. In a series of 1067 transplants, the graft's upper cava was kept short to prevent kinking and the recipient's three hepatic veins were opened into one cuff to widen the join; venous outflow stenosis followed 0.54% of the piggyback implantations³. Caval replacement was still chosen when a tumour lay close to the IVC³.

   On the plate

   The whole graft washes, and a cut line runs along its top, where the hepatic veins meet the IVC under the diaphragm.

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2. 02The recipient, step 2 of 4: The portal vein. Show it on the plate.

   Joined second⁴. In the hepatoduodenal ligament the portal vein lies behind, with the common bile duct to its right and the hepatic artery to its left^1,2.

   Why

   With the outflow ready, the portal vein is joined next, with a continuous 6/0 suture in the robotic series⁴, and releasing the portal clamp reperfuses the graft²⁰.

   Watch for

   Reperfusion can cause post-reperfusion syndrome: the blood pressure falls and the pulmonary artery pressure goes up, thought to be from the cold, acidic blood that enters the circulation when the clamp is released²⁰. In a small living-donor graft the danger is too much portal flow; a portal pressure under 15 mmHg is recommended, particularly with an older donor or a marginal graft¹⁴.

   On the plate

   The cut line across the portal vein, the middle of the three structures below the liver.

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3. 03The recipient, step 3 of 4: The hepatic artery. Show it on the plate.

   Joined third, with interrupted sutures in the robotic series⁴.

   Why

   Without arterial flow the bile duct can die: hepatic artery occlusion is a cause of bile duct necrosis¹³. Early hepatic artery thrombosis complicated 4.4% of 21,822 transplants in a systematic review; 53.1% of those grafts were replaced and a third of the patients died¹¹.

   Watch for

   Reported risk factors include arterial conduits, variant arterial anatomy, a long operation and low recipient weight¹¹. High portal flow can also lower arterial flow, through the hepatic artery buffer response¹⁴. The robotic series uses fine interrupted sutures, 7/0 or 8/0⁴.

   On the plate

   The cut line on the vessel below the liver to the right of the portal vein on the plate (the patient's left): the hepatic artery.

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4. 04The recipient, step 4 of 4: The bile duct. Show it on the plate.

   Last: duct-to-duct⁴, or a Roux-en-Y hepaticojejunostomy, to a loop of jejunum. In primary sclerosing cholangitis, a 2026 meta-analysis of 12 non-randomised studies linked Roux-en-Y with better patient and graft survival, though duct-to-duct caused less cholangitis⁸.

   Why

   The bile duct comes last⁴. Duct-to-duct keeps the sphincter of Oddi and endoscopic access, takes less time and carries a lower risk of septic complications; a loop of jejunum is used when the recipient has biliary disease, the ducts differ in size, or after earlier biliary surgery or retransplantation¹³.

   Watch for

   Leaks come early, and strictures early or late: leaks are about 23% of biliary complications and anastomotic strictures about 47%¹³. Strictures follow 5 to 15% of transplants, and up to 30% after living-donor grafts¹³.

   On the plate

   The cut line on the bile duct, the structure to the left of the portal vein on the plate (the patient's right).

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LAYER 01Anatomy

Two operations in two places: the donor's kidney comes out from behind the peritoneum, and the graft goes into the recipient's iliac fossa, outside the peritoneum, beside the psoas muscle^9,15. Two pieces of anatomy recur through the steps: the order of the structures at the hilum, and the fact that the graft ureter has only one blood supply¹⁵.

1. 01Anatomy, step 1 of 6: Position and relations. Show it on the plate.

   In the donor the left kidney lies behind the peritoneum: it is reached by moving the left colon towards the midline to open the retroperitoneal space, and then opening Gerota's fascia⁹. In the recipient the graft goes into the iliac fossa by an extraperitoneal approach, in a gutter made beside the psoas muscle¹⁵. The right fossa is usually preferred, because its external iliac vein lies more superficially³ and runs a more horizontal course¹⁵.

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2. 02Anatomy, step 2 of 6: The hilum, front to back. Show it on the plate.

   At the hilum the structures keep a stable order from front to back: the renal vein, then the artery, then the pelvis and ureter¹⁵. When a kidney goes into the opposite side's fossa, as a left kidney into the right, its collecting system becomes the most anterior structure, which keeps the ureter away from the iliac vessels¹⁵. That is why the graft on this plate shows its pelvis and ureter in front and its vein deepest¹⁵.

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3. 03Anatomy, step 3 of 6: Renal arteries and their variants. Show it on the plate.

   Multiple renal arteries are common: they were seen in 18.2% of 214 living donors in one series, without worse graft function¹⁰. Not every artery has to be saved: one under 1 mm, especially to the upper pole, may be tied if the area left without blood is under 15% of the upper or middle pole, but lower-pole arteries over 1 mm should be joined if possible, to prevent ischaemia of the ureter³. The graft ureter relies solely on blood from the preserved renal artery branches¹⁵.

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4. 04Anatomy, step 4 of 6: Renal veins and their variants. Show it on the plate.

   The Kidney Disease: Improving Global Outcomes (KDIGO) guideline advises taking the left kidney when there is no reason to take the right, because its longer venous pedicle makes the operation easier¹⁸. The left renal vein's tributaries, the gonadal, adrenal and lumbar veins, are divided in the donor operation⁹. In a meta-analysis of 105 studies, a retroaortic left renal vein, running behind the aorta, was found in about 3% of people, a circumaortic one, ringing the aorta, in about 3.5%, and multiple renal veins in 16.7%, far more often on the right (16.6%) than on the left (2.1%)¹⁹.

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5. 05Anatomy, step 5 of 6: The ureter and its blood. Show it on the plate.

   The transplanted ureter relies solely on blood from the preserved renal artery branches, which run in the tissue around it; ischaemia of its distal end is a leading cause of early ureteric problems, and most leaks occur at that distal end¹⁵. So the ureter is taken with at least 1 cm of that tissue, and cut as short as possible to reduce later ischaemic complications³.

