Laparoscopic right hepatectomy for living donor

American perspectives for LDLT in 2024

Living donor liver transplantation (LDLT) was first performed in the US in 1989, primarily benefiting pediatric patients. Its adoption for adults faced setbacks after a donor death in 2001, causing widespread risk aversion. Despite ethical justification and demonstrated safety, LDLT remains underutilized, with fewer than 10% of liver transplants being LDLT. Recent trends indicate improved access to deceased donor liver transplantation (DDLT) due to increased organ donation and technological advances like Normothermic Regional Perfusion (NRP). However, LDLT remains critical, especially for pediatric patients and specific adult populations who benefit significantly from it. Barriers to LDLT include public and clinician apprehensions about donor risks, despite studies showing low-complication rates. Non-directed donations and broader social media engagement have increased donor pools, though the volume of LDLT in the US remains lower than in Asia due to limited training and experience. The A2ALL consortium has been pivotal in studying LDLT safety and outcomes. Currently, around 40 US centers perform LDLT, with high-volume centers leading by example. Training paradigms for LDLT are evolving, with initiatives like the ASTS LDLT master class aiming to enhance surgical expertise. While LDLT is embedded in US liver-transplant practices, its expansion is hampered by risk aversion and the availability of DDLT. Nonetheless, LDLT is essential for addressing the supply-demand mismatch in liver transplantation.

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.

Application of the IDEAL framework in hepatopancreatobiliary surgery: a review of the literature

PURPOSE

To evaluate every stage of surgical innovation and generate high-quality research evidence, the IDEAL (Idea, Development, Exploration, Assessment, Long-term study) framework was developed. This study aimed to explore the application of the IDEAL framework in hepatopancreatobiliary surgery and identify factors limiting its dissemination.

METHODS

We conducted a citation search of 8 core IDEAL framework articles in PubMed, Embase, Web of Science, and Scopus databases from 2009 to 2022. Two independent reviewers screened and selected articles related to hepatopancreatobiliary surgery.

RESULTS

A total of 1621 articles were identified through citation search. Following screening, 132 articles were finally retained, including 75 original studies (57%) and 57 secondary studies (43%). Of the original studies, only 10 articles (13%) accurately applied the IDEAL framework in methodology, distributed as follows: 1 in pre-IDEAL stage (0), 2 in Idea stage (1), 7 in Development stage (2a), 1 in Exploration stage (2b), and no articles in Assessment and Long-term study stages (3, 4). In the secondary studies, 36 articles (63%) mentioned and discussed the IDEAL framework, and all supported its application.

CONCLUSIONS

The application of the IDEAL framework in hepatopancreatobiliary surgery is increasingly widespread, as evidenced by its substantial citation in numerous articles. However, the utilization of the IDEAL framework remains predominantly confined to the early stages of innovation in hepatopancreatobiliary surgery, coupled with instances of misapplication stemming from insufficient comprehension of the framework. Further efforts are necessary to extend the impact of the IDEAL framework and provide surgeons with comprehensive guidance for its judicious implementation.

Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center

Laparoscopic donor right hepatectomy (LDRH) is a technically challenging procedure. There is increasing evidence demonstrating the safety of LDRH in high-volume expert centers. We report our center's experience in implementing an LDRH program in a small- to medium-sized transplantation program.

Methods

Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4).

Results

The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality.

Conclusions

Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Indications for open hepatectomy in the era of laparoscopic liver resection: a high volume single institutional study

Background/Aim

Since the introduction of laparoscopy for liver resection in the 1990s, the performance of laparoscopic liver resection (LLR) has been steadily increasing. However, there is currently no data on the extent to which laparoscopy is used for liver resection. Herein, we investigated the extent to which laparoscopy is performed in liver resection and sought to determine whether surgeons prefer laparoscopy or laparotomy in the posterosuperior (PS) segment.

Methods

For this retrospective observational study, we enrolled patients who had undergone liver resection at the Samsung Medical Center between January 2020 and December 2021. The proportion of LLR in liver resection was calculated, and the incidence and causes of open conversion were investigated.

