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Review Article

Multi‑Organ Retrieval in Donation after Brain Stem Death

Unnikrishnan Gopalakrishnan, Jimmy Mathew1, Kirun Gopal2, Rehna Rasheed3
Departments of Gastrointestinal Surgery, Plastic and Reconstructive Surgery, 2Cardiac Surgery and 3Opthalmology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
1

Abstract
Organ donation after brain stem death is quite common in the west. In India, the procedure is still gaining acceptance. The surgical steps for
multi‑organ retrieval have evolved in different centers with significant variations, and the scientific evidence levels for each technique are
low. Organ retrieval requires a fairly rapid surgical technique to avoid ischemic injury to the target organs yet avoid iatrogenic injuries. This
article offers and outline of the multi‑organ donation procedure. It details the abdominal organ retrieval techniques and touches on thoracic
organs and composite tissue grafts as well. It also briefly touches upon machine perfusion of organs.

Keywords: Brain stem death, multi‑organ retrieval, organ donation

Introduction 2. Verify that the certification of brain stem death is done on

This article aims to provide a general overview on how the organ
retrieval process takes place after brain stem death declaration
and is aimed primarily to familiarise those physicians who
seldom encounter such procedures during their routine clinical
practice. Individual units evolve their own techniques over time,
dictated both by their clinical practice and available skill sets.
The technique at Amrita Institute of Medical Sciences, Kochi,
is adapted from the standard operating procedure for organ
retrieval after brain stem death from Cambridge Transplant
Centre, Addenbrooke’s Hospital, Cambridge, UK.
Organ retrieval is a challenging procedure, both technically as
well as logistically. It often happens at off‑hours in hospitals
that are unfamiliar to the operating team. The operating team
is also under pressure from contradicting priorities of rapid
retrieval to prevent organ injury and need to avoid iatrogenic
damage to organs during retrieval. Although there is extensive
literature on organ procurement operations, the level of
evidence for surgical steps are mostly low.
Steps before taking the potential donor to the theater:
1. Potential donor’s name, age, and hospital ID numbers to
be checked and verified by the lead surgeon in the retrieval
team and to be matched with the information provided from
the Kerala network for organ sharing/coordinating body
Submitted: 07-May-2020 Accepted: 08-May-2020 Published: 18-Aug-2020
the appropriate government forms and is in accordance
with the current laws of the state
3. Verify the consent forms to ensure that the consent
includes all the organs that are scheduled for retrieval,
including retrieval of blood vessels
4. Blood group to be cross‑checked
5. Labs results: complete blood count, serum electrolytes,
liver function tests, amylase, lipase, renal function
tests, coagulation parameters, urine routine, and viral
markers (HIV, hepatitis B, hepatitis C) to be cross‑checked.
Pay particular attention to electrolytes as they are likely
to change rapidly in a brain stem dead patient and may
have an impact on the outcome of the implant
6. The current hemodynamic status, including inotrope and
vasopressor use, fluid intake and output, and ongoing
medications, should be noted.
General Recommendations
1. It is ideal to have a single experienced donor surgical team
to do the retrieval of all abdominal organs and a team for
thoracic organ retrieval, rather than have individual teams
Address for correspondence: Dr. Unnikrishnan Gopalakrishnan,
Department of GI Surgery, Amrita Institute of Medical Sciences,
Kochi ‑ 682 041, Kerala, India.
E‑mail: unnikrishnang@aims.amrita.edu

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DOI: How to cite this article: Gopalakrishnan U, Mathew J, Gopal K, Rasheed R.

10.4103/AMJM.AMJM_36_20 Multi-organ retrieval in donation after brain stem death. Amrita J Med
2020;16:95-9.