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6. 06Anatomy, step 6 of 6: What the team reads on imaging

   KDIGO recommends renal imaging, for example computed tomography (CT) angiography, in every living donor candidate¹⁸; it maps the number, course and branching of the renal vessels, especially the renal vein¹⁰. When the two kidneys differ, or one has an abnormality that still allows donation, the more severely affected kidney is the one donated¹⁸. After transplantation, vascular complications occur in 3 to 15% of recipients, and image-guided treatment is preferred to surgical revision²⁰.

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LAYER 02The operation

The donor

1. 01The donor, step 1 of 3: Which kidney. Show it on the plate.

   Laparoscopic living-donor nephrectomy is the gold standard^2,8. The donor keeps the better kidney; if both are equal the left is taken⁸, because its renal vein is longer^7,10.

   Why

   Donor safety decides first: when the kidneys differ in function, or one has an abnormality that does not prevent donation, the Kidney Disease: Improving Global Outcomes (KDIGO) guideline says the more severely affected kidney should be donated, so the donor keeps the better one¹⁸. Otherwise the left kidney is taken in laparoscopic donor nephrectomy, because its longer venous pedicle makes the technique easier¹⁸.

   Watch for

   The anatomy must be known before the operation: KDIGO recommends renal imaging, for example computed tomography (CT) angiography, in every donor candidate¹⁸. It maps the number, course and branching of the vessels, especially the renal vein, and multiple renal arteries are common: 18.2% of 214 donors in one series¹⁰.

   On the plate

   The small framed figure at the top right washes: the donor's left kidney in place, before any cut.

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2. 02The donor, step 2 of 3: The left renal vein. Show it on the plate.

   It crosses in front of the aorta just below the superior mesenteric artery, with the left renal artery behind it¹. The right kidney can be taken too, its vein sometimes extended with gonadal or iliac vein¹⁰.

   Why

   Its length is why the left kidney is preferred¹⁸; the operation frees it by dividing the veins that join it, the gonadal, adrenal and lumbar veins, before the renal vein itself is stapled beyond the adrenal vein⁹.

   Watch for

   Check the CT for a variant: a retroaortic left renal vein is found in about 3% of people and a circumaortic one in about 3.5%¹⁹. A right kidney has its own trap: multiple renal veins are much more common on the right, 16.6% against 2.1% on the left¹⁹.

   On the plate

   In the donor figure: the long left renal vein crossing in front of the aorta, the adrenal vein entering from above, the gonadal vein from below and a lumbar vein behind (dashed); the artery runs hidden behind the vein.

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3. 03The donor, step 3 of 3: The cuts. Show it on the plate.

   The gonadal and adrenal veins are sealed and divided and the lumbar vein clipped. The ureter is clipped as low as possible and divided, then the renal artery is stapled close to the aorta and the renal vein beyond the adrenal vein, and both are divided⁹. In one study of male donors, clipping the ureter and gonadal vein above where they cross the iliac vessels prevented orchialgia, pain in the testis¹¹.

   Why

   Everything is ready before the blood supply is cut: in the procedure outline the back table is set up, the ureter divided and a retrieval bag placed first; then the artery and vein are stapled, and the kidney is removed at once and flushed with cold preservation solution⁹. One series of 63 donors prepared the extraction site at the start to reduce the warm ischaemia time¹⁰.

   Watch for

   Secure the artery by transfixion: KDIGO says non-transfixing clips such as Hem-o-lok should not be used on the donor's renal artery, only a suture ligature or a staple anchored in the vessel wall¹⁸, after reports of harm that included a donor's death¹⁰. Keep the tissue around the ureter, at least 1 cm of it³, because the ureter's blood vessels run through it¹⁵.

   On the plate

   The donor's cut lines appear: the artery and the vein at the aorta, the artery's cut behind the vein's, and the ureter low.

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The back table

1. 01The back table, step 1 of 2: The back table: flush and tie. Show it on the plate.

   On the back table the graft's blood is washed out and replaced with cold preservation solution, a mandatory step³. Small accessory veins and the major lumbar veins are suture-ligated, the ureter keeps at least 1 cm of its surrounding tissue, and removing the fat around the kidney can wait until after revascularisation³.

   Why

   Each tie has a purpose: the small veins are suture-ligated to prevent bleeding from the hilum after the operation, and some surgeons ligate all the major lymphatic vessels to prevent a later lymphocele³; the tissue around the ureter is kept because the ureter's blood vessels run through it¹⁵.

   Watch for

   Check the vessel lengths for the side chosen: a right renal artery or a left renal vein that is too long will kink, and a short vein from a deceased donor can be lengthened with a piece of that donor's external iliac vein, internal jugular vein or inferior vena cava³.

   On the plate

   The graft washes on its own, before any join is made.

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2. 02The back table, step 2 of 2: The back table: more than one artery. Show it on the plate.

   Multiple renal arteries are common, 18.2% of 214 living donors in one series¹⁰. A deceased donor's arteries can stay together on one Carrel patch of aorta; otherwise two arteries of similar size are joined side to side, or a small one end-to-side into a larger one^3,15.

   Why

   Joined on the bench, several arteries can go into the recipient through one arterial join^3,15. Not every artery must be saved: one under 1 mm, especially at the upper pole, may be tied if less than 15% of the upper or middle pole is left without blood³.

   Watch for

   Lower-pole arteries over 1 mm should be joined if possible, to prevent ischaemia of the ureter³, which relies solely on the preserved renal artery branches for its blood¹⁵.

   On the plate

   The graft washes again: its arteries are prepared before the arterial join is made.

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The recipient

1. 01The recipient, step 1 of 5: The approach. Show it on the plate.

   Open surgery uses a curved Gibson incision in the lower quadrant, parallel to the inguinal ligament from the anterior superior iliac spine to the midline 2 cm above the pubis, and the graft goes outside the peritoneum²; the hockey-stick incision is a common variant^2,3. The right side is usually preferred because its external iliac vein is more superficial³.

