Sequence of pancreatic retreival

• Inspection of the pancreas, look for signs of pancreatitis such as petechial haemmorhages, oedema and fat necrosis.
• Check the arterial anatomy, if the right hepatic artery originates from the superior mesenteric artery then it should be ligated at the upper border of the pancreas. After organ flush the abberant artery can be divided here leaving sufficient length for anastamosis to the splenic artery on the bench, alternatively it can be anastamosed directly to the recipeients proximal right hepatic artery. Check for an abberant left hepatic artery coursing through the lesser omentum, as this can be damaged during stomach mobilisation which is required for pancreas retrieval.
• Once the arterial anatomy has been ascertained the organs are flushed with preservative solution. In pancreas and multivisceral retrieval many centers prefer to flush with University of Wisconsin solution through the aortic cannula and not to perform any flushing through the portal system.
• The pancreas is carefully mobilised leaving the spleen attached to minimise trauma to the pancreas due to handling. Cautery is avoided close to the duodenum.
• The hepatic flexure is taken down and reflected across to the left of the abdomen.
• Kocher's manoeuvre is carried out, mobilising the duodenum and pancreas until there is 2-3 cm of the left renal vein exposed.
• The small bowel mesentry is mobilised and the right colon is reflected to the left of the abdomen, exposing the aorta and the inferior vena cava, the duodenum and head of pancreas with the superior mesenteric vein entering the lower part of the pancreas.
• The lesser sack is now opened separating the omentum from the greater curve of the stomach leaving the omentum attached to the colon.
• The spleen is mobilised from the left upper quadrant, this gives access to the short gastric vessels which are ligated.
• Slings are placed around D1 and the junction of D3 to D4.
• The common bile duct is ligated above the duodenum
• The splenic artery is ligated close to the coeliac axis, becuase the splenic artery retracts into the pancreas it is common practice to place a 6/0 prolene suture into into prior to division so it can be easily identified on the bench.
• The portal vein is divided at its midpoint between the liver and the pancreas.
• The duodenum is divided at the slings with a stapling device.
• The transvers mesocolon is divided ligating any branches from the superior mesenteric vessels.
• The small bowel mesentry is divided, usually in stages with mutliple ligatures or with a vascular stapling device.
• The superior mesenteric vessels are divided at the lower border of the pancreas, especial care is taken to avoid narrowing the inferior pancreatico-duodenal artery which comes off the superior mesenteric artery in the pancreas close to the lower border.
• The superior mesenteric artery is dissected to the aorta and a Carrel patch is taken with the origin of the superior mesenteric artery.
• An iliac artery graft is retrieved (common iliac and external and internal branchs) for anastomosis at the bench.