Results

A total of 1,095 patients were included in this study. LLR accounted for 79% of the total liver resections. The percentage of previous hepatectomy (16.2% vs. 5.9%, P<0.001) and maximum tumor size (median 4.8 vs. 2.8, P<0.001) were higher in the open liver resection (OLR) group. Subgroup analysis revealed that tumor size (median 6.3 vs. 2.9, P<0.001) and surgical extent (P<0.001) in the OLR group were larger than those in the LLR group. The most common cause of open conversion (OC) was adhesion (57%), and all OC patients had tumors in the PS.

Conclusions

We investigated the recent preference of practical surgeons in liver resection, and found that surgeons preferred OLR to LLR when treating a large tumor located in the PS.

Complete transition from open surgery to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomies

This study was designed to review laparoscopic living donor liver transplantations (LDLTs) at a single center that achieved complete transition from open surgery to laparoscopy. LDLTs performed from January 2013 to July 2021 were reviewed. Comparisons between open and laparoscopic surgeries were performed according to periods divided into initial, transition, and complete transition periods. A total of 775 LDLTs, 506 laparoscopic and 269 open cases, were performed. Complete transition was achieved in 2020. Bile duct variations were significantly abundant in the open group both in the initial period (30.2% vs. 8.1%; p < 0.001) and transition period (48.1% vs. 24.3%; p < 0.001). Portal vein variation was more abundant in the open group only in the initial period (13.0% vs. 4.1%; p = 0.03). Although the donor reoperation rate (0.0% vs. 4.1%; p = 0.02) and Grade III or higher complication rate (5.6% vs. 13.5%; p = 0.03) were significantly higher in the laparoscopy group in the initial period, there were no differences during the transition period as well as in overall cases. Median number of opioids required by the donor (three times [interquartile range, IQR, 1-6] vs. 1 time [IQR, 0-3]; p < 0.001) was lower, and the median hospital stay (10 days [IQR, 8-12] vs. 8 days [IQR, 7-9]; p < 0.001) was shorter in the laparoscopy group. Overall recipient bile leakage rate (23.8% vs. 12.8%; p < 0.001) and overall Grade III or higher complication rate (44.6% vs. 37.2%; p = 0.009) were significantly lower in the laparoscopy group. Complete transition to laparoscopic living donor hepatectomy was possible after accumulating a significant amount of experience. Because donor morbidity can be higher in the initial period, donor selection for favorable anatomy is required for both the donor and recipient.

Laparoscopic donor and recipient hepatectomy followed by robot-assisted liver graft implantation in living donor liver transplantation

Minimally invasive surgery has been introduced for liver transplantations. Although laparoscopic or robot-assisted living donor hepatectomy is being used, minimally invasive surgery is rarely performed in recipients during liver transplantation. A 63-year-old patient (body mass index: 21.9 kg/m² ) with primary biliary cirrhosis underwent total laparoscopic explant hepatectomy, followed by robot-assisted liver engraftment using advanced technological innovations. The total operation time for the recipient was 12 h 20 min, including laparoscopic explant hepatectomy (140 min) and robot-assisted engraftment (220 min). Achieving hepatic and portal vein anastomoses consumed 35 and 28 min, respectively. The hepatic artery anastomosis and bile duct reconstruction took 83 and 66 min, respectively. The estimated blood loss was 3600 ml. The warm and cold ischemic times were 87 and 220 min, respectively. The patient received 10 units each of red blood cells and fresh frozen plasma during the surgery and recovered from early allograft dysfunction after liver transplantation. This case study suggests that laparoscopic explant hepatectomy followed by robot-assisted engraftment is feasible in selected recipients only. We obtained informed consent for this innovative procedure from the patient and from her living donor.

