Ex Vivo Surgery

Ex vivo surgery involves the removal of as many as six abdominal organs from the body so that any cancerous tumors can be excised. The organs are then either reimplanted into the body or replaced by healthy donor organs.

Key Facts

  • Ex vivo surgery is performed when tumors cannot be removed using more conventional techniques. Usually this is because the tumors have grown around blood vessels.
  • This technique allows doctors to completely remove cancerous tissue and cells from any affected organs.
  • The conditions that require ex vivo surgery are extremely rare. But for those who need it, this technique can be life-saving.


Ex vivo surgery is performed on patients with abdominal tumors that cannot be removed in any other way. This may be because the tumors have grown around vital blood vessels or are hiding behind other organs, which means that removing them with more conventional techniques could cause irreparable damage to the surrounding tissue.


Ex vivo surgery is a rare and complex operation that’s personalized for each patient depending on the size and number of their tumors, where these tumors are located, and how many organs are affected. The following gives a generalized outline for what this procedure may look like.


After a patient is diagnosed and their tumors are determined to be inoperable with conventional techniques, they are evaluated for ex vivo surgery. This involves first assessing whether ex vivo surgery will be able to successfully remove the tumors. The patient’s mental and physical health is then evaluated to confirm they are able to undergo surgery and any potential postoperative complications.

Similar to the evaluation process used for liver transplantations, doctors will review any existing medical issues, as well as take a number of different tests. These may include:

  • Blood Tests: These test how well the liver is functioning, screen for viruses like hepatitis and HIV, check to see if the cancer has spread to the bloodstream, and more.
  • Cardiac Evaluation: This is to ensure the heart is strong enough for a transplantation operation. It may include an echocardiogram (EKG), stress test, and cardiac angiogram.
  • Motility Evaluation: This tests how well food moves through the digestive tract.
  • Pulmonary Evaluation: This may be necessary for smokers or patients with a lung disorder. It will include tests to determine the blood’s ability to carry oxygen.
  • Psychiatric Evaluation: This assesses underlying mental health issues, such as depression, and helps the patient and their family prepare for the operation.
  • Radiologic Tests: These will help determine the patient’s overall health. They may include chest x-rays, CT scans, MRIs, and more.

Wait List

If the cancer can be removed from some organs with ex vivo surgery but not others, a patient may also require an organ transplantation. This means they will be placed on a national waiting list.

This is not a static list. Instead, it is a database that contains medical information (e.g., blood type, body size, and medical urgency) for anyone in need of a new organ in the United States and Puerto Rico. Whenever a new donor organ becomes available, its characteristics (e.g., size and blood type) are matched against the medical information of each candidate in the database. This generates a unique, one-time list.

Wait times will be affected by a variety of factors, such as the patient’s location, health, and the organ they need. For instance, patients who need intestinal transplants can expect a relatively short waiting period since this type of transplant is uncommon. However, those who need livers are prioritized based on their MELD (Model of End-Stage Liver Disease) score.

Learn more on the Liver Transplant Waiting List page.


Regardless of how it is personalized, ex vivo surgery involves removing organs with cancerous growths, excising the tumors and any other cancerous tissue from them, then either implanting the original organs back into the body or replacing them with healthy donor organs. Successfully doing this will require the surgeon to sever then reestablish all of the organs’ veins, arteries, and other vital connections. The entire process can take 12 to 24 hours or more to complete.

The following is the general step-by-step process of an ex vivo operation:

  1. Preparation: The patient undergoes a final physical exam so staff can start preparing them for surgery.
  2. Anesthesia: Just before surgery, an anesthesiologist will give the patient general anesthesia. This will put them into a deep sleep for the entirety of the operation.
  3. Incision: The surgeon will begin by making a long incision across the abdomen to gain access to the organs. The size of this incision will depend on the patient.
  4. Removal: All existing connections are severed from the diseased organs. The surgeon removes them from the patient.
  5. Excision: The tumors and cancerous tissue are removed from the organs.
  6. Implantation: The original organs and any donor organs are implanted inside the patient. This involves attaching them to their body’s veins, arteries, and any other vital connections.
  7. Closure: When all bleeding is controlled, the surgeon sews the incision closed.

The following are some of the types of doctors that may be involved in an ex vivo operation:

  • Anesthesiologist: A specialist in administering sedatives and anesthetics.
  • Gastroenterologist: A specialist in diseases of the digestive system.
  • Gastrointestinal Oncologist: A specialist in cancer within organs involved in digestion.
  • Hepatologist: A specialist in the liver, pancreas, and gallbladder.
  • Radiologist: A specialist in imaging organs.
  • Transplant Surgeon: A specialist in removing and implanting organs.


Ex vivo surgery is usually considered only as a last resort, which means very few alternatives to it exist. While conventional treatments such as chemotherapy or immunotherapy may be able to slow the cancer’s growth, ex vivo surgery is the only viable treatment that can remove the cancer completely.

Risks and Complications

Ex vivo surgery is an extremely complex procedure, which means it comes with significant risks. The most common include postoperative hemorrhage, vascular leaks or obstruction, and biliary leaks or obstruction.

The following are some other risks associated with ex vivo surgery:

  • Bile leaks
  • Depression or anxiety
  • Donated organ failure or rejection
  • Increased risk of skin and certain other cancers
  • Infection
  • Internal bleeding
  • Intestinal leaks
  • Vascular complications

What to Expect Afterwards

Ex vivo surgery can be a life-saving procedure. However, patients may experience a range of outcomes and recovery times depending on the organs transplanted, the severity of their conditions, and their overall health. Patients who receive donor organs will also likely have to take some form of medication for the rest of their lives.


Patients may remain hospitalized for one month or more, depending on the extent of their surgery. During this time, their surgical team will evaluate them for any signs of possible complications and assist with the recovery process, such as by providing proper nutrition and exercise routines. Afterwards, they can return home to recuperate. This process can take several months to over a year.

Next Steps

Our center is a world leader in ex vivo surgery. Columbia surgeons like Dr. Tomoaki Kato have helped pioneer this surgery by performing hundreds of ex vivo operations, including several six-organ procedures. Our doctors continue to improve ex vivo techniques and expand its scope to encompass a variety of conditions. Our goal is to make this surgery as accessible to as many people as possible.

Call us at (877) LIVER MD/ (877) 548-3763 or use our online form to schedule an appointment.


Ex Vivo Surgery Success
Dr. Tomoaki Kato performed surgery to remove a large cancerous tumor impacting patient Heather McNamara's major organs.