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Organ procurement for transplantation was first accomplished by the Soviet surgeon Yu Yu Voronoy, who performed the first human kidney transplant on April 3, 1933. The donor was a 60-year-old man who died on admission to the hospital from a traumatic brain injury; the kidney was removed 6 hours postmortem and transplanted into the thigh of a 26-year-old woman with acute renal failure from mercury poisoning. The allo-graft did produce several milliliters of urine before the patient died 2 days after transplantation. The first attempt at liver transplantation, on March 1, 1963, by Thomas Starzl, was possible only after successful liver procurement from a child who had died after cardiac surgery, but was left on the heart-lung machine to allow for procurement.

Kidney transplantation in the 1950s and 1960s was primarily from live donors. However, in 1966 the concept of brain death was established in France by Guy Alexandre, who described the removal of kidneys from “heart-beating” cadavers with subsequent transplantation. In the United States, public support for this concept was overwhelming and led to the Harvard Ad Hoc Committee report in 1968 that outlined the criteria for brain death determination. The donor pool increased markedly after these policies entered clinical practice.

Hemodialysis is one of the main modalities for renal replacement therapy in patients with end-stage renal disease. Successful hemodialysis is contingent upon the creation of proper vascular access. Chronic vascular access was first established in 1960 by Scribner and colleagues when they created a shunt between the radial artery and the cephalic vein using an external Silastic device. However, this device was fraught with problems such as bleeding, clotting, and infection. In 1966, Breschia and Cimino described a surgical fistula between the radial artery and the cephalic vein just proximal to the wrist, thereby eliminating the external shunt and enabling a high flow system for hemodialysis. To this day, it remains the procedure of choice for patients with end-stage renal disease in need of chronic hemodialysis.

Several principles should be followed when planning vascular access surgery. In general,primary fistulas are better than prosthetic grafts due to better long-term patency and lower risk of infection and thrombosis. The upper extremity is preferable to the lower extremity and the nondominant arm should be employed first. If possible, a distal site should be selected first, preserving the upper arm for subsequent use. Careful pre-operative vascular assessment is performed with palpation of the radial, ulnar, and brachial pulses; an Allen's test is performed on both sides. The superficial veins of the arm should be carefully assessed with application of a proximal tourniquet. In some cases, the cephalic vein is readily evident at the wrist, antecubital fossa area, or in the lateral aspect of the upper arm. Once a decision has been made to perform access surgery, no venipunctures or blood pressure monitoring should be performed in that arm. If no superficial veins are apparent, the venous system may be assessed by ultrasound examination of the arm. Both the cephalic and basilic systems are interrogated, as well as the deep venous system and the central veins. Patients with suspected central venous stenosis or prior catheters inserted on the ipsilateral side, or with abnormal findings on ultrasound, may be assessed by conventional venography. If central stenoses are found, they should be corrected by endovascular techniques preoperatively, or an alternate site for access should be sought.

The kidney, the first organ to be used for living-donor transplants, is the most common type of organ donated by living donors today. In the Unites States, the number of living kidney donors now outnumbers the number of deceased kidney donors. Initially it was felt that only close family members could be potential donors. However, it is well recognized now that there does not need to be any direct relationship between the donor and recipient to achieve a highly successful outcome.Any healthy person is a potential kidney donor, including relatives, coworkers, friends, and acquaintances.

A living-donor kidney transplant offers significant advantage over its deceased-donor counterpart. Living-donor kidney recipients enjoy improved long-term success, avoid a prolonged wait, and are able to plan the timing of their transplant in advance. Moreover, they have a significantly decreased incidence of delayed graft function and increased potential for human leukocyte antigen (HLA) matching.As a result, living-donor transplants generally have better short- and long-term results, as compared with deceased-donor transplants. Of course, the risks to the living donor must be acceptably low. The donor must be fully aware of potential risks and must freely give informed consent. But as long as these conditions are met, the search for a living donor should not be restricted to immediate family members. Results with living, unrelated donors are comparable to those with living, related (non—HLA-identical) donors.

In the last 35 years, few fields of medicine have undergone the rapid advances that have been seen with kidney transplantation. From the development of the surgical techniques necessary for transplantation at the beginning of the century, to the dawn of modern transplantation with the introduction of immunosuppressants in the late 1950s, and to its current status as the treatment of choice for end-stage renal disease (ESRD), renal transplantation has enjoyed remarkable progress. The surgical techniques for organ transplantation, including methods of vascular anastomosis, were developed in animal models by Carrel and Guthrie in the early 1900s. The first clinical deceased renal transplant was performed in 1933 by the Ukrainian surgeon Voronoy, with unsuccessful results secondary to the immunologic barrier. In the 1950s these obstacles were circumvented by performing the procedure between identical twins. The era of modern renal transplantation began with the introduction of the immunosuppressive agent azathioprine, and renal transplantation was established as a viable option for the treatment of ESRD.

