Surgical and Logistical Aspects of Donor Limb Procurement in Hand and Upper Extremity Transplantation

Abstract

Hand and upper extremity transplantation offers a promising reconstructive solution for select patients lacking a functional upper limb. For such an endeavor, it is imperative that multiple medical and surgical specialties and teams work in concert to achieve a common goal. Sixteen years from the first successful hand transplantation, the number of centers performing or planning to perform hand transplantation worldwide has increased considerably. This procedure may become the standard of care for properly selected patients in the not-too-distant future. To facilitate this transition, unified protocols are required. In this manuscript, we focus on the donor limb procurement process, including the sequence of events, logistics, and inter-specialty team interaction. Through review of the current literature, we acknowledge and address possible variations, and provide an illustrative overview of the operation. It is important that all members involved in this procedure, including the Organ Procurement Organization (OPO), solid organ procurement teams, and donor hospital staff, are aware of this process. Opportunities for future research in this field are further discussed.

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow

“…This bag is then placed into another bag and closed in the same fashion. A final third bag with ice water is used as per solid organ transplant protocol 4 (Figure 6).…”

“…1,2 Indications for suitable donors for hand allotransplantation have been previously outlined. 3,4 Unlike solid organ transplantation, hand transplantation is not a life-saving surgery, but a quality of life-improving surgery. Due to the relatively high metabolic demand of muscles, the permissible ischemia time for limb transplantation is shorter than that of solid organs.…”

“…As such, it is advisable to perform the limb procurement prior to aortic cross-clamping by the solid organ teams. [4][5][6] Thus, the hand allotransplant procurement team must have an efficient method of procurement, making it feasible to proceed with limb procurement without jeopardizing the health of the solid organs. However, current literature lacks sufficient "how to" publications explaining the nuances of transplant allograft procurement.…”

Building a Hand and Upper Extremity Transplantation Program: Lessons Learned From the First 20 Years of Vascularized Composite Allotransplantation

“…Donor limb procurement can occur in 3 possible timeframes: prior to, simultaneously with, or immediately following solid organ procurement, with prior to solid organ procurement being the most common method. 19 Following a quick identification of key neurovascular structures under tourniquet control, the limb is quickly amputated at the appropriate level and the donor wound closed, flushed with cold preservation solution, wrapped in moist sterile gauze, placed in 2 plastic bags, sealed, and placed in a cooler of ice for transport. 3,8 Cosmetic prostheses are usually left with the OPO staff to place on the residual limbs after solid organ procurement is complete.…”

Anaesthetic management of bilateral hand transplantation

“…[ 2 ] Use of tourniquet minimises blood loss in the heart-beating donor and reduces the risk of destabilisation due to blood loss. [ 3 ] The standard immunosuppression involves induction therapy with antibodies combined with multi-drug maintenance therapy.…”