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.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

A Novel Technique for Bile Duct Division During Laparoscopic Living Donor Hepatectomy to Overcome Biliary Complications in Liver Transplantation Recipients: "Cut and Clip" Rather Than "Clip and Cut"

BACKGROUND

This study was designed to analyze the clinical impact of a new bile duct division technique during laparoscopic living donor hepatectomy.

METHODS

Laparoscopic donor right hepatectomies performed by a single surgeon between December 2016 and August 2019 were included. Magnetic resonance cholangiopancreatography of the donors was reconstructed, and the length of the common channel of the dividing intrahepatic duct was measured. Patients were divided into 2 groups based on the bile duct division techniques of "clip and cut" versus "cut and clip." Outcome of bile duct division was categorized based on the graft and bile duct type and number of bile duct openings.

RESULTS

A total of 147 transplantations were included. Outcomes in the "cut and clip" group were better than those in the "clip and cut" group with regard to obtaining an adequate division point (94.2% versus 78.8%; P = 0.019). The "cut and clip" showed superior biliary stricture-free survival than the "clip and cut" group (hazard ratio [HR], 0.456; confidence interval [CI], 0.217-0.957; P = 0.038) whereas recipients with hepaticojejunostomy (HR, 3.358; CI, 1.090-10.350; P = 0.035) and bile duct type other than type I (HR, 2.214; CI, 1.143-4.289; P = 0.018) showed increased risk for biliary stricture-free survival. Better outcome in terms of obtaining a single opening was also obtained in the "cut and clip" group (68.2% versus 84.6%; P = 0.040), and this difference was significant especially with a common channel shorter than 10 mm (45.5% versus 81.2%; P = 0.043).

CONCLUSIONS

The "cut and clip" technique showed superior outcomes to the "clip and cut" technique in terms of fewer bile duct openings and biliary stricture-free survival of the recipients.

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose

To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery.

Methods

Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included. Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed.

Results

Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30.

Conclusion

This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA)

OBJECTIVE

The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

BACKGROUND

Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

METHODS

A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

RESULTS

Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

CONCLUSIONS

The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Image guidance using two-dimensional illustrations and three-dimensional modeling of donor anatomy during living donor hepatectomy

BACKGROUND

For living donor liver transplantation, preoperative imaging is required for the safety of both the donor and the recipient. We previously initiated our image-guidance program using two-dimensional illustrations and three-dimensional modeling in September 2018; herein, we analyzed the resultant changes in the clinical outcomes.

METHODS

Living donors and recipients who underwent liver transplantation between September 2017 and August 2019 were included. Cases with image guidance were compared to those without image guidance regarding the operative outcome, especially bile-duct opening in the graft as well as surgical complications.

RESULTS

Among 200 living donor transplantation, 90 transplantations were completed with image guidance. The image-guidance group had a higher rate of laparoscopy (80.9% vs. 97.8%; p < .001) as compared with the group without image guidance. Although there was no difference in the type of bile duct (p = .144), more grafts with single bile-duct openings were found in the image-guidance group (52.7% vs. 80.0%; p = .001). Consequently, achievements in bile-duct openings were superior in the image-guidance group (p = .022). There were no differences in bile leakage, graft failure, or number of deaths during the first month post-transplantation.

CONCLUSION

As we initiated our image-guidance program for living donor liver transplantation, clinical outcomes, especially bile-duct division, were improved relative to before implementation.

Current status of liver transplantation in Asia

In spite of early adoption of the brain death legislation, and all efforts at promoting deceased donation, various social, economic and cultural factors have acted as road blocks to the furthering of deceased donor liver transplantation (DDLT) in most Asian societies. On the other hand, Asian liver transplant centers have been the pioneers, innovators, and technical advancement catalysts for the world to follow, especially with regards to living donor liver transplantation (LDLT). With some high volume centers performing more than 200 LDLTs a year with good outcomes in the donor and recipient, techniques to expand the living donor pool have also been adopted like ABO-incompatible, paired exchange and dual lobe living donor liver transplants. Although large multicenter, and registry data as regards safety and outcomes of minimally invasive donor hepatectomy are awaited, expert centers have pioneered, and now regularly perform purely laparoscopic and robotic living donor hepatectomies, especially in Korea.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report

Background

We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT).