For the majority of individuals with ESRD,transplantation results in superior survival, improved quality of life,and lower costs as compared with chronic dialysis.There are very few absolute contraindications and so most patients with ESRD should be considered as potential candidates. The surgery and general anesthesia, however, impose a significant cardiovascular stress.The subsequent lifelong chemical immunosuppression is also associated with considerable morbidity. Therefore, evaluation of a potential recipient must focus on identifying risk factors that could be minimized or may even contraindicate a transplant.

The world's first clinical pancreas transplant was performed at the University of Minnesota on December 16, 1966, to treat a uremic diabetic patient. Since that time, nearly 15,000 pancreas transplants have been performed around the world, the major ity in the United States.

A successful pancreas transplant can establish normoglycemia and insulin independ ence in diabetic recipients. It also has the potential to halt progression of some second ary complications of diabetes. No current method of exogenous insulin administration can produce a euglycemic, insulin-independent state akin to that achievable with a technically successful pancreas graft. Pancreas transplants are performed to improve the quality of life over that achieved by the alternative treatment — exogenous insulin admin istration. But as a treatment for type 1 diabetes, pancreas transplants have not yet achieved widespread application in all diabetics because the operative procedure is asso ciated with complications, albeit of increasingly lower incidence, coupled with long-term side effects of immunosuppression, which together may exceed the complications due to diabetes. Thus, pancreas transplants are preferentially performed in diabetic patients with renal failure who are also candidates for a kidney transplant, and who would require immunosuppression to prevent rejection of the kidney. A pancreas transplant alone is appropriate for diabetics whose day-to-day quality of life is so poor from a management standpoint (e.g., labile serum glucose with ketoacidosis or hypoglycemic episodes, pro gression of severe diabetic retinopathy, nephropathy, neuropathy, or enteropathy) that chronic immunosuppression is justified to achieve insulin independence.

The field of liver transplantation has undergone remarkable advances in the last two decades. An essentially experimental procedure in the early 1980s, a liver transplant is now the treatment of choice for patients with acute and chronic liver failure. Patient survival at 1 year posttransplant has increased from 30% in the early 1980s to more than 85% at present. The major reasons for this dramatic increase include refined surgical and preservation techniques, better immunosuppressive protocols, more effective treatment of infections, and improved care during the critical perioperative period.Yet a liver transplant remains a major undertaking, with the potential for complications affecting every major organ system.

The history of liver transplantation began with experimental transplants performed in dogs in the late 1950s. The first liver transplant attempted in humans was in 1963 by Thomas Starzl. The recipient was a 3-year-old boy with biliary atresia,who unfortunately died of hemorrhage. The first successful liver transplant was in 1967, again by Starzl.Yet, for the next 10 years, liver transplants remained essentially experimental, with survival rates well below 50%. Still, advances in the surgical procedure and in anesthetic management continued to be made during that time. The major breakthrough for the field came in the early 1980s, with the introduction and clinical use of the immunosuppres-sive agent cyclosporine. Patient survival dramatically improved, and liver transplant was soon being recognized as a viable therapeutic option for patients with liver failure.Results continued to improve through the 1980s, thanks to ongoing improvements in immuno-suppression,in critical care management,in surgical technique,and in preservation solu-tions.The late 1980s and 1990s saw a dramatic increase in the number of liver transplants. However,there was an even greater increase in the number of patients waiting for a transplant, which in turn increased waiting times, as well as mortality rates while waiting.

Intestinal transplantation has evolved from an experimental procedure with limited success to standard of care for patients with intestinal and parenteral nutrition failure, achieving outcomes commensurate with other solid-organ transplants. Paramount to achieving the success of intestinal and multivisceral organ transplant procedures has been the refinement of donor organ procurement and transplantation techniques. Early graft failures and deaths due to technical and donor-related complications have been minimized using the techniques described here, leaving the current challenge largely of optimizing immunologic and infection management strategies. Techniques depicted here are those of choice in our experience, while mention is made of alternative techniques that may be preferred by others. Because patients requiring intestinal transplantation often present with multiple organ failures and require multiorgan transplantation, modification of these techniques may be required on an individual basis. Addition of renal allotransplantation, inclusion of the colon in a small-bowel or multivisceral graft, and modified multivisceral transplantation with preservation of the native liver are some of the common modifications. Intimate description of all possible techniques is beyond the scope of the chapter.

The three most common types of allografts involving the small intestine are isolated intestinal transplantation, combined liver—small bowel transplantation, and multivis-ceral transplantation. These are described in turn, detailing our commonly preferred methods for both donor and recipient surgical techniques.