© 2020 Amrita Journal of Medicine | Published by Wolters Kluwer - Medknow 95

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Gopalakrishnan, et al.: Multi‑organ retrieval in donation after brain stem death
for each organ. If this cannot be achieved, all surgical
teams should clearly discuss and define individual roles
and limits so that miscommunications and incoordination
during the retrieval process are kept to a minimum
2. Before starting the retrieval process, it is critical to discuss
the planned steps, not only among the surgical teams
but also with the anesthetists and the nursing team in
the theatre, many of whom may be unfamiliar with the
retrieval process
3. Classical procedure involves a midline laparotomy and
a median sternotomy even when no thoracic organs are
being retrieved.
All attempts must be made to minimize the warm and cold
ischemia times once the procedure is started. Warm ischemia
time is used to describe two physiologically distinct periods
of ischemia:  (1) Ischemia during organ retrieval, from the
time of cross‑clamping  (or of asystole in nonheart‑beating
donors), until cold perfusion is commenced and (2) Ischemia
during implantation, from the removal of the organ from ice
until reperfusion.[1]
Cold ischemia time is defined as the time from cross‑clamp
of the aorta and cold flush in the donor to the time of the first
anastomosis in the recipient.[2]
4. In a multi‑organ retrieval, the order of removal organs
is generally heart, lungs, liver, pancreas, kidneys, and
vessels.
Organ Preservation Fluids
Various preservation solutions have been tried, and quite a
few are available commercially for organ preservation during
storage and transport. All organ preservation solutions are
aimed at preserving cell integrity and contain additives for
the same. The various chemicals added function as buffers,
impermeants, electrolytes, free radical scavengers, nutrients,
and in some cases, colloids.
Although the University of Wisconsin  (UW) solution is
considered the gold standard, head‑to‑head comparisons with
Histidine‑Tryptophan‑Ketoglutarate solution and Celsior
solutions have not shown significant difference in graft
outcomes for liver and kidneys. Small bowel and Pancreas
retrievals use UW as the preferred solution.
Examine the patient before starting:
• Consider the need for breast/testes/rectal/skin examination
• Evaluating for heart and lung organ retrieval includes
evaluation of fluid management and requirement for
cardiovascular agents. Hemodynamic monitoring
continues in the operating room, including blood
pressure  (BP) and central venous pressure evaluation.
The aim is to achieve a normal mean arterial pressure
and to avoid overhydration. Ventilator settings are
reviewed to assess for adequate tidal volume and
FiO2  <0.5. Positive end-expiratory pressure (PEEP)  is
maintained at physiological levels around 5 cm of H2O.
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The chest is assessed for any external injury or prior
surgical scar. For heart retrieval, the electrocardiogram
and echocardiogram is reviewed to assess for normal
heart contractility and valve function with no significant
hypertrophy or anatomical abnormalities. For lung
retrieval assessment, the ABG should be normal, and
CXR should not show any significant opacities. An onsite
flexible bronchoscopy should also be done to assess the
airway for anatomical abnormalities and the presence of
secretions and whether they are infected or not
• Examine the abdomen and chest. Previous laparotomies
or a sternotomy might make the retrieval difficult.
An ultrasound abdomen to assess liver, kidney
sonomorphology, and rule out intraabdominal mass
• An nasogastric tube will decompress the stomach and
make the abdominal retrieval easier
• If there are lower limb arterial lines, let the anesthetist
know that they will lose trace during the surgery.
Before Starting
• Prophylactic antibiotics are to be given according to the
unit’s policy
• Though anesthetic agents are not essential, muscle
relaxants are used to inhibit spinal reflexes and provide
adequate muscle relaxation
• Inform anesthetist that lung inf lation need to be
temporarily suspended during sternotomy
• Request the anesthetist to target
• Systolic BP of >100 mmHg to maintain organ perfusion.
In case the BP drops to use volume first rather than
inotropes
• A central venous pressure of 10–15 mmHg
• Oxygen saturation >95%
• Lactate <2.
In the event of a cardiac and/or lung retrieval, the above
requirements may need to be adjusted as they tend to prefer
to keep the donors relatively “dry.”
• In case of any sudden hemodynamic instability technique
may need to be adapted for rapid retrieval
• Heparin is given at a dose of 300 IU/kg around 5 min
before cross‑clamping
• The ventilator can be turned off after cross‑clamping and
venting the blood and perfusion fluid out through the