   Why

   The right iliac fossa is usually preferred because its external iliac vein lies more superficially³ and runs a more horizontal course, which makes the venous join simpler¹⁵. In the open operation the inferior epigastric vessels, and in women the round ligament, are usually tied and divided, while the spermatic cord is simply retracted medially³.

   Watch for

   Lymphocele, a collection of lymph beside the graft, is the trap here: the lymphatics around the iliac vein are tied as it is prepared, and avoiding excessive dissection is the most important prevention³. Joining the artery to the internal iliac artery slightly increases it³.

   On the plate

   The fossa washes, with both cut lines: the curved Gibson incision low on the abdomen and the short midline incision used for the robot.

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2. 02The recipient, step 2 of 5: The graft's place. Show it on the plate.

   Outside the peritoneum in the right iliac fossa^2,4, in the gutter beside the psoas muscle¹⁵, so it lies lateral to the iliac vessels with its hilum turned towards them. A left kidney is turned front to back to face the right iliac vessels, which brings its pelvis and ureter to the front^1,15,16.

   Why

   The graft is laid in a gutter made beside the psoas muscle, outside the peritoneum, with its hilum towards the iliac vessels¹⁵. Turning a left kidney over brings its collecting system to the front, which keeps the ureter away from the iliac vessels¹⁵.

   Watch for

   Vessel length must suit the position: a right renal artery or a left renal vein that is too long will kink, causing graft dysfunction and hypertension³.

   On the plate

   The graft washes, lateral to the iliac vessels, with its pelvis and ureter in front and its vein the deepest structure.

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3. 03The recipient, step 3 of 5: The vein. Show it on the plate.

   The renal vein goes end-to-side to the external iliac vein^2,15, first when the artery goes end-to-side to the external iliac artery¹⁵. On this plate it passes deep to the external iliac artery to reach the vein.

   Why

   When the artery will go end-to-side to the external iliac artery, the vein is joined first, so that the arterial join can then be aligned; when the artery goes to the internal iliac artery, the artery goes first, which helps position the vein¹⁵.

   Watch for

   Thrombosis of the graft's artery or vein occurs in 0.1 to 8.2% of transplants²⁰. A long clamp on the iliac vein adds a risk of deep vein thrombosis, which is why one technique chapter joins the artery first, to shorten it³.

   On the plate

   The cut line where the renal vein meets the external iliac vein, lower and more medial than the arterial join; the renal vein passes deep to the artery to reach it.

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4. 04The recipient, step 4 of 5: The artery. Show it on the plate.

   End-to-side to the external iliac artery, with a Carrel patch of aorta when the kidney comes from a deceased donor, or end-to-end to the internal iliac artery, when the artery may go first^2,3,15.

   Why

   End-to-side to the external iliac artery is generally preferred, especially when the donor artery carries a healthy Carrel patch of aorta; the internal iliac artery is more prone to atherosclerosis¹⁵. Several arteries can be brought together on one Carrel patch, joined separately, or joined side to side first¹⁵.

   Watch for

   Arterial stenosis is the commonest vascular complication, in 3 to 12.5% of recipients²⁰. A polar artery that is tied leaves part of the kidney without blood, so lower-pole arteries over 1 mm should be joined if possible³.

   On the plate

   The cut line where the renal artery meets the external iliac artery, above the venous join.

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5. 05The recipient, step 5 of 5: Reperfusion, then the ureter. Show it on the plate.

   Once blood flows through the kidney, the ureter is joined to the bladder dome or side wall, not the trigone, where the native ureters enter, by an extravesical Lich-Gregoir ureteroneocystostomy: the bladder mucosa is opened under the reflected detrusor, the bladder muscle, and the ureter sewn to it^2,3,5; the detrusor is then closed over it to make a short anti-reflux tunnel³. It leaks less and causes less haematuria than the Politano-Leadbetter technique⁵, and a routine stent probably reduces major urological complications⁶.

   Why

   The order of unclamping varies: one technique chapter releases the artery first and the veins once the graft has filled³, while a pictorial essay removes the venous clamp first¹⁵. The ureter is then cut to the smallest possible length, to reduce later ischaemic complications, and joined without tension^3,15; every technique aims to prevent leakage, stricture and reflux³.

   Watch for

   Most leaks occur at the distal end of the graft ureter, where ischaemia is a leading cause of early problems¹⁵. Stents are debated because of the risk of infection; one centre uses one and removes it after 3 weeks³.

   On the plate

   The ureter and the bladder wash, with the cut line where the ureter enters the upper side wall of the bladder.

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LAYER 01Anatomy

The pancreas graft comes with more than the gland: a segment of the donor's duodenum, into which its main duct opens and which carries its exocrine juice into the recipient's bowel or bladder^3,10, and two separate arteries that are joined into one before implantation^2,5.

1. 01Anatomy, step 1 of 6: Position and relations. Show it on the plate.

   The pancreas lies at the level of the transpyloric plane (L1) and, apart from its tail, behind the peritoneum¹⁰. Its head sits in the C-shaped curve of the duodenum, with the aorta and the inferior vena cava (IVC) behind it; the stomach lies in front, across the lesser sac; and the tail, the only intraperitoneal part, reaches the splenic hilum in the splenorenal ligament with the splenic vessels¹⁰.

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2. 02Anatomy, step 2 of 6: Parts and the duct. Show it on the plate.

   From right to left come the head, with the hook-like uncinate process below it lying behind the superior mesenteric vessels; the neck, which overlies those vessels; the body, which crosses the midline behind the stomach; and the tail¹⁰. The main pancreatic duct runs the length of the gland and joins the common bile duct to form the ampulla, which opens at the major duodenal papilla in the second, descending part of the duodenum, surrounded by the sphincter of Oddi^1,10.

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3. 03Anatomy, step 3 of 6: Two arterial systems. Show it on the plate.

