OT notes · Thoracic / Trauma

Deceased-donor multi-organ retrieval

Usual anaesthesia
Donor ventilated and supported by the anaesthesia team (no anaesthetic for pain; muscle relaxant and haemodynamic support as per team)
Position
Supine with both arms tucked; prep from chin to upper thighs
Setting
emergency

Operative note template for abdominal organ retrieval from a brain-stem dead donor (liver, kidneys, with or without pancreas and vessels), with a filled example for liver and both kidneys retrieved from a road accident donor.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • organ found unsuitable for transplant during retrieval
  • injury to an organ or its vessels during retrieval
  • cardiac arrest in the donor before cross-clamp
  • delay to post-mortem in a medico-legal case
  • surgical incision from neck to pubis on the body
  • organs not used being disposed of as per rules

Pre-operative details for this operation

  1. Donor identityname, age, hospital number, donor registry / allocation number checked against wristband at time out
  2. Brain-stem death certificationForm 10 signed by all members of the Board of Medical Experts; date and time of both sets of tests; names of board members
  3. Authorisation for donationForm 7 if the donor pledged in life (and was not revoked); Form 8 declaration signed by the near relative or person in lawful possession of the body in every case; organs authorised
  4. Medico-legal caseNoYes: police informed, post-mortem arranged
  5. Cause of death and ICU coursedays on ventilator, vasopressors, cardiac arrest episodes
  6. Donor testsblood group, liver and renal function, sodium, CBC, clotting, HIV, hepatitis B and C, syphilis, CMV, cultures
  7. ImagingCT abdomen: vascular anatomy, steatosis, kidney size
  8. Organs allocated and teams presentliver / kidneys / pancreas / heart / lungs; receiving centres

Anaesthesia and position

  1. Donor supportventilation, vasopressors, BP and urine output during dissection
  2. Antibiotic prophylaxisdrug and time
  3. Positionsupine, arms tucked; lines and monitors checked working after positioning
  4. Equipmenttwo cautery units, suction (three if thoracic team), sternal saw, cannulas, cold preservation solution, sterile slush and ice

Operative findings

  1. Livercolour, consistency, edges, steatosis, injury; biopsy taken or not
  2. Hepatic arterial anatomyNormalReplaced / accessory left (from left gastric)Replaced / accessory right (from SMA)
  3. Kidneysnumber of arteries and veins each side, cysts, capsule damage, perfusion
  4. Pancreas / bowel / other organsnormal / injured / not retrieved
  5. Unexpected findingstumour, infection, trauma: biopsies sent

Procedure (steps)

  1. Incisionmidline laparotomy with median sternotomy
  2. Cattell-Braasch and Kocher mobilisationright colon, small bowel mesentery, duodenum; right ureter protected; both renal veins seen
  3. Distal aorta prepared for cannulationabove bifurcation, two ties; lumbar branches; accessory renal arteries from iliacs looked for
  4. IMV prepared for portal flushor portal vein direct
  5. Liver mobilised and hilum dissectedfalciform and left triangular ligaments; gastrohepatic ligament (accessory left artery); GDA tied; CBD divided and gallbladder flushed; portal vein cleared
  6. Supraceliac aorta prepared for cross-clampcrura divided, tape passed or limited dissection
  7. Systemic heparindose (units and units/kg) and time; the two chapters differ: liver chapter 300-400 units/kg IV several minutes before cross-clamp, kidney chapter 30,000 units IV with the distal aorta tied 3 minutes later; write what was actually given
  8. Cannulationaorta (cannula size), IMV (cannula size); distal aorta tied
  9. Cross-clamp and flushtime of cross-clamp (start of cold ischaemia); vent site (suprahepatic IVC / right atrium); solution, temperature, aortic and portal volumes; slush
  10. Liver (with or without pancreas) removedaortic cuff with coeliac, portal vein length, IVC divided above renal veins
  11. Kidneys removed en blocureters with generous tissue taken deep in pelvis, adrenal plane, IVC cuff about 1 cm above right renal vein, aorta at SMA
  12. Vessels retrievediliac arteries and veins for the liver team
  13. Back tablekidneys separated, measured (length, width, vessels, ureter), cysts biopsied; liver IVC and hilum cleaned

Closure, drains and dressing

  1. Donor incision closuretechnique and suture
  2. Bodycleaned, handed over to relatives / mortuary / police as per MLC status; time

Specimens and implants

  1. Organs retrievedeach organ, side, packaging (solution, bags, ice), label, receiving centre, time dispatched
  2. Biopsiesliver, kidney, cysts, lymph nodes: sent where
  3. Organs not usedreason and disposal

