Pure laparoscopic donor right hepatectomy: perspectives in manipulating a flexible scope

Criteria for selecting living liver donors to optimize recipient outcomes in pure laparoscopic donor right hepatectomy: a cohort study

BACKGROUND

Although the adoption of pure laparoscopic donor hepatectomy has expanded driven by considerations of donor cosmesis and function, the criteria for selecting candidates for pure laparoscopic donor right hepatectomy (PLDRH) continue to be debated. This study aimed to delineate the distinctive characteristics of donors and recipients who underwent conventional open-donor right hepatectomy (CDRH) during the era of PLDRH.

MATERIALS AND METHODS

The authors conducted a retrospective review of a prospectively collected single-centre database encompassing all right hepatectomies at Seoul National University Hospital from April 2016 to December 2021, a period during which there were no absolute contraindications for PLDRH.

RESULTS

During the exclusive PLDRH period, there were still 63 cases of CDRH alongside 362 cases of PLDRH. The CDRH donors were older, had a lower estimated remnant liver volume, and a higher incidence of expected multiple openings in the portal vein and bile duct based on preoperative imaging compared with PLDRH donors. In the subgroup analysis, including only donors meeting two or more criteria (age ≥40 years, estimated remnant liver volume ≥35%, or multiple anticipated vessel openings), recipients in the PLDRH group exhibited significantly more early major complications ( P =0.029) compared with those in the CDRH group.

CONCLUSION

As PLDRH gains traction in practice, it is essential to acknowledge that specific donor conditions, such as advanced age, limited remnant liver volume, and anticipation of multiple portal or bile duct openings, may merit contemplating CDRH as a means of optimizing recipient outcomes.

Лапароскопическое изъятие левого латерального сектора печени у прижизненного донора.. [DOI: 10.61726/5567.2024.63.97.001]

