Introduction: Multivisceral transplantation in adults is characterized by limited indications, primarily observed within the context of multi-operated patients afflicted with conditions such as short bowel syndrome and complete thrombosis of the splenomesenteric axis. This type of donation remains exceedingly rare in adult transplantation in Spain. A mere 11 transplants have been carried out by a single center. In this video, we will explain the extraction technique.
Material and methods: Case report video explaining our extraction technique
Discussion: The extraction technique begins with a house-shaped incision in cases where full-thickness abdominal wall transplantation is being considered.
Cattell-Braasch maneuver is performed for an adequate exposure of the major abdominal vascular axes up to the level of the left renal vein, which is a very useful marker since the superior mesenteric artery (SMA) is usually found cranially to it in an almost constant manner. This is dissected and vascular control is performed. The inferior mesenteric vein (IMV) is dissected and released. Then, a segment of 3-5 cm of the aorta is released below the renal arteries and above the femoral bifurcation, leaving ligatures in place for subsequent cannulation. The inferior vena cava is left passed beneath the renal veins, above the femoral bifurcation, with two ligatures for subsequent cannulation.
Liberation of the lesser sac is performed to proceed with the disection of the short vessels and spleen. Identification and ligation of the left middle colic artery and vein. Colonic section is performed at the level of the left transverse colon. We preserve the right colon as it provides better recipient tolerance, allowing for lesser fluid loss and contributing to less morbidity.
Dissection of the inferior pancreatic margin. Splenic mobilization and release of the pancreatic tail-body. Bile duct lavage, which can be performed through the gallbladder or after cholecystectomy. 
Then, hepatic triangular ligaments release and section of the distal esophagus as close to the diaphragm as possible.
The aortic artery, inferior mesenteric vein and vena cava are then cannulated and perfusion with preservation solution is started. Once the bowel is well perfused, the mesenteric superior artery (MSA) is clamped to avoid bowel and pancreatic edema.
Once the organs have been washed,  vena cava and aortic artery aredivided above the renal vein exit, taking care to leave a patch that includes the MSA and the celiac trunk for direct anastomosis or to create a cuff that includes both vascular ostium. Aortic artery sectioned at thoracic level for later ligation of the retroaortic lumbar on the back table.
Section of the suprahepatic cava at thoracic level, release of cava, aorta and liver from the diaphragmatic pillars and graft extraction.
Conclusion: We present a new technique that may minimize biliary ischemia-reperfusion injury.