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Organ packagingeach organ in cold preservation solution, in three sterile bags, on ice; labelled with donor number, organ, side
  2. Documents with each organdonor blood group and virology, anatomy (arteries, veins, ureter length), damage noted, cross-clamp time
  3. Cold ischaemianote time of cross-clamp and dispatch; liver best within 12 hours
  4. Vessel graftspacked with the liver, labelled
  5. Injuries or anomaliesdescribed in detail, photos if needed, and told to the receiving surgeon directly
  6. Body handoverto mortuary for post-mortem (MLC) or to relatives; time and person
  7. Familyinformed that retrieval is complete; grief support as per hospital

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. D.G., 34 years, 72 kg, road traffic accident with severe head injury, declared brain-stem dead in the neuro-ICU; wife authorised donation of liver and both kidneys; medico-legal case.

Case details

Date: 02/12/2026. Deceased-donor retrieval of liver and both kidneys. Main OT.

Donor in OT 01:00. Time out 01:15. Incision 01:25. Heparin 02:40. Cross-clamp 02:45. Liver out 03:30. Kidneys out 03:55. Closure completed 04:30.

Retrieval surgeon: Dr A. (Consultant, Transplant Surgery). Assistants: Dr B. (MCh resident) and Dr C. (MS 3rd-year resident, General Surgery, writing this note). Anaesthetist: Dr D. Scrub nurse: Sr E. Transplant coordinator: Mr F.

Indication and pre-op

Brain-stem death certified by the Board of Medical Experts on Form 10. First set of tests 14:00, second set 20:30 on 01/12/2026. Certificate signed by all board members.

Authorisation for donation by wife on Form 8, for liver and both kidneys. Heart and lungs not authorised.

Medico-legal case. Written request made to the Station House Officer for timely retrieval; police permission received 23:40. Post-mortem to follow retrieval; forensic doctor informed.

Donor name, hospital number and allocation number checked against the wristband at time out with the whole team.

Blood group B positive. HIV, HBsAg, anti-HCV, VDRL negative. Sodium 148 mmol/L. AST 48, ALT 52 U/L. Creatinine 1.0 mg/dl. On noradrenaline, BP 110/70 mmHg, urine 100 ml/h.

CT abdomen: no steatosis on report, single renal artery each side.

Antibiotic prophylaxis given at 01:10 as per unit protocol (drug chart).

Anaesthesia and position

Donor ventilated and supported by Dr D. Supine with both arms tucked. Lines and monitors checked after positioning.

Painted with povidone-iodine from chin to upper thighs and draped.

Findings

Liver: normal colour, soft, sharp edges, no visible steatosis. No biopsy.

Hepatic artery: replaced left hepatic artery from the left gastric artery. Left gastric artery kept. No replaced right artery.

Kidneys: single artery and single vein on each side. No cysts. Capsule intact.

Pancreas: not allocated. Bowel normal. No tumour seen.

Procedure

Midline laparotomy and median sternotomy. Chest and Balfour retractors placed.

Cattell-Braasch and Kocher manoeuvres: right colon, small bowel and duodenum mobilised. Right ureter protected. Left and right renal veins identified.

Distal aorta dissected above the bifurcation and encircled with two umbilical tapes. No accessory renal artery from the iliacs.

Inferior mesenteric vein dissected lateral to the ligament of Treitz and looped with two silk ties.

Falciform and left triangular ligaments divided. Gastrohepatic ligament opened carefully: replaced left hepatic artery found and preserved; left gastric artery not tied.

Common hepatic artery traced to the GDA; GDA tied with silk and divided. Distal CBD tied and divided; gallbladder opened and flushed with saline. Portal vein cleared.

Crura divided and supraceliac aorta prepared for the clamp.

Inj heparin 25,000 units IV (about 350 units/kg) at 02:40.

Distal aorta tied, 24 Fr aortic cannula placed and secured. IMV tied and a 14 Fr cannula placed for portal flush.

Supraceliac aorta clamped at 02:45 (start of cold ischaemia). Suprahepatic IVC opened at the right atrium to vent. UW solution at 4 C: 3 L through the aorta and 2 L through the portal cannula. Ice slush in the abdomen and both paracolic gutters.

Liver removed with an aortic cuff containing the coeliac axis and the left gastric artery (for the replaced left artery), portal vein, and IVC divided above the renal veins, at 03:30.

Kidneys removed en bloc: ureters taken with generous surrounding tissue deep in the pelvis, right adrenal divided in its plane, IVC cut about 1 cm above the right renal vein, aorta cut at the SMA, at 03:55.

Both common, external and internal iliac arteries and veins retrieved for the liver team.

Back table: kidneys separated with aortic patch for each artery and a caval cuff with the left renal vein. Right kidney 11 x 6 cm, artery 2.5 cm, vein 1.5 cm, ureter 14 cm. Left kidney 11.5 x 6 cm, artery 3 cm, vein 4 cm, ureter 15 cm. No capsular tear.