В педиатрической практике трансплантация фрагментов печени позволяет достичь высоких результатов [Bowring M.G., 2020] и, при этом, полностью гарантировать безопасность родственных доноров. В то же время, при выполнении трансплантации «взрослый – ребенок», практически отсутствуют этические вопросы, поскольку, чаще всего, донором является один из родителей реципиента. Тем не менее, важной задачей остается создание условий для ускорения реабилитации и минимизации хирургической травмы у донора, в этой связи, внедрение миниинвазивных методов имеет особое значение. В последние два десятилетия миниинвазивные подходы к резекциям печени прочно вошли в арсенал крупных гепатобилиарных центров. Это стало возможным благодаря накопленному опыту открытой хирургии печени, а также технологическому прогрессу [Morise Z., 2017]. Однако, применение лапароскопического подхода у родственных доноров фрагментов печени по-прежнему остается предметом живого интереса в трансплантологических центрах всего мира. Первые сравнительные исследования оказались весьма обнадеживающими и продемонстрировали перспективность этого подхода [Broering D. C., 2018]. Накопление подобного опыта, анализ кривой обучения, стандартизация хирургической техники по-прежнему являются важными вопросами развития данного направления. В России лапароскопическое изъятие фрагмента печени для последующей трансплантации было впервые выполнено в ФГБУ «НМИЦ ТИО им. Академика В. И. Шумакова» в 2016 году. Также, в России впервые в мире произведено полностью лапароскопическое изъятие одновременно фрагмента печени и почки для последующей трансплантации детям [Готье С. В., 2016, Gautier S. V., 2019]. Цель исследования. Оптимизация хирургической техники и результатов лапароскопического изъятия левого латерального сектора у прижизненных доноров фрагмента печени на основании анализа накопленного опыта. Задачи исследования. 1. Сравнить результаты открытого и лапароскопического изъятия левого латерального сектора у прижизненных доноров. 2. Определить критерии селекции прижизненных доноров для лапароскопического изъятия левого латерального сектора печени. 3. Стандартизировать хирургическую технику выполнения лапароскопической латеральной секторэктомии печени. 4. Оценить результаты трансплантации левого латерального сектора, полученного открытым и лапароскопическим путём, у реципиентов. 5. Изучить кривую обучения выполнения лапароскопической латеральной секторэктомии печени у родственного донора. Научная новизна. На сегодняшний день, лапароскопическое изъятие левого латерального сектора печени у прижизненных доноров выполняется лишь в нескольких центрах в мире. Суммарный накопленный опыт по всему миру не превышает 500 операций. В настоящее время, по данным литературы, существует лишь несколько исследований, посвященных данной тематике. Проведение псевдорандомизации позволило объективизировать результаты и увеличить их достоверность. Изучение кривой обучения выполнения лапароскопической латеральной секторэктомии печени позволяет оценить потенциал внедрения данной методики в клинические центры. Новыми являются данные сравнительного анализа клинических результатов проведения открытого и лапароскопического изъятия левого латерального сектора печени у живых доноров, а также сравнительного анализа результатов трансплантаций у реципиентов, получивших соответствующие трансплантаты. Новыми являются разработанные рекомендации по селекции доноров для лапароскопического изъятия левого латерального сектора. Впервые разработаны алгоритмы, протоколы и рекомендации по выполнению хирургического вмешательства лапароскопической резекции левого латерального сектора печени у родственного донора. Практическая значимость исследования. Впервые в России на основании доказательной медицины установлена клиническая эффективность и безопасность лапароскопической левой латеральной секторэктомии у прижизненных доноров фрагмента печени. Разработана и стандартизирована хирургическая техника, позволяющая максимально снизить интра- и послеоперационные осложнения у доноров левого латерального сектора печени, а также получать трансплантаты высокого качества. Внедрение научных разработок в клиническую практику позволит: • обезопасить хиругическое пособие у доноров путем снижения интраоперационой кровопотери и минимизации хирургической травмы; • ускорить послеоперационную реабилитацию у доноров; • получить хороший косметический эффект после оперативного пособия. Методология и методы исследования. В исследовании проведен статистический анализ клинических данных, результатов оперативного вмешательства, лабораторных и инструментальных исследований до, во время и после резекции левого латерального сектора печени у родственных доноров и трансплантации левого латерального сектора детям. Проведен статистический анализ клинических данных, результатов трансплантаций левого латерального сектора печени у реципиентов, получивших трансплантат от доноров, оперированных открыто и лапароскопически. Основные положения, выносимые на защиту 1. Лапароскопическое изъятие левого латерального сектора является эффективным и безопасным методом, позволяющим уменьшить операционную травму и ускорить реабилитацию, а также получить хороший косметический эффект. 2. Результаты трансплантации левого латерального сектора печени детям от доноров, оперированных лапароскопически, сопоставимы с аналогичными от доноров, оперированных по классической открытой методике. 3. Унификация хирургической методики позволяет уменьшить длительность операции, а также позволяет добиться максимального снижения интра- и послеоперационных осложнений у доноров. 4. Более строгая селекция доноров для лапароскопического изъятия левого латерального сектора позволяет снизить риск интраоперационных осложнений на этапе становления методики и наработки хирургического опыта. Степень достоверности и апробация результатов Достоверность результатов определяется объемом проведенных исследований с использованием современных методов статистической обработки. Апробация работы состоялась 15 июля 2020 года на совместной конференции научных и клинических подразделений федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Министерства здравоохранения Российской Федерации (ФГБУ «НМИЦ ТИО им. ак. В.И. Шумакова» Минздрава России) и кафедры трансплантологии и искусственных органов Института клинической медицины имени Н.В. Склифосовского Федерального государственного автономного образовательного учреждения высшего образования Первый осковский государственный медицинский университет имени И.М. Сеченова Министерства здравоохранения Российской Федерации (Сеченовский Университет). Материалы диссертации доложены и обсуждены на III Российском национальном конгрессе «Трансплантация и донорство органов» (Москва 2017г.), на 15-м международном конгрессе по донорству органов (ISODP, Дубай, ОАЭ), на 10-м Всероссийском съезде трансплантологов (Москва, 2020 г.), и на международном съезде трансплантологического общества (The Transplantation Society, Сеул, Южная Корея, 2020г.). Внедрение результатов исследования в практику Результаты исследования используются в хирургическом отделении № 2 федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Министерства здравоохранения Российской Федерации, в отделении онкологии и детской хирургии федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр детской гематологии, онкологии и иммунологии имени Дмитрия Рогачёва» Министерства здравоохранения Российской Федерации, а также в образовательной программе кафедры трансплантологии и искусственных органов Института клинической медицины имени Н.В. Склифосовского Федерального государственного автономного образовательного учреждения высшего образования Первый осковский государственный медицинский университет имени И.М. Сеченова Министерства здравоохранения Российской Федерации (Сеченовский Университет). Личный вклад автора. Автор принимал непосредственное участие в разработке концепции и постановке задач исследования; в оперативных вмешательствах у родственных доноров печени и операциях по трансплантации печени; самостоятельно осуществлял сбор материала для исследования. Автором самостоятельно сформирована база данных, проведена статистическая обработка, анализ и интерпретация полученных результатов. Публикации по теме диссертации По теме диссертации опубликовано 15 научных работ, из них 3 статьи в центральных рецензируемых журналах, рекомендованных ВАК, а также 2 статьи в международных журналах.

Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital

Pure laparoscopic donor hepatectomy (PLDH) has become a routine procedure at Seoul National University Hospital, and the pure laparoscopic method is now being applied to liver recipients as well. This study aimed to review the procedure and outcomes of PLDH to identify any areas that required improvement. Data from 556 donors who underwent PLDH between November 2015 and December 2021 and their recipients were retrospectively reviewed. Among these, 541 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). The mean hospital stay of the donor was 7.2 days, and the rate of grade I, II, IIIa, and IIIb complications was 2.2%, 2.7%, 1.3%, and 0.9%, respectively, without any irreversible disabilities or mortalities. The most common early and late major complications in the recipient were intraabdominal bleeding (n = 47, 8.5%) and biliary problems (n = 198, 35.6%), respectively. Analysis of the PLDRH procedure showed that operative time, liver removal time, warm ischemic time, Δhemoglobin%, Δtotal bilirubin%, and postoperative hospital stay decreased significantly as the number of cases accumulated. In conclusion, the operative outcomes of PLDRH improved as the number of cases increased. However, continuous caution is needed because major complications still occur in donors and recipients even after hundreds of cases.

Scope actuation system for articulated laparoscopes

BACKGROUND

An articulated laparoscope comprises a rigid shaft with an articulated distal end to change the viewing direction. The articulation provides improved navigation of the operating field in confined spaces. Furthermore, incorporation of an actuation system tends to enhance the control of an articulated laparoscope.

METHODS

A preliminary prototype of a scope actuation system to maneuver an off-the-shelf articulated laparoscope (EndoCAMaleon by Karl Storz, Germany) was developed. A user study was conducted to evaluate this prototype for the surgical paradigm of video-assisted thoracic surgery. In the study, the subjects maneuvered an articulated scope under two modes of operation: (a) actuated mode where an operating surgeon maneuvers the scope using the developed prototype and (b) manual mode where a surgical assistant directly maneuvers the scope. The actuated mode was further assessed for multiple configurations based on the orientation of the articulated scope at the incision.

RESULTS

The data show the actuated mode scored better than the manual mode on all the measured performance parameters including (a) total duration to visualize a marked region, (a) duration for which scope focus shifts outside a predefined visualization region, and (c) number of times for which scope focus shifts outside a predefined visualization region. Among the different configurations tested using the actuated mode, no significant difference was observed.

CONCLUSIONS

The proposed articulated scope actuation system facilitates better navigation of an operative field as compared to a human assistant. Secondly, irrespective of the orientation in which an articulated scope's shaft is inserted through an incision, the proposed actuation system can navigate and visualize the operative field.

Прижизненное донорство фрагментов печени. Тактика ведения родственных доноров фрагмента печени в условиях стационара, а также амбулаторно после резекции печени. 2023. [DOI: 10.61726/7507.2024.31.90.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Учебно-методическое пособие для практикующих врачей, клинических ординаторов, магистров и студентов 5-6 курсов высших медицинских учебных заведений "Прижизненное донорство фрагментов печени. Тактика ведения родственных доноров фрагмента печени в условиях стационара, а также амбулаторно после резекции печени"

Outcomes of simultaneous laparoscopic, hybrid, and open resection in colorectal cancer with synchronous liver metastases: a propensity score-matched study