   The head, uncinate process and duodenum are supplied through the pancreaticoduodenal arcade: the superior pancreaticoduodenal artery, from the gastroduodenal artery, and the inferior pancreaticoduodenal artery, from the superior mesenteric artery (SMA)^5,10. The body and tail are supplied mainly by branches of the splenic artery⁵. A graft therefore keeps both the SMA and the splenic artery, and the Y-graft turns them into a single arterial inflow^2,5.

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4. 04Anatomy, step 4 of 6: One vein out. Show it on the plate.

   The head drains into the superior mesenteric vein (SMV) and the body and tail into the splenic vein, both tributaries of the portal vein^5,10. The graft's portal vein is cut above the duodenum, leaving enough length for the venous join⁵; if it is still too short, a donor iliac vein extends it².

   Sources2510

5. 05Anatomy, step 5 of 6: What the team watches on imaging

   After the transplant, colour and spectral Doppler ultrasound is essential for checking the graft's vessels, multiphase computed tomography (CT) angiography with late arterial and venous phases shows them in detail, and magnetic resonance imaging (MRI) gives better contrast resolution⁵. The main threat is clotting: acute thrombosis of a graft vessel occurs in 2 to 10% of recipients, most often in the vein and usually within 4 to 6 weeks⁵.

   Source5

6. 06Anatomy, step 6 of 6: Who receives which graft. Show it on the plate.

   A simultaneous pancreas-kidney transplant (SPK) is for people with type 1 diabetes and uraemia, a pancreas after kidney (PAK) for those whose kidney transplant already works, and a pancreas transplant alone (PTA) for those without uraemia³; the 2021 World Consensus found that SPK also benefits suitable recipients with type 2 diabetes, improving survival and quality of life compared with staying on dialysis⁹. It also found that SPK and pancreas alone can improve long-term survival, and that every type improves quality of life⁹.

   Sources39

LAYER 02The operation

The donor

1. 01The donor, step 1 of 3: Retrieval. Show it on the plate.

   The pancreas comes out with the duodenum and spleen, keeping stumps of the superior mesenteric artery (SMA), the splenic artery and the portal vein³. The gastroduodenal artery (GDA) is ligated, and the SMA beyond the inferior pancreaticoduodenal artery; the superior mesenteric vein (SMV) below the pancreas and the splenic vessels at the splenic hilum are tied, and the portal vein is cut above the duodenum⁵.

   Why

   The pancreas is removed after the liver, en bloc with the duodenum and spleen, keeping its vessel stumps for the back table³; the SMA is divided at its origin from the aorta and the portal vein above the duodenum, leaving enough length for the venous join⁵. The donor matters too: risk factors for surgical complications include a donor older than 45, a body mass index over 28 and death from cerebrovascular disease³.

   Watch for

   A damaged gland is discarded: signs of acute pancreatitis, oedema, haematoma or fatty infiltration lead to discard³. Long storage harms it too: preservation for more than 20 hours is a risk factor for complications³.

   On the plate

   The whole graft washes: head, neck, body and tail, with the duodenal segment at the top.

   Sources35

2. 02The donor, step 2 of 3: The back table. Show it on the plate.

   On the back table, the side table where the graft is prepared in ice-cold solution, the spleen is removed and the duodenum shortened, keeping only its second part, stapled^2,3. That segment carries the papilla, where the main pancreatic duct opens¹.

   Why

   The duodenum is shortened with staplers, keeping only the second part, so that the enteric drainage has no redundant bowel². That segment carries the major papilla, where the main duct opens, so it becomes the graft's exocrine outlet into the recipient's bowel or bladder^3,10.

   Watch for

   The duodenal segment is where leaks start: intestinal leaks follow 5 to 8% of transplants, mostly in the immediate postoperative period³. On the back table its ends are closed and invaginated³.

   On the plate

   Only the duodenal segment washes, the short loop at the top of the graft, before any join is made.

   Sources12310

3. 03The donor, step 3 of 3: The Y-graft. Show it on the plate.

   The donor's common iliac artery with its fork: the external iliac limb is joined to the SMA and the internal iliac limb to the splenic artery⁵, so one arterial join to the recipient is enough². A donor iliac vein extension is used if the portal vein is short².

   Why

   The graft has two arteries, the SMA and the splenic artery; the Y-graft gives them a single arterial inflow, which simplifies the reconstruction and minimises the warm ischaemia time².

   Watch for

   Match the limbs: the external iliac limb goes to the SMA and the internal iliac limb to the splenic artery⁵. Arterial thrombosis makes up about a quarter to a third of graft thromboses, and it comes early⁵.

   On the plate

   The Y-graft washes with its two bench joins, to the SMA and to the splenic artery; the stem's join to the recipient comes later.

   Sources25

The back table

1. 01The back table, step 1 of 1: The back table: last checks. Show it on the plate.

   If the graft's portal vein is not long enough, a donor iliac vein is added to give a tension-free venous join². A final flush with methylene blue then shows any bleeding points before the graft goes in².

   Why

   The aim is a tension-free venous join², because venous thrombosis is the commonest vascular complication of the graft⁵.

   Watch for

   Bleeding and pseudoaneurysm are among the most life-threatening complications, at about 2.4%⁵; the methylene blue flush finds sources of bleeding while they can still be dealt with on the back table².

   On the plate

   The whole graft washes on the back table, before any join is made.

   Sources25

The recipient

1. 01The recipient, step 1 of 4: The vein. Show it on the plate.

   Vein before artery². The graft's portal vein goes end-to-side to the inferior vena cava (IVC) or an iliac vein, systemic drainage, as drawn here^4,5.

   Why

   The vein is joined before the artery². Systemic drainage into the iliac vein or IVC is technically more accessible and so is preferred, while portal drainage is more physiological; neither shows a clear difference in glucose control or graft survival⁵, and the 2021 World Consensus found that portal drainage does not clearly improve metabolic parameters⁹.

   Watch for

   Venous thrombosis is the commonest vascular complication, usually within 4 to 6 weeks⁵, and splenic or portal vein thrombosis is the leading cause of early graft loss². In the robotic technique the head-down position gives the portal vein a straight course to the external iliac vein, for free outflow without stasis².