Case presentation

A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO₂ insufflation and the head-up position. SpO₂ decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO₂ or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax.

Conclusion

This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO₂ gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Laparoscopic major liver resections: Current standards

Laparoscopic liver resection was slow to be adopted in the surgical arena at the beginning as there were major barriers including the fear of gas embolism, risk of excessive blood loss from the inability to control bleeding vessels effectively, suboptimal surgical instruments to perform major liver resection and the concerns about oncological safety of the procedure. However, it has come a long way since the early 1990s when the first successful laparoscopic liver resection was performed, spurring liver surgeons worldwide to start exploring the roles of laparoscopy in major liver resections. Till date, more than 9000 cases have been reported in the literature and the numbers continue to soar as the hepatobiliary surgical communities quickly learn and apply this technique in performing major liver resection. Large bodies of evidence are available in the literature showing that laparoscopic major liver resection can confer improved short-term outcomes in terms of lesser operative morbidities, lesser operative blood loss, lesser post-operative pain and faster recovery with shorter length of hospitalization. On the other hand, there is no compromise in the long-term and oncological outcomes in terms of comparable R₀ resection rate and survival rates of this approach. Many innovations in laparoscopic major hepatectomies for complex operations have also been reported. In this article, we highlight the journey of laparoscopic major hepatectomies, summarize the technical advancement and lessons learnt as well as review the current standards of outcomes for this procedure.

Influence of Body Mass Index ≥30 on Pure Laparoscopic Donor Right Hepatectomy

Background

Pure laparoscopic donor right hepatectomy (PLDRH) for donors with obesity has not been previously investigated. This study aimed to investigate the influence of donor obesity (BMI ≥30 kg/m²) on and clinical outcomes after PLDRH.

Material/Methods

Records of all living donors who underwent PLDRH between November 2015 and May 2018 and open conventional donor right hepatectomy (CDRH) between January 2011 and October 2015 at Seoul National University Hospital were retrospectively reviewed. The donors were divided into 3 groups: PLDRH BMI ≥30, PLDRH BMI <30, and CDRH BMI ≥30.

Results

Donors in the PLDRH BMI ≥30 group (n=7) were compared with those in the PLDRH BMI <30 (n=65; control 1) and CDRH BMI ≥30 (n=8; control 2) groups. Graft weight was significantly heavier in PLDRH BMI ≥30 than in control 1 (P=0.012). The lowest hemoglobin (Hb) value was higher (P=0.014) and ΔHb% was lower (P=0.005) in PLDRH BMI ≥30 than in control 1. Similarly, the lowest Hb value was higher (P=0.021) and ΔHb% was lower (P<0.001) in PLDRH BMI ≥30 than in control 2. The peak alanine aminotransferase (ALT) (P=0.029) and ΔALT% were higher in PLDRH BMI ≥30 than in control 2. No significant differences in hospital stay and postoperative complications were found between PLDRH BMI ≥3 and control 1, as well as between PLDRH BMI ≥3 and control 2.

Conclusions

This study revealed that PLDRH is feasible in donors with obesity.

Pure Laparoscopic Versus Open Left Hepatectomy Including the Middle Hepatic Vein for Living Donor Liver Transplantation