atrium/cava.
Abdominal Multi Organ Retrieval
The procedure can be divided into four stages, namely
dissection, cannulation, perfusion, and explantation, followed
by bench preparation and packing.
The donor is placed in the supine position. Midline laparotomy
and a median sternotomy are done, and sternal retractor is
placed and opened to expose the heart and the pericardium.
The medial edges of the abdominal incision are turned
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Gopalakrishnan, et al.: Multi‑organ retrieval in donation after brain stem death
outwards and fixed to the skin laterally with stout sutures to
allow complete exposure of the abdominal organs. In the very
obese donors, the abdominal incision may need to be cruciate
to allow adequate exposure.
An initial assessment of the abdominal organs for any
unsuspected pathology is done. The gastro‑oesophageal
junction, stomach, duodenum, liver and gallbladder, pancreas,
colon, kidneys, ovaries and uterus, spleen, mesenteric lymph
nodes, and small bowel should be assessed. The organs to
be retrieved need to be assessed specifically. A grossly fatty
or cirrhotic liver, fatty pancreas, or shrunken kidneys may
necessitate a change in retrieval plans and will need to be
communicated to the implant teams urgently.
The surgical steps vary considerably from unit to unit. The
dissection comprises a warm phase before the perfusion
and a cold phase after perfusion. A detailed dissection in the
warm phase makes it easier to pick up anatomical variations,
especially of the vascular structures, allow a shortened cold
phase, and reduce the time for the organs to be put on ice.
However, vascular damage in the warm phase generally
impacts the usability of the organs and will probably result
in organ loss.
Warm Dissection
The initial step is to do a full mobilization of the right colon
and duodenum  (Cattel Braasch maneuver), lifting them
off the posterior structures so that the aorta, inferior vena
cava (IVC) and the right kidney and ureters are exposed fully.
The confluence of the renal veins with the IVC is identified.
The inferior mesenteric vein is identified to the left of the
duodenojejunal flexure.
The preferred site for arterial cannulation is the right common
iliac artery. In case it is diseased, the lower part of the abdominal
aorta is the next preferred option. In patients who have severely
diseased aorta/iliac vessels, retrograde cannulation from the
descending thoracic aorta is also an option.
When the liver is retrieved, most units use portal perfusion
as well. The site for portal perfusion is usually an inferior
mesenteric vein. Sometimes, infracolic superior mesenteric
vein or the portal vein may be used. Now, the dissection
moves to the liver hilum. The bile duct is dissected and divided
roughly 2 cm above the duodenum. A cholecystectomy may be
Table 1: Cold preservation times for heart beating
nonmarginal organs
Optimal (h) Usable (h)
Heart <3
Lung <3
Small bowel <4
Pancreas <10
Liver <12
Kidney <24
Amrita Journal of Medicine  ¦  Volume 16  ¦  Issue 2  ¦  April-June 2020
done at this stage, and the bile duct is flushed out with saline
to remove any bile. The gastroduodenal artery is divided, and
the common hepatic artery is dissected back to the celiac axis.
Further steps are optional before perfusion and cardiac arrest.
These include mobilization of the right and left lobes of the
liver, mobilization of the left colon to allow easy access and
cooling of the left kidney, identification of both ureters at the
pelvic brim and looping of the infra‑hepatic vena cava above
the renal veins.
Cannulation
At this point, heparinization is done at 300 IU/kg body
weight. After 5 min the cannulation target vessels are opened
and cannulated with appropriately sized perfusion cannulae.
Once cannulation is done, the left pleura is opened, and the
heart is retracted to the left to access the descending thoracic
aorta. After the aorta is cross clamped, the ice cold perfusion
is started, and the anesthetist is requested to stop ventilating
the lung. The perfusion solution and blood will need to be
vented out; this is usually achieved through the right auricular
appendage. When a cardiac team is also retrieving the
cross‑clamp may need to be moved to the supra celiac aorta
and the vent to the IVC. 2–3 L of crushed saline ice slush is
placed around the liver, in the lesser sac over the pancreas,
and the anterior to the kidneys. The perfusion is allowed to
complete. During this period, the donor will achieve asystole.
Cold Dissection
Liver explantation
Once perfusion is complete, the cold dissection can start. The
left renal vein is divided as it joins the IVC, infrarenal aorta
is bisected in the anterior midline, and the superior mesentric
artery (SMA) is transected just after its origin. The left gastric
and the splenic arteries are divided, and the supracoeliac aorta