We aimed to compare the short- and long-term outcomes of simultaneous laparoscopic, hybrid, and open resection for colorectal cancer and synchronous liver metastases. We retrospectively analyzed the data of 647 patients with simultaneous resection of colorectal cancer and liver metastases between January 2006 and December 2018 at three tertiary referral hospitals. Patient’s baseline characteristics, perioperative outcomes, pathological examination results, liver-specific recurrence rate and survivals were compared between the propensity score-matched groups. Forty-two and 81 patients were selected for the laparoscopic vs. hybrid groups, and 48 and 136 patients for laparoscopic vs. open groups, respectively. The laparoscopic group had fewer wound complications (2.1 vs. 13.2%; p = 0.028) than the open group, and a shorter postoperative hospital stay than the hybrid and open groups (8 vs. 11 days, p < 0.001 for both). The 5-year liver-specific recurrence rates were 38.7% and 46.0% in the laparoscopic and hybrid groups, respectively (p = 0.270), and 34.0% and 37.0% in the laparoscopic and open groups, respectively (p = 0.391). Simultaneous laparoscopic resection for colorectal cancer and liver metastases can be performed safely with significantly enhanced postoperative recovery and comparable long-term outcomes compared to hybrid and open resection.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals

BACKGROUND

Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM.

METHODS

A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications.

RESULTS

An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm²; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05).

CONCLUSION

Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

Comparative outcomes of pure laparoscopic and open donor right hepatectomy: the first report from a Southeast Asian transplant center

Background

Pure laparoscopic donor right hepatectomy (PLDRH) can provide better operative outcomes for the donor than conventional open donor right hepatectomy (CODRH). However, the complexity of the procedure typically makes transplant teams reluctant to perform it, especially in low-volume transplant centers. We compared the outcomes of PLDRH and CODRH to demonstrate the feasibility of PLDRH in a low-volume transplant program.

Methods

We carried out a retrospective study of adult living donor liver transplantation in Chiang Mai University Hospital from January 2015 to March 2021. The patients were divided into a PLDRH group and a CODRH group. Baseline characteristics, operative parameters, and postoperative complications of donors and recipients were compared between the two groups.

Results

Thirty patients underwent donor hepatectomy between the dates selected (9 PLDRH patients and 21 CODRH patients). The baseline characteristics of the 2 groups were not significantly different. The median graft volume of the PLDRH group was 693.8 mL, which was not significantly different from that of the CODRH group (726.5 mL) The PLDRH group had a longer operative time than the CODRH group, but the difference was not statistically significant (487.5 min vs 425.0 min, p = 0.197). The overall complication rate was not significantly different between the two groups (33.3% vs 22.2%, p = 0.555). Additionally, for the recipients, the incidence of major complications was not significantly different between the groups (71.3 vs 55.6%, p = 0.792).

Conclusion

Even in the context of this low-volume transplant program, whose staff have a high level of experience in minimally invasive hepatobiliary surgery, PLDRH showed similar results to CODRH in terms of perioperative outcomes for donors and recipients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01507-0.

Pure laparoscopic versus open donor hepatectomy for adult living donor liver transplantation - A systematic review and meta-analysis

Background

Pure laparoscopic donor hepatectomy (PLDH) for adult living donor liver transplantation (LDLT) remains controversial. The aim of this study was to undertake a systematic review and meta-analysis of donor outcomes following PLDH for adult LDLT.

Materials and Methods

Systematic review in line with the meta-analysis of observational studies in epidemiology guidelines.

Results

Eight studies were included in the systematic review and six in the meta-analysis. A total of 575 donors underwent PLDH for adult LDLT. The mean donor age was 32.8 years with a BMI of 23.4 kg/m² and graft weight of 675 g. The mean operative time was 353 min and the conversion rate was 2.8% (n = 16). Overall morbidity was 10.8% with 1.6% major complications (Clavien-Dindo grade 3b), zero mortality and 9.0 days length of stay (LOS). The meta-analysis demonstrated that the operative time was significantly shorter for the open donor hepatectomy group (mean difference 29.15 min; P = 0.006) and the LOS was shorter for the PLDH group (mean difference -0.73 days; P = 0.02), with a trend towards lesser estimated blood loss in PLDH group. However, no difference between the two groups was noted in terms of overall morbidity or major complications.