   On the plate

   The cut line on the graft's portal vein, where it meets the recipient's IVC behind the graft.

   Sources2459

2. 02The recipient, step 2 of 4: The artery. Show it on the plate.

   The stem of the Y-graft goes end-to-side to the recipient's right common or external iliac artery⁵.

   Why

   With the bench work done, one join is enough: the Y-graft's common iliac stem goes end-to-side to the recipient's iliac artery⁵.

   Watch for

   Arterial pseudoaneurysm and bleeding are among the most life-threatening complications, at about 2.4%⁵. Arterial thrombosis is an early complication, so the arterial flow is checked with Doppler ultrasound⁵.

   On the plate

   The cut line where the stem of the Y-graft meets the recipient's right common iliac artery, below the venous join.

   Source5

3. 03The recipient, step 3 of 4: Reperfusion, then the bowel. Show it on the plate.

   Exocrine drainage is enteric in over 90%: a side-to-side duodeno-jejunostomy or duodeno-ileostomy, or a Roux-en-Y loop of jejunum^2,4,5. Bladder drainage, a duodenocystostomy, is still used, mainly in pancreas-alone transplants, where urinary amylase helps to monitor rejection^4,5; it can cause metabolic acidosis, from bicarbonate lost in the urine, dehydration, haematuria and reflux pancreatitis^3,4, and 10 to 25% of patients, up to half in some series, later need conversion to enteric drainage^3,5.

   Why

   Enteric drainage is used in over 90% of transplants⁵. Bladder drainage is not associated with more immediate surgical complications, but it carries more urological and metabolic complications⁹, which lead to enteric conversion in up to 50% of cases⁵.

   Watch for

   The exocrine leak is an early complication, reported in up to 20% of pancreas transplants, though it causes less than 1% of graft losses⁵. Graft pancreatitis is among the most common complications, and early acute pancreatitis raises the risk of graft loss at one year⁵.

   On the plate

   The duodenal segment washes with its cut line, the side-to-side join to a loop of the recipient's small bowel at the top of the plate.

   Sources23459

4. 04The recipient, step 4 of 4: SPK: the kidney. Show it on the plate.

   At the same operation the kidney usually goes in the opposite iliac fossa, here the left, with the same joins as on Plate II².

   Why

   A simultaneous pancreas-kidney transplant is for type 1 diabetes with uraemia³, and the World Consensus found that it can improve long-term survival, also in suitable recipients with type 2 diabetes⁹. In the open operation the two grafts usually go on opposite sides, the pancreas on the right and the kidney on the left².

   Watch for

   The pancreas may lie inside the peritoneum: on low-quality data, the World Consensus found no evidence that intraperitoneal placement increases surgical complications⁹. The kidney's joins are those of Plate II².

   On the plate

   The kidney washes at the lower right of the plate, in the left iliac fossa, with its vessels running out of view.

   Sources239

LAYER 01Anatomy

A heart transplant replaces the pump but keeps the recipient's back wall: the recipient keeps a cuff of posterior left atrium around its own pulmonary veins, and the donor heart is joined to that cuff, to the two venae cavae and to the two great arteries^2,5.

1. 01Anatomy, step 1 of 7: Position, surfaces and borders. Show it on the plate.

   The heart lies in the middle mediastinum, inside the pericardium⁶. Its anterior (sternocostal) surface is formed by the right ventricle, its left border by the left ventricle with part of the left atrium, its right border by the right atrium, and its base, at the back, by the left atrium⁶. Behind the ascending aorta and pulmonary trunk, and in front of the superior vena cava (SVC), the transverse pericardial sinus separates the arterial vessels from the venous ones⁶.

   Source6

2. 02Anatomy, step 2 of 7: The chambers and the five joins. Show it on the plate.

   A bicaval transplant makes five joins: the left atrium, the inferior vena cava (IVC), the SVC, the pulmonary artery and the aorta². The deepest is the left atrium, at the base of the heart: the recipient keeps a cuff of posterior left atrium around the entry of its pulmonary veins, and the donor's cuff is made by connecting the incisions between its four pulmonary veins^5,6. The recipient's SVC is cut at the cavo-atrial junction, and a wide IVC cuff is left⁵.

   Sources256

3. 03Anatomy, step 3 of 7: The coronary arteries. Show it on the plate.

   The coronary arteries run in the sulci: the right coronary artery and the circumflex branch of the left coronary artery in the coronary (atrioventricular) sulcus with the coronary sinus, the anterior interventricular (left anterior descending) artery with the great cardiac vein on the front, and the posterior interventricular artery with the middle cardiac vein behind⁶. A donor heart is checked for coronary disease: coronary angiography is advised in donors with risk factors such as age over 45 or diabetes⁵.

   Sources56

4. 04Anatomy, step 4 of 7: The conducting system. Show it on the plate.

   The sinoatrial node lies in the upper wall of the right atrium, where the SVC enters, and the atrioventricular node in the atrioventricular septum near the opening of the coronary sinus⁷. The biatrial technique's right atrial incision can cause rhythm disorders: in one series sinus rhythm was present at discharge in only about 82% of biatrial recipients².

   Sources27

5. 05Anatomy, step 5 of 7: Nerves near the heart

   The phrenic nerves, the only motor nerves of the diaphragm, run on the fibrous pericardium: the right lateral to the SVC and over the right atrium, the left over the left ventricle, each in front of its lung root⁹. Injury to one paralyses its hemidiaphragm, which then moves paradoxically, and injury to both can be life-threatening⁹. The left recurrent laryngeal nerve loops around the aortic arch just beyond the ligamentum arteriosum, and injury to one recurrent nerve gives a hoarse, breathy voice¹⁰.

   Sources910

6. 06Anatomy, step 6 of 7: A variant that changes the operation. Show it on the plate.

   A persistent left SVC occurs in about 0.3% of people and in up to 5% of those with congenital abnormalities⁸. In a transplant recipient it should be dealt with early in the operation, to keep venous drainage uninterrupted; in two recipients it was rerouted through a 14 mm polytetrafluoroethylene (PTFE) graft to the right atrial appendage⁸.