is transected above the coeliac artery. The portal vein is divided
to free the hepatic hilum. The diaphragm is divided, and the
Supra hepatic vena cava is divided at the level of the atrium.
The infra haptic vena cava is divided above the right renal
vein. Now placing a finger into the vena cava will allow the
liver to be lifted anteriorly, and the tissues behind, including
the adrenal gland, can be transected to explant the liver.
Kidney explantation
The left colon mesentery is divided close to the colon. Both
ureters are divided as they close the pelvic brim, and the
proximal end are dissected with their surrounding tissue. The
posterior aortic wall is divided in the midline and the inferior
venal cava at its formation. After completion of the dissection
and retrieval, both kidneys would have half the aortic wall,
6
8
and the right kidney will have the IVC with it.
8 The iliac vessels are carefully dissected and harvested for use
24 in pancreas or liver implantation. In case a multi‑visceral block
24 or small bowel retrieval is performed, a segment of the thoracic
48 aorta will also be retrieved for use a conduit.
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Gopalakrishnan, et al.: Multi‑organ retrieval in donation after brain stem death
Pancreas Retrieval
When the pancreas is retrieved, the warm phase dissection
would include the opening of the greater omentum, and
preparation of the portal vein for cannulation. Mobilization
of the left colon and short gastric vessel division are optional.
The gastroduodenal artery (GDA) is not divided into the warm
phase to avoid ischemia to the pancreatic head.
In pancreas retrievals, the portal perfusion for the liver is
through the portal vein directly and the portal system is vented
just below this perfusion cannula so that there is no congestion
of the pancreas due to occluded outflow.
In the cold phase, the GDA is divided, the pylorus and the
proximal jejunum are stapled, and small bowel mesentery
is transected. Short gastric vessels are divided fully, and the
transverse colon mesentery is divided to free the pancreas of
all its anterior attachments. The pancreas is dissected off the
retroperitoneum with the spleen, and the duodenum en‑bloc,
the cut end of the splenic artery, GDA and SMA are tagged
with sutures.
Multi Visceral Block Retrievals
In this retrieval scenario, the liver, pancreas‑spleen, and the
small bowel are retrieved en‑block. The arterial patch will
include the coeliac and SMA on a single patch, and the venous
outflow will be the vena cava that is along with the graft liver.
Small Bowel Retrieval
Superior mesenteric artery and superior mesenteric vein are
the vascular pedicles. Dissection and retrieval of the rest of
the organs are carried out as described above.
Closure
All unused tissue is returned to the abdominal cavity. The
abdomen is sucked and mopped to dryness. The closure is a
single layer of continuous running suture, which includes the
skin only.
Back Table Preparation and Packing
Well perfused organs do not need further perfusion on the
back table. In cases where there is doubt of poor perfusion,
the organs can be flushed with further perfusion fluids. The
common bile duct is flushed again before packing the liver. The
perinephric fat is divided on the convex border of the kidney to
expose the kidney so that it cools more rapidly in the icebox.
In the pancreas and small bowel retrieval, a small incision is
made on the bowel and the intestinal contents are carefully
removed, and the lumen is flushed with UW solution. The
opened area is stapled off before packing.
The retrieved organs are packed with preservative fluid in a
plastic bag and saline ice slush in an outer bag and placed in
the icebox and transported to the recipient team.
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Thoracic Organ Retrieval
After the abdominal dissection is over access to the thoracic
organs is through a midline sternotomy. Both pleura are
widely opened. The heart and lungs are assessed for any
obvious abnormalities. Further steps vary based upon
whether it is a heart only or heart and lung harvest. The
superior vena cava (SVC), IVC, and aorta are dissected and
looped. If the lung is also to be harvested, the trachea is
mobilized through the space between the aorta and the right
pulmonary artery (PA) and looped. Then after confirming that
the abdominal team is ready and the recipient for the heart
and lungs is ready to minimize the cold ischemia time, the
patient is heparinized with 300 IU/kg unfractionated heparin.
Then, purse strings are taken in the distal ascending aorta
and the main PA and canulated. Once all teams are ready, the
invasive lines are pulled out by the anesthetist, and the SVC
is clamped. Then, the heart is lifted up, and an incision is
made in the base of the left atrium (LA) to vent the left side
