Simultaneous Liver-Kidney Transplant Operative Note

Patient: [Patient name and identifiers]

Date of Operation: [Date]

Start Time / End Time: [Start time] / [End time]

Location: [Operating room/site]

Primary Surgeon: [Name, credentials]

Co-Surgeon(s): [Name(s), credentials] (Omit if none)

Assistants: [Name(s), credentials/role] (Omit if none)

Anesthesia Team: [Name(s), credentials]

Anesthesia Type: [General / regional / combined]

Pre-operative Diagnosis: [Diagnoses leading to SLK]

Post-operative Diagnosis: [Diagnoses after procedure] (Usually same as pre-operative unless new findings)

Procedures Performed:

• [Orthotopic liver transplant with technique]
• [Deceased donor kidney transplant with implantation site]
• [Additional procedures if applicable] (e.g., portal vein thrombectomy, venovenous bypass, native nephrectomy; list each on its own line with laterality/site)

Indications

[Indication summary in 3–6 sentences: indication for simultaneous liver-kidney transplant including end-stage liver disease and qualifying renal dysfunction; key recipient factors affecting surgical approach such as prior operations, portal vein thrombosis, or anatomic variants; confirmation of informed consent; planned sequence if nonstandard]

Intraoperative Findings

• [Abdominal domain and adhesions affecting exposure]
• [Portal vein status including thrombosis if present]
• [Hepatic venous/caval anatomy influencing outflow strategy]
• [Arterial inflow quality and variants]
• [Iliac vessel quality, calcification, bladder condition]
• [Other findings that changed management]

(Include only findings that affected intraoperative decisions; do not re-document pre-op diagnoses unless observation altered management)

Donor Graft Summary

Donor Type: [DBD / DCD / living]

Donor Identifiers: [Per transplant policy; note if liver and kidney from same donor]

Graft Anatomy: [Notable variants and back-table reconstructions]

Preservation: [Cold storage solution; kidney pump parameters if pumped; liver machine perfusion modality and duration if used]

Extra Vessels/Conduits: [Source and identifiers] (Omit if none)

(If separate back-table note exists, reference it and include only critical items here)

Critical Timepoints and Ischemia Metrics

(Record timestamps with timezone. For any time not recorded, document "Unknown/not recorded" and note expected source. Do not back-calculate durations without documented timestamps. Definitions must match institutional policy.)

Case Timepoints:

• Incision time: [Timestamp]
• Anhepatic phase start: [Timestamp]
• Liver reperfusion (portal): [Timestamp]
• Liver reperfusion (arterial): [Timestamp] (If documented separately)
• Kidney out-of-ice: [Timestamp]
• Kidney reperfusion: [Timestamp]
• Procedure end time: [Timestamp]

Liver Ischemia:

• Donor cross-clamp: [Timestamp] (If available from OPO)
• Liver out-of-cold: [Timestamp]
• Cold ischemia time: [Duration]
• Recipient warm ischemia time: [Duration]
• Anhepatic time: [Duration]

Kidney Ischemia:

• Donor cross-clamp: [Timestamp] (If available from OPO)
• Kidney out-of-cold: [Timestamp]
• Total cold ischemia time: [Hours]
• Warm ischemia/anastomotic time: [Minutes]

Intraoperative Management

• Lines/monitoring: [Arterial line, central line, PA catheter, other]
• Estimated blood loss: [Volume in mL] (State "Unknown" if not recorded)
• Transfusions: [PRBC units, FFP units, platelets units, cryoprecipitate units, cell saver mL] (State "None" if none given)
• Urine output: [mL] (Include if clinically meaningful)
• Vasopressors/inotropes: [Agents and summary of requirements]
• Antibiotic prophylaxis: [Agent(s) and timing]
• Immunosuppression induction: [Agent(s), dose(s)] (If given in OR)
• Complications/unexpected events: [Event, intervention, status at case end] (State "None" if none)

(Do not replicate minute-to-minute hemodynamics from anesthesia record)

Operative Course

[Narrative summary: incision type(s) and exposure; sequence of transplantation (liver-first / kidney-first); venovenous bypass use with cannulation sites if applicable; additional procedures performed]

Liver Transplant

Hepatectomy: [Adhesiolysis extent; ascites volume; portal vein status and thrombectomy if performed; cava management (piggyback / bicaval)]

Venous Outflow Anastomosis: [Configuration (end-to-end / side-to-side / triangulated cavoplasty); conduit if used]

Portal Vein Anastomosis: [Configuration; size mismatch management; reperfusion time; immediate graft appearance]

Hepatic Artery Anastomosis: [Recipient inflow artery; anastomosis type; reconstruction details (Carrel patch / interposition conduit); flow assessment results]

Biliary Reconstruction: [Technique (duct-to-duct / Roux-en-Y hepaticojejunostomy); anastomosis configuration; stent or T-tube use; leak test result]

Hemostasis and Closure: [Hemostasis adjuncts; drains (type, location); closure status if staged]

(Use concise "standard technique" statements if no deviation; expand if complications occurred)

Kidney Transplant

Implantation Site: [Right / left iliac fossa; retroperitoneal / intraperitoneal / orthotopic; incision type; recipient vessel condition]

Venous Anastomosis: [Renal vein to recipient vein; configuration]

Arterial Anastomosis: [Renal artery(ies) to recipient artery; configuration; multiple artery reconstruction if applicable; perfusion assessment]

Reperfusion: [Time; immediate graft appearance (color, turgor); urine output in OR] (Document if anuric without implying prognosis)

Ureteral Reconstruction: [Technique (extravesical ureteroneocystostomy / ureteroureterostomy / other); stent type and size if placed; bladder findings]

Hemostasis and Closure: [Lymphatic control; drain placement; fascial and skin closure]

(If nonstandard technique such as en bloc SLK or orthotopic kidney, describe rationale and reconstruction)

Specimens, Implants, and Drains

Specimens: [Native liver; additional specimens (thrombus, biopsies, lymph nodes)] (Omit section if none)

Implants: [Device name, size, site, identifiers for each] (Omit if none)

Drains: [Type, location, exit site for each drain; temporary closure or packs if applicable]

Counts and Safety

[Counts correct / discrepancy with actions taken]. [Wound classification] (If used locally)

Disposition and Postoperative Plan

Status at Case End:

• Destination: [ICU / PACU]
• Airway: [Intubated / extubated]
• Hemodynamics: [Stable / vasopressor support with agents]
• Renal support: [None / CRRT / other]
• Drains and lines: [List]

Immediate Plan:

• Labs and monitoring: [Timing and targets]
• Imaging: [Doppler ultrasound timing per protocol]
• Anticoagulation: [Agent, dose, start time, parameters]
• Antibiotics: [Agent(s) and duration]
• Immunosuppression: [Plan or reference to protocol]
• Specific concerns: [Key risks, thresholds for escalation, instructions for receiving team]