   Source8

7. 07Anatomy, step 7 of 7: What the team measures first. Show it on the plate.

   Before listing, right heart catheterisation measures the recipient's pulmonary pressures and resistance¹². When the pulmonary artery systolic pressure is 50 mmHg or more and either the transpulmonary gradient is 15 mmHg or more or the pulmonary vascular resistance is 3 Wood units or more, the 2024 guideline of the International Society for Heart and Lung Transplantation (ISHLT) recommends testing, in steps, whether this pulmonary hypertension can be reversed: a vasodilator challenge, then 24 to 48 hours of diuretics, inotropes and vasodilators in hospital, then mechanical support to unload the left ventricle¹². It sets no absolute cut-off, but when severe pulmonary hypertension stays irreversible despite these measures, a heart transplant alone is not recommended¹²: the donor heart cannot adapt to a high resistance, and acute right heart failure follows⁵. Every donor heart is checked by echocardiography for left ventricular hypertrophy⁵, and donors are matched to recipients for size by predicted heart mass, because an undersized heart raises mortality after the transplant, especially in a recipient with pulmonary hypertension¹².

   Sources512

LAYER 02The operation

The donor

1. 01The donor, step 1 of 4: The cannulas. Show it on the plate.

   The heart and lungs are retrieved at the same operation. Cardioplegia, the cold solution that stops the heart, goes into the ascending aorta, and a cannula for the lung flush into the pulmonary artery at its bifurcation⁴.

   Why

   Assessment comes before any cannula: the heart is evaluated once the pericardium is opened, and the lungs are inspected and palpated for atelectasis, pneumonia, adhesions and effusion⁴. Prostaglandin E1 goes into the pulmonary artery before cross-clamping⁴.

   Watch for

   Donor quality is judged here too: left ventricular hypertrophy should be looked for by echocardiography in every donor, and donors older than 45 may be used after careful screening for coronary disease when the ischaemic time is expected to be under 4 hours⁵.

   On the plate

   The donor heart washes whole; no join or cut is drawn yet.

   Sources45

2. 02The donor, step 2 of 4: Clamping. Show it on the plate.

   The superior vena cava (SVC) is ligated, the inferior vena cava (IVC) clamped and cut above the clamp, and the aorta cross-clamped⁴.

   Why

   The cavae come first so that the right heart is emptied before the heart is stopped: tying the SVC and cutting the IVC vents the right heart¹³, and only then is the aorta cross-clamped⁴.

   Watch for

   The whole transplant is planned to keep the donor heart's ischaemic time under 4 hours; for longer times or marginal hearts, the recipient team may release the cross-clamp early, after the left atrial and aortic joins⁵.

   On the plate

   The heart still washes whole while the cavae are tied or cut and the aorta is cross-clamped.

   Sources4513

3. 03The donor, step 3 of 4: Venting. Show it on the plate.

   The tip of the left atrium is cut off to vent the lung flush⁴.

   Why

   The lung flush comes back to the left atrium through the pulmonary veins, so the tip of the left atrium is cut off to let it drain, and the flush starts at that moment^4,5.

   Watch for

   This opening is a vent, not the division: the heart will need its left atrial cuff for its first join⁵, and when the lungs are taken too, each lung is implanted with its own venous cuff¹¹.

   On the plate

   The left atrial appendage washes, high on the heart's left side (on your right): the tip that is opened.

   Sources4511

4. 04The donor, step 4 of 4: Removal. Show it on the plate.

   The heart comes out first, then the lungs⁴.

   Why

   After the cross-clamp and the flushes the heart is procured first; the lungs are then freed by dividing the pericardium near the diaphragm, the pulmonary ligaments and the mediastinal pleura, and taken with the trachea stapled twice⁴.

   Watch for

   Every cut is made for the implanting teams: improper procurement can make the lung implantation difficult⁴, and the heart team needs its aorta, pulmonary artery, both cavae and a left atrial cuff^2,5.

   On the plate

   The whole donor heart washes as it is lifted out.

   Sources245

The back table

1. 01The back table, step 1 of 1: The back table: the left atrial cuff. Show it on the plate.

   On the back table the aorta and pulmonary artery are separated first, and the donor's left atrial cuff is made by connecting the incisions between its four pulmonary veins⁵.

   Why

   This cuff is what the first join uses: it is sewn to the cuff of posterior left atrium that the recipient has kept⁵.

   Watch for

   Each cuff is cut for the technique chosen: for a bicaval implant the donor's SVC is cut at the level of the azygos vein opening, while for a biatrial implant the SVC is tied and the right atrium opened from the IVC to the right atrial appendage⁵.

   On the plate

   The donor heart washes whole; its left atrial cuff, at the back, cannot be seen from the front.

   Source5

The recipient

1. 01The recipient, step 1 of 5: The left atrium. Show it on the plate.

   The donor's left atrial cuff goes to the recipient's cuff around the pulmonary veins: the first of the five joins, behind the heart².

   Why

   Both published orders begin here^2,5. The left atrium forms the base of the heart, at the back⁶, and it is sewn cuff to cuff with a double-armed running 3/0 polypropylene suture⁵.

   Watch for

   This is the hidden join: it lies at the back of the heart, behind the four joins that follow^2,6, and the recipient's cuff must keep an adequate portion of posterior left atrial tissue⁵.

   On the plate

   The dashed loop behind the base of the heart washes: the left atrial join, hidden from the front.

   Sources256

2. 02The recipient, step 2 of 5: The IVC. Show it on the plate.

   Donor IVC to recipient IVC².

   Why

   Joining the cavae directly, instead of the two right atria, preserves the geometry of the right atrium and the tricuspid valve⁵. In the bicaval order of one series the IVC comes second².

   Watch for

   The recipient's IVC is cut with a wide cuff, while its SVC is cut at the cavo-atrial junction⁵. The biatrial alternative causes more tricuspid regurgitation².