of the heart. Subsequently, the IVC is divided about a cm
above the diaphragm to leave a cuff for the liver team. Pool
suckers are placed in the pericardium to drain the blood. The
aorta is then cross clamped as high as possible, and 1.5l of
HTK solution is given. At the same time, perfadex is given
into the PA. Care should be taken to ensure the heart does
not distend while the cardioplegia is being delivered. Cold
saline is also poured over the heart and lungs for topical
protection. After the cardioplegia is delivered, organ retrieval
proceeds from front to back. The cardioplegia and pulmonary
perfusion cannulas are removed. The SVC is divided below
the clamp, and then, the IVC is completely divided. The
aorta is divided usually just distal to the arch vessels after
disconnecting the arch vessels. Next, the PA is divided just
at the PA bifurcation keeping the bifurcation intact. Next,
the LA is opened on the right side midway between the right
pulmonary veins and the Sondergaard’s groove vertically to
ensure enough tissue on both sides for the heart and lung
implantation teams. Then, the heart is lifted up, and the
previously created LA incision is extended to the right to
join the previous incision and then to the left to the base of
the left atrial appendage. This leaves the superior margin
of the left atrium, which is divided from both sides, and the
heart is removed.
The heart is taken to the back table and flushed with cold saline.
Then, all the valves are inspected. If a patent foramen ovale
is present it is closed. Then, it is triple bagged in cold saline
and placed in the icebox for transportation.
Now, attention is turned to the lungs. Another 3 L of
perfadex in total is given retrograde through the pulmonary
veins to flush out any clots. Then, the inferior pulmonary
ligaments are divided bilaterally and the posterior
pericardium is also incised. Then, the right lung is lifted up
and retracted to the left side, exposing the tissues posterior
to the hilum. The lung is separated from the esophagus and
other posterior mediastinal structures through the avascular
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plane. The same is done on the left side. During this time,
the lungs are continued to be ventilated with low tidal
volume. Then, the trachea is pulled up and stapled as high
as possible after pulling back the endotracheal tube and
deflating the lungs to around 3/4th its fully inflated state, and
the trachea is stapled. The lungs are then removed en bloc
and taken to the back table, inspected and bagged similar
to the heart for transport. The cold preservation times of
various organs are given in Table 1.
Composite Tissue Retrieval
Composite tissue transplants, sometimes called reconstructive
transplants, including face, larynx, knee, uterus, and penis has
been transplanted. Composite tissue transplants are usually not
life‑saving procedures, are highly visible parts of the body,
closely related to the identity of the individual, or essential
for normal functioning as an active participant in society.
Composite grafts are taken from deceased donors. Organs
like hands are replaced readily, after retrieval, with a replaced
with prosthesis before handing over the body to the relatives.
The level at which the hand is removed depends on the length
required for the recipient.
Cornea Retrieval
Only the corneoscleral button is retrieved, and a clear plastic
shell is placed over it. The rest of the ocular tissues are left
undisturbed, and the lids kept apposed.
After retrieval of the organs, the skin is sutured and dressed.
The body of the donor is then returned to the relatives to
complete the final rites. It is to be noted that the time of death
is the time of the second apnoea test.
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Machine Perfusion of Organs
In view of the increasing waiting list for organs, efforts have
been made to use organs that were once considered marginal.
Trying to preserve organs by machine perfusion was proposed
in 1934 by Lindbergh and Carrel.
Machine perfusion may be hypothermic or normothermic
and involves a machine circulating the perfusate through the
organs blood vessels. Kidneys preserved using hypothermic
machine perfusion showed less primary nonfunction and
early graft dysfunction and had better 1‑year graft survival.[3]
Normothermic machine perfusion may allow organs that may
otherwise be discarded to be “tested” on the perfusion machine
to assess their metabolism and allow usage of organs that are
metabolically acceptable.[4]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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et al. Impact of cold ischemia time on outcomes of liver transplantation:
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3. Bellini  MI, Nozdrin  M, Yiu  J, Papalois  V. Machine perfusion for
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