Back-Table Allograft Preparation Procedure Note

Date/Time: [Start and end time or time completed]

Location: [Operating room and back table area]

Operator: [Surgeon performing preparation]

Assistants: [Assistants, if any]

Recipient: [Recipient name and MRN]

Donor ID: [OPTN/UNOS Donor ID only] (Do not include donor name or DOB)

Organ: [kidney (left/right) / liver (whole/split) / pancreas]

Donor Type: [living / deceased; DCD / DBD; preservation method if relevant]

Indication

[One to two sentences indicating bench/back-table preparation of the specified donor allograft for transplantation into the named recipient] (If part of a multi-organ transplant, state which organ(s) this note covers.)

Organ Check-In and Verification

[Organ check-in confirmation per institutional protocol upon arrival to the transplant hospital]

• [External label verification: donor ID, organ type, laterality, and package integrity]
• [Discrepancies identified and resolution, including who was notified and when] (If none, state "No discrepancies identified.")

[Pre-transplant verification prior to anastomosis: donor ID, organ and laterality, donor blood type, recipient identifiers and blood type, ABO compatibility confirmation, verification that correct organ is intended for correct recipient, and who performed verification by role] (If a dedicated bench time-out was performed, document it; otherwise, state verification occurred as part of the transplant case time-out.)

[Reference to separate documentation if applicable] (If verifications are captured in a separate institutional form or system, reference its location rather than duplicating content.)

Preservation and Setup

• [Preservation solution(s) used for storage and flush] (e.g., UW, HTK, Celsior)
• [Back-table flush details: solution, route, approximate volume, and effluent quality]
• [Temperature and handling conditions]
• [Machine perfusion reference if used] (Reference perfusion record; do not duplicate data.)
• [Extra donor vessels or conduits available] (e.g., iliac artery/vein segments, patches)

Initial Graft Inspection

• On receipt: [Gross appearance, color, capsular/serosal integrity, edema, hematoma, procurement-related injuries, anatomic variations, attached extra tissues]
• During bench preparation: [New findings during handling/dissection] (Include only if new findings identified; otherwise omit.)

Procedure Description

Universal preparation steps: [Removal of excess perigraft fat and tissue; identification and preparation of vascular inflow/outflow structures; ligation of small branches and lymphatics; preparation of relevant ductal structure]

Kidney Bench Preparation

(Include only if a kidney is being prepared.)

• [Laterality: left / right]
• [Arterial anatomy: number of arteries, aortic/Carrel patch configuration, accessory vessels]
• [Venous anatomy: renal vein length and quality, caval cuff or extensions, controlled tributary stumps]
• [Ureter: single / double, length, periureteral tissue preservation, observed perfusion]
• [Reconstructions performed: arterial patch modification, conjoined patch, venous extension; specify conduit source and technique] (If none, state "No reconstruction required.")
• [Flush assessment: cortical perfusion uniformity, venous efflux adequacy]

[Kidney allograft prepared as above and deemed ready for implantation.]

Liver Bench Preparation

(Include only if a liver is being prepared.)

• [Graft type: whole / split; gallbladder removed / left in situ]
• [Outflow anatomy: hepatic veins, IVC segment if present, accessory hepatic veins and management]
• [Inflow anatomy: portal vein length and quality, hepatic artery anatomy including variants, intimal quality]
• [Biliary anatomy: duct length, number of ducts, integrity, any observed injury]
• [Dissection sequence and branch control]
• [Reconstructions performed: hepatic vein venoplasty, portal vein conduit, arterial reconstruction; specify conduit source and technique] (If none, state "No reconstruction required.")
• [Flush results: portal flush, arterial flush, bile duct leak check if performed]

[Liver allograft prepared as above and deemed ready for implantation.]

Pancreas Bench Preparation

(Include only if a pancreas is being prepared.)

• [Donor duodenum segment: length, staple line integrity, any reinforcement or trimming]
• [Spleen management: removed / preserved segments]
• [Arterial anatomy: SMA and splenic artery integrity, intimal quality]
• [Portal vein: length, quality, thrombus assessment]
• [Y-graft arterial reconstruction: anastomoses to SMA and splenic artery, conduit source and technique] (If none, state "No Y-graft required.")
• [Portal vein extension if performed: conduit source and technique]
• [Mesenteric vessel and peripancreatic tissue management]
• [Flush assessment: parenchymal perfusion quality, duodenal appearance]

[Pancreas allograft prepared as above and deemed ready for implantation.]

Variations, Injuries, and Repairs

• [Anatomic variants with implications for implantation]
• [Procurement-related injuries noted on receipt]
• [Iatrogenic bench injuries and repairs performed]
• [Specific concerns for implanting surgeon]

(If none, state: "No significant anatomic variations. No injuries identified. No repairs required.")

Disposition

• [Post-preparation placement: sterile bag with preservation solution on ice / transferred to machine perfusion / handed directly to implantation field]
• [Time of handoff] (If available.)
• [Label verification confirmed if graft was repackaged]

[Graft ready for implantation.] (If graft deemed unsuitable, document reason and to whom escalation occurred.)

Specimens and Implants

• [Specimens sent: type, destination, and indication]
• [Vascular conduits used: source and configuration]
• [Manufactured implants: type and serial/lot numbers]

(If none, state "None.")

Complications and EBL

[Complications during bench preparation and management] (If none, state "No complications.")

EBL: [Estimated blood loss] (Typically minimal.)

Attestation

[Operator attestation that the preparation was performed as described, with electronic signature and date/time]

(Meta-instructions: If information for a required field is unavailable, document what is known and reference where additional documentation exists. Do not fabricate specific values. The OPTN verification and check-in must always be addressed, either with content or by referencing the location of official documentation. Include only organ-specific sections relevant to the graft(s) prepared.)