   On the plate

   The cut line on the IVC, at the lower right of the heart (on your left).

   Sources25

3. 03The recipient, step 3 of 5: The SVC. Show it on the plate.

   Donor SVC to recipient SVC².

   Why

   The SVC is joined third in that series², and it enters the right atrium where the sinoatrial node lies⁷. Joining the SVC itself, instead of opening the right atrium, protects the rhythm: the biatrial right atrial incision can cause rhythm disorders, and 18.2% of biatrial recipients needed a pacemaker against 3.0% after bicaval².

   Watch for

   In the modified bicaval technique the SVC is sewn after the clamp is off, on the beating heart: this shortens the warm ischaemia, but the join is harder as exposure worsens².

   On the plate

   The cut line on the SVC, at the top right of the heart (on your left).

   Sources27

4. 04The recipient, step 4 of 5: The pulmonary artery. Show it on the plate.

   Donor pulmonary artery to the recipient's².

   Why

   In the bicaval order of one series the pulmonary artery is joined fourth²; a 2023 review joins it second, straight after the left atrium⁵.

   Watch for

   In the modified bicaval technique it is sewn on the beating, reperfused heart, which is harder, especially in redo operations and for less experienced surgeons².

   On the plate

   The cut line on the pulmonary trunk, to the left of the aorta's (on your right).

   Sources25

5. 05The recipient, step 5 of 5: The aorta. Show it on the plate.

   The last join; the cross-clamp comes off after it². In the modified bicaval technique the clamp comes off after the left atrium, IVC and aorta, and the SVC and pulmonary artery are sewn on the beating heart².

   Why

   The cross-clamp comes off after the aortic join, ending the warm ischaemia that began when the heart left cold storage: a mean of 66 minutes with the bicaval technique, and 48 with the modified technique, which releases the clamp after the left atrium, IVC and aorta².

   Watch for

   When the ischaemic time is over 4 hours or the heart is marginal, the clamp may be removed right after the left atrial and aortic joins⁵. After release the surgeon waits for sufficient reperfusion and places temporary atrial and right ventricular pacing wires⁵.

   On the plate

   The cut line on the ascending aorta, between the SVC and the pulmonary trunk.

   Sources25

LAYER 01Anatomy

Each lung is joined in three places, the bronchus, the pulmonary artery and the venous cuff³, but only one of its two blood supplies comes back: the donor's bronchial arteries are cut at retrieval and rarely reconnected, so the new bronchus lives for weeks on retrograde flow from the pulmonary arteries¹¹. The bronchial join is planned around that fact¹¹.

1. 01Anatomy, step 1 of 7: Position and the lung root. Show it on the plate.

   The root of each lung contains a bronchus, a pulmonary artery and two pulmonary veins, which enter at the hilum, a wedge-shaped area on the lung's mediastinal surface¹⁵. On the left lung the anterior border carries a deep cardiac notch, made by the apex of the heart¹⁵.

   Source15

2. 02Anatomy, step 2 of 7: Lobes and fissures. Show it on the plate.

   The right lung has an oblique and a horizontal fissure: the horizontal runs from the sternum at the level of the 4th rib to meet the oblique¹⁵. The left lung has only the oblique fissure, between its superior and inferior lobes, and its lingula belongs to the superior lobe, corresponding to the right middle lobe^14,15.

   Sources1415

3. 03Anatomy, step 3 of 7: Bronchopulmonary segments. Show it on the plate.

   Each lobe divides into bronchopulmonary segments, each served by its own branch of the bronchial tree and functionally separate from its neighbours, which is why a single segment can be removed¹⁴. The right lung has ten and the left about eight or nine, as some left segments fuse; veins and lymphatics run in the septa between segments¹⁴.

   Source14

4. 04Anatomy, step 4 of 7: Two arterial supplies. Show it on the plate.

   The paired pulmonary arteries bring deoxygenated blood, while the bronchial arteries, about 70% of them straight from the thoracic aorta at T5 to T6, supply the bronchi, the lung roots and the visceral pleura^11,15. A donor lung loses its bronchial arteries at retrieval, and they are rarely reconnected: its bronchus depends on retrograde filling from the pulmonary arteries until the recipient's bronchial circulation reaches it, typically in 2 to 4 weeks¹¹.

   Sources1115

5. 05Anatomy, step 5 of 7: Pulmonary veins and their variants. Show it on the plate.

   Two pulmonary veins leave each lung for the left atrium¹⁵, and the classic pattern of four separate openings is the most common; variants include a left common pulmonary vein and a separate right middle vein¹⁶. The bronchial veins drain to the azygos vein on the right and to the accessory hemiazygos vein on the left¹⁵. In the transplant the donor's veins come with a venous cuff, joined last³.

   Sources31516

6. 06Anatomy, step 6 of 7: Nerves at the root

   The phrenic nerve passes in front of each lung root, on the pericardium, and the vagus behind it^1,17. Injury to a phrenic nerve paralyses its hemidiaphragm, which then moves paradoxically¹⁷. The left recurrent laryngeal nerve loops around the aortic arch just beyond the ligamentum arteriosum, and injury to it gives a hoarse, breathy voice¹⁸.

   Sources11718

7. 07Anatomy, step 7 of 7: Size matching

   Donor lungs are matched to the recipient's chest: oversized lungs may cause ventilatory dysfunction, atelectasis and haemodynamic instability, though an oversized graft carries a lower risk of the most severe primary graft dysfunction¹². Lungs can also be reduced to fit, and one series of 75 lobar transplants found no difference in survival at 1, 3 and 5 years compared with standard transplants¹².

   Source12

LAYER 02The operation

The donor

1. 01The donor, step 1 of 2: Flush and vent. Show it on the plate.

   The lungs are flushed through the pulmonary artery and vented through the left atrium².

   Why

   Before any flush the lungs are inspected and palpated for atelectasis, pneumonia, adhesions and effusion, and the anaesthetist relieves any atelectasis by manual pressure². The flush goes in through a cannula on the main pulmonary artery at its bifurcation, after prostaglandin E1, and comes out through the opened tip of the left atrium².