Conclusions

Perioperative outcomes of PLDH are similar to the standard open approach in highly specialised centers with trend towards lesser blood loss and overall shorter hospital stay. Careful donor selection and standardisation of the technique are imperative for the successful implementation and adoption of the procedure worldwide.

Initial experience with a robotic hepatectomy program at a high-volume laparoscopic center: single-center experience and surgical tips

Background

Despite the development of laparoscopic surgery, there are still inherent limitations associated with conventional laparoscopic instruments such as restrictions in movement and an inability for articulation. Robotic surgery may help to overcome the limitations of conventional laparoscopic surgery. The aim of this study was to present our initial experience with robotic hepatectomy (RH) and discuss the steps required to develop an RH program at a high-volume laparoscopic hepatectomy (LH) center.

Methods

We retrospectively reviewed prospectively collected data for 14 consecutive patients who underwent RH between 2017 and 2018. Clinicopathological characteristics and perioperative outcomes were compared with those reported in previous studies. The operation time of each procedure was analyzed to assess RH proficiency based on experience.

Results

Of the 14 patients, 12 patients (85.7%) underwent robotic major hepatectomy. Median patient age was 54.5 years, while median body mass index (BMI) was 25.2 kg/m². The median operation time was 360 (range: 145–544) min. The median estimated blood loss (EBL) was 300 (range: 50–1,400) mL. Conversion to open surgery was not required in any case. The median length of hospital stay was 5 (range: 4–14) days. Major complications occurred in 2 patients (14.2%), although both recovered without sequelae. The time required for hilar dissection, docking, and parenchymal transection gradually decreased after the first two cases of RH.

Conclusions

From our initial experience, RH might be considered as a feasible procedure in the liver resection, even in major hepatectomy. In addition, surgeons with sufficient experience in LH could rapidly adapt for RH. However, we have to make a system for education and monitoring of this innovative surgery for the patients’ safety.

Influence of Large Grafts Weighing ≥ 1000 g on Outcome of Pure Laparoscopic Donor Right Hepatectomy

BACKGROUND

Depending on a transplant center's level of experience, utilization of pure laparoscopic donor right hepatectomy (PLDRH) may be limited due to graft size or anatomical variations. Here, we aimed to evaluate the influence of large hepatic grafts (≥ 1000 g) when performing PLDRH in both donors and recipients of such grafts.

METHODS

Medical records of living donors who underwent either PLDRH from November 2015 to August 2019 or open conventional donor right hepatectomy (CDRH) from January 2010 to August 2019 and those of the graft recipients were retrospectively reviewed. Donors were separated into three groups: PLDRH graft ≥ 1000 g (n = 10; study group), PLDRH graft < 1000 g (n = 280; control-I group), and CDRH graft ≥ 1000 g (n = 24; control-II group).

RESULTS

Total operative duration (P = 0.017) and warm ischemia time (P < 0.001) were significantly longer in the study than in the control-I and control-II groups, respectively. ΔAlanine aminotransferase% was significantly lower in the study than in the control-I group (P = 0.001). There was no significant difference in minor complication incidence between the study and control-I (P = 0.068) and control-II (P = 0.618) donors. There were no major complications in the study and control-II donors, whereas six control-I donors (2.1%) experienced a major complication (P = 1.000). Length of hospitalization was significantly shorter in the study than in the control-II group (P < 0.001). There was no significant difference in early and late major complication incidence for recipients between the study and control-I and control-II groups.

CONCLUSIONS

PLDRH for grafts weighing ≥ 1000 g appears to be safe and feasible when performed by experienced surgeons in a well-equipped center.

Shorter operation time and improved surgical outcomes in laparoscopic donor right hepatectomy compared with open donor right hepatectomy

BACKGROUND

Pure laparoscopic donor right hepatectomy is a complex procedure, and the safety and feasibility of this operation remain unclear. This study aimed to evaluate the clinical outcomes and learning curve of this operation performed by a single surgeon.