Pure laparoscopic donor hepatectomy (PLDH) has become increasingly accepted in the era of minimally invasive surgeries. However, the outcomes of pure laparoscopic donor left hepatectomy (PLDLH) are relatively less known than for left lateral sectionectomy or right hepatectomy. This study aimed to report our experience with and the outcomes of PLDLH including the middle hepatic vein (MHV) and to compare these outcomes with conventional donor left hepatectomy (CDLH). The medical records of living liver donors between January 2010 and January 2018 at Seoul National University Hospital were retrospectively reviewed. Donors who underwent left hepatectomy including the MHV were included. To minimize selection bias, donors who underwent CDLH after the initiation of the PLDH program were excluded. Finally, there were 18 donors who underwent CDLH and 8 who underwent PLDLH. The median (interquartile range [IQR]) warm ischemia time (11 [10-16] minutes versus 4 [2-7] minutes; P = 0.001) was longer in the PLDLH group than the CDLH group. The total operation time (333 [281-376] minutes versus 265 [255-308] minutes; P = 0.09) and time to remove the liver (245 [196-276] minutes versus 182 [172-205] minutes; P = 0.08) were also longer in PLDLH although not statistically significant. The length of postoperative hospital stay was significantly shorter in the PLDLH group (7 [7-8] days versus 9 [8-10] days; P = 0.01). There were no postoperative complications in the PLDLH group. The rate of complications in recipients was similar in both groups. In conclusion, PLDLH including the MHV appears to be safe and feasible. Further analysis including longterm outcomes is needed.

Comparison of liver regeneration in laparoscopic versus open right hemihepatectomy for adult living donor liver transplantation

Backgrounds/Aims

This study aims to compare differences between laparoscopic donor right hemihepatectomy (LDRH) and open donor right hemihepatectomy (ODRH) in the quality of the operation, postoperative complications, and liver regeneration measured via volumetry.

Methods

This study included 119 patients who underwent living donor right hemihepatectomy at Samsung Medical Center from January 2016 to December 2017. We compared several aspects of LDRH and ODRH and analyzed the results using the independent t-test, chi-square test and Fisher's exact test.

Results

Among 119 enrolled patients, 66 patients (55.5%) underwent open surgery, and 53 patients (44.5%) underwent laparoscopic surgery. The mean operation time was significantly shorter for ODRH (290.57±54.04 minutes) than LDRH (312.28±53.5 minutes) (p=0.031). Estimated blood loss was significantly less in LDRH (258.49±119.99 ml) than ODRH (326.52±157.68 ml) (p=0.011). The remnant liver recovered to 83.35±10.71% of the preoperative estimate whole liver volume (pre-EWLV) in the ODRH group and 84.04±8.98% of the pre-EWLV in the LDRH group (p=0.707). The percentage of increased estimated liver volume to postoperative estimate remnant liver volume (post-ERLV) was 137.62±40.34% in the ODRH group and 130.56±36.78% in the LDRH group, and there was no statistically significant difference between the two groups (p=0.326). An analysis of postoperative complications showed no significant differences.

Conclusions

LDRH is safe, and there is no significant difference in hepatic regeneration compared with ODRH. Therefore, LDRH can be applied for living donation of liver.

Learning curve of laparoscopic living donor right hepatectomy

Background

The feasibility and learning curve of laparoscopic living donor right hepatectomy was assessed.

Methods

Donors who underwent right hepatectomy performed by a single surgeon were reviewed. Comparisons between open and laparoscopy regarding operative outcomes, including number of bile duct openings in the graft, were performed using propensity score matching.

Results

From 2014 to 2018, 103 and 96 donors underwent laparoscopic and open living donor right hepatectomy respectively, of whom 64 donors from each group were matched. Mean(s.d.) duration of operation (252·2(41·9) versus 304·4(66·5) min; P &lt; 0·001) and median duration of hospital stay (8 versus 10 days; P = 0·002) were shorter in the laparoscopy group. There was no difference in complication rates of donors (P = 0·298) or recipients (P = 0·394) between the two groups. Total time for laparoscopy decreased linearly (R2 = 0·407, β = –0·914, P = 0·001), with the decrease starting after approximately 50 procedures when cases were divided into four quartiles (2nd versus 3rd quartile, P = 0·001; 3rd versus 4th quartile, P = 0·023). Although grafts with bile duct openings were more abundant in the laparoscopy group (P = 0·022), no difference was found in the last two quartiles (P = 0·207).

Conclusion

Laparoscopic living donor right hepatectomy is feasible and an experience of approximately 50 cases may surpass the learning curve.