   Watch for

   Time counts: prolonged ischaemic times should be minimised because of their relation to lung transplant outcomes¹¹. Improper procurement can make the implantation difficult for the surgeon².

   On the plate

   Both lungs wash: the donor's grafts before removal.

   Sources211

2. 02The donor, step 2 of 2: Removal. Show it on the plate.

   After the heart is taken, the pulmonary ligaments are divided and the trachea is double-stapled and cut².

   Why

   The heart comes out first; then the pericardium is cut near the diaphragm, the pulmonary ligaments divided, the front of the oesophagus dissected, the mediastinal pleura freed on both sides, and the aortic arch divided on the left and the azygos arch on the right². The trachea is encircled for the final assessment, then stapled twice and divided between the staple lines².

   Watch for

   From this moment the bronchus has lost its bronchial arteries: the bronchial blood supply is interrupted during the harvest and is rarely restored¹¹.

   On the plate

   Both lungs wash as they are taken out together.

   Sources211

The back table

1. 01The back table, step 1 of 1: Preparing the donor bronchus. Show it on the plate.

   Before the bronchial join the donor bronchus is shortened to about one or two cartilage rings above the lobar carina^11,12; some authors argue for an even shorter bronchus, at the level of the bronchial carina¹².

   Why

   The donor bronchus has lost its bronchial arteries and depends on retrograde flow from the pulmonary arteries, and reducing its length is key to minimising ischaemia at the join¹¹.

   Watch for

   Technique matters too: telescoped joins raised concern because of a 48% rate of bronchial stenosis in one report, and the best technique is still debated¹¹.

   On the plate

   The bronchial cut lines wash: the trimmed ends, which become the first join.

   Sources1112

The recipient

1. 01The recipient, step 1 of 5: The clamshell. Show it on the plate.

   Through incisions under both breasts, both pleural spaces are opened in the 4th intercostal space and the sternum is divided across between them^4,8: the clamshell, used for bilateral sequential lung transplantation³.

   Why

   The clamshell opens both pleural spaces through the 4th intercostal space and divides the sternum across, exposing all the intrathoracic structures through one incision⁴. That exposure matters most for the left hilum, which can be hard to reach because the heart lies over it³.

   Watch for

   Moving the heart to reach the left hilum can cause marked haemodynamic instability and may force cardiopulmonary bypass; a stitch in the oblique sinus can hold the heart out of the way instead³.

   On the plate

   The clamshell's cut line runs across the chest just below the 4th rib, through both sides and the sternum.

   Sources348

2. 02The recipient, step 2 of 5: One side, then the other. Show it on the plate.

   On each side the recipient's lung is removed by pneumonectomy and the donor lung joined in its place³.

   Why

   Bilateral sequential transplantation is the preferred operation, and in the registry report of the International Society for Heart and Lung Transplantation (ISHLT) cited by a 2014 paper, 74% of lung transplants were bilateral³. One lung is replaced at a time, so that the other carries the circulation, and bypass is avoided when feasible: one centre used it electively only for severe pulmonary hypertension or a combined cardiac procedure^3,13.

   Watch for

   That load can harm the first new lung, which is exposed to the full cardiac output; extracorporeal membrane oxygenation (ECMO) is considered when the patient worsens at the first or second clamping of the pulmonary artery, on a combination of hypercapnia, a saturation under 90%, a cardiac index under 2 L/min/m2 and a marked rise in pulmonary pressure¹³. In one of five recipients in one report, rising pulmonary pressure with right ventricular strain after the right lung forced bypass for the left³.

   On the plate

   Both lungs wash: each is removed and replaced in turn.

   Sources313

3. 03The recipient, step 3 of 5: The bronchus. Show it on the plate.

   The main bronchus is joined first³.

   Why

   The bronchus is joined first³. The donor bronchus is kept short, within one or two cartilage rings of the lobar carina, because reducing its length is key to minimising ischaemia at the join^11,12.

   Watch for

   Airway complications follow 2 to 33% of transplants, 7 to 8% at most centres¹¹. Dehiscence (1 to 10%) appears within one to five weeks and stenosis, the commonest, within two to nine months; severe primary graft dysfunction raises the rate¹¹.

   On the plate

   The cut lines on both main bronchi, just short of the lobar branches: the first join on each side.

   Sources31112

4. 04The recipient, step 4 of 5: The pulmonary artery. Show it on the plate.

   Then the pulmonary artery³. The right one runs behind the ascending aorta and the superior vena cava and in front of the right bronchus¹; the left passes in front of the descending aorta and over the left main bronchus, so it is the highest structure in the left hilum^1,5.

   Why

   The artery comes second, after the bronchus³. Clamping it sends the whole cardiac output through the other lung, so worsening during the first or second clamping of the pulmonary artery is one of the reasons to start ECMO¹³.

   Watch for

   Cardiopulmonary bypass has been linked to severe primary graft dysfunction (an odds ratio of 1.89 for its most severe grade against ECMO in one study), though a meta-analysis found no significant difference¹².

   On the plate

   The cut lines on the pulmonary arteries; on the left the artery sits highest at the hilum, above the bronchus.

   Sources1351213

5. 05The recipient, step 5 of 5: The atrial cuff. Show it on the plate.

   Last, the cuff of left atrium around the donor's pulmonary veins is joined to the recipient's; before this join is tied, the lung is re-inflated and air is let out through it³.

   Why

   The venous cuff is the last join, and it also lets the graft be de-aired: the lung is re-inflated and de-airing is done at the venous end of the join³.

   Watch for

   Reperfusion is a risk period: a high inspired oxygen fraction during reperfusion is a reported risk factor for primary graft dysfunction¹², and severe primary graft dysfunction goes with a high rate of airway complications¹¹.

   On the plate

   The cuffs low in each hilum, behind the heart's outline, wash: the venous joins.

   Sources31112