Closure

Sternum and abdomen closed with a continuous heavy suture in one layer. Skin closed. Body cleaned and dressed.

Specimens and implants

Organs: liver with iliac vessels in UW solution, three sterile bags, on ice, labelled; to receiving centre 1 at 04:10.

Right and left kidneys, each in UW solution, three bags, on ice, labelled with side; to receiving centres 2 and 3 at 04:20.

Anatomy sheet, blood group and virology reports sent with each organ. No biopsies. No organ discarded.

End of procedure

Mop, needle and instrument count correct before closure, confirmed by scrub nurse.

No injury to any organ or vessel during retrieval.

Retrieval report on the organs removed (this note) sent with the body for the post-mortem doctor.

Body handed to the mortuary for post-mortem at 04:45, received by Mr G. Wife informed by the transplant coordinator.

Post-op orders

Receiving teams informed by phone of the replaced left hepatic artery (kept on the aortic patch with the left gastric artery) and of the cross-clamp time 02:45.

Copy of Form 10, Form 8 and this note filed with the transplant coordinator.

Signature

Dr C., JR-3, General Surgery, for Dr A. Reg. no. ________. 02/12/2026, 05:00. Countersigned by Dr A.

Must document for this operation

  • Brain-stem death certificate details and the authorisation form, with names and times. Retrieval is lawful only after certified brain-stem death and valid authorisation, and these are the first documents checked in any inquiry.
  • Donor identity and allocation number checked at time out. Each organ goes to a different recipient, and a wrong label cannot be undone.
  • Time of cross-clamp. Cold ischaemia time starts here, and it affects graft function in every recipient.
  • Vascular anatomy, especially accessory or replaced arteries, and how they were kept. The implanting surgeon plans the back-table reconstruction from this.
  • Any injury or abnormality of an organ, in detail. The receiving team decides whether the organ can be used, and the note shows when the injury happened.
  • Kidney measurements and ureter length. These go with the organ and are needed for allocation and implantation.
  • Medico-legal status and body handover. The post-mortem must not be compromised, and the chain of custody of the body must be clear.

Common mistakes in these notes

  • Not recording the cross-clamp time or the volumes of flush.
  • Writing 'normal anatomy' without checking for replaced hepatic arteries or extra renal arteries.
  • Not recording the form numbers and times for brain-stem death and authorisation.
  • Leaving out the body handover time and person in a medico-legal case.
  • Not noting organ damage before the organ leaves the theatre.

Indian practice and paperwork

  • Organs may be removed from a brain-stem dead body only when a certificate in Form 10 has been signed by all members of the Board of Medical Experts. Write the form and its times in the note. (Transplantation of Human Organs and Tissues Rules 2014, rule 5(4)(c), https://www.legitquest.com/act/transplantation-of-human-organs-and-tissues-rules-2014/9F25)
  • Authorisation: if the donor pledged in life it is on Form 7, but the near relative (or person in lawful possession of the body) must still sign the declaration on Form 8 in every case. Record both where they apply. (Transplantation of Human Organs and Tissues Rules 2014, rule 5(1)(a) and (b), rule 5(4)(a) and (b), https://www.legitquest.com/act/transplantation-of-human-organs-and-tissues-rules-2014/9F25)
  • In a medico-legal case the doctor must ask the Station House Officer (or SP / DIG) to allow timely retrieval, with a copy to the designated post-mortem doctor, and retrieval must not jeopardise finding the cause of death. The retrieving doctor must prepare a medical report on the organs retrieved at the time of retrieval; it goes into the post-mortem notes, so write this note before the body leaves. (Transplantation of Human Organs and Tissues Rules 2014, rule 6(1) to (3), https://www.legitquest.com/act/transplantation-of-human-organs-and-tissues-rules-2014/9F25)
  • Tissues and organs not used are human anatomical waste for the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Englesbe MJ, ed. (Mulholland MW, editor-in-chief). Operative Techniques in Transplantation Surgery. Wolters Kluwer; 2015, Ch 14, Procurement of Liver for Transplantation (Shah MB, Maynard EC); Ch 1, Standard Deceased Donor Kidney Procurement (Gooden CW), e-book PDF pp. 186-196; 21-36.
  • Transplantation of Human Organs and Tissues Rules, 2014 (text via LegitQuest, re-checked 29 Sep 2026): rule 5(1)(a),(b) and 5(4)(a),(b) Forms 7 and 8; rule 5(4)(c) Form 10 signed by all Board members; rule 6 medico-legal cases. www.legitquest.com/act/transplantation-of-human-organs-and-tissues-rules-2014/9F25

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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