METHODS

We retrospectively reviewed the initial 100 donors who underwent pure laparoscopic donor right hepatectomy or open donor right hepatectomy by a single surgeon from December 2012 to May 2019. Endpoints analyzed included intraoperative results, postoperative complications, and learning curve, which was evaluated using the cumulative sum method based on the operation time. We divided the pure laparoscopic donor right hepatectomy group into initial and recent groups based on the time point of overcoming the learning curve.

RESULTS

The operative time was significantly shorter in the recent pure laparoscopic donor right hepatectomy group (n = 57; 181.0 ± 35.7 min) than in the open donor right hepatectomy (n = 50; 203.0 ± 37.3 min) and initial pure laparoscopic donor right hepatectomy (n = 43; 282.2 ± 59.2 min) groups (P < .001). Moreover, the length of hospital stay in the recent pure laparoscopic donor right hepatectomy group was significantly reduced compared to that in the open donor right hepatectomy group (7.7 ± 1.2 vs 5.8 ± 1.4; P < .001). The complication rate was reduced from 10% in the open donor right hepatectomy group and 8% in the initial pure laparoscopic donor right hepatectomy group to 2% in the recent pure laparoscopic donor right hepatectomy group.

CONCLUSION

As technology advances, the surgical outcomes of pure laparoscopic donor right hepatectomy are comparable and the operation time of pure laparoscopic donor right hepatectomy is superior to those of open donor hepatectomy.

Advances in the surgical outcomes of 300 cases of pure laparoscopic living donor right hemihepatectomy divided into three periods of 100 cases: a single-centre case series

Background

Minimally invasive surgery has been widely used for hepatobiliary operations. This study aimed to determine the safety and feasibility of pure laparoscopic living donor right hepatectomy.

Methods

From November 2015 to April 2019, 300 cases of adult pure laparoscopic living donor right hepatectomy performed at Seoul National University Hospital were divided into three subgroups of periods 1-3 of 100 cases each: 1-100, 101-200, and 201-300, respectively. We retrospectively reviewed and analysed the safety and feasibility outcomes.

Results

The operative time (period 1: 318.9±62.2 min, period 2: 256.7±71.4 min, period 3: 227.7±57.4 min) and blood loss (period 1: 419.7±196.5 mL, period 2: 198.9±197.2 mL, period 3: 166.0±130.0 mL) gradually decreased (P<0.01). Similarly, the length of hospital stay decreased (period 1: 8.1±2.0 days, period 2: 7.3±3.1 days, period 3: 6.9±2.4 days, P<0.01). There was no requirement for intraoperative transfusions or care in the intensive care unit. The overall complication rate was 20/300 (6.7%), of which 8/300 (2.7%) were Clavien-Dindo grade III and above. Complications were not different among the three periods. In terms of anatomical variations, the incidences of multiple portal veins, multiple hepatic arteries, and multiple bile ducts were 32/300 (10.7%), 11/300 (3.7%), and 161/300 (53.7%), respectively. No differences were found among the three periods.

Conclusions

Owing to the technical improvements over time, pure laparoscopic living donor hepatectomy is currently feasible and safe even for donors with anatomical variations.

Techniques for laparoscopic liver parenchymal transection

Laparoscopic liver surgery has gained wide acceptance resulting in a paradigm shift of liver surgery. Technical innovations and accumulation of surgeon's experience have allowed laparoscopic liver resection (LLR) to become an effective procedure with favorable peri- and post-operative outcomes. Through the overall process of LLR, liver parenchymal transection remains the most critical step with the aim of minimizing blood loss and secures the appropriate cutting line, i.e., securing major vessels and obtaining adequate surgical margin clearance for malignancies. Multiple preoperative imaging modalities and intraoperative ultrasonography findings may contribute to the best determination of the appropriate cutting line during the LLR; however, technical expertise in minimizing and controlling bleeding during liver parenchymal transection is still a challenge for safe LLR, and therefore represents a major concern for hepatobiliary surgeons. Along with the historical fact that the technique of liver parenchymal transection itself is chosen according to surgeon's preference and "savoir-faire", the best technical modality in laparoscopic liver parenchymal transection remains to be determined. However, better understanding the technical issue may serve a contribution to the standardization of LLR. This review article therefore focuses on the technical aspects of the laparoscopic liver parenchymal transection.