Pure Laparoscopic Donor Hepatectomies: Ready for Widespread Adoption?

Laparoscopic and robotic hepatectomy in living liver donors. Current state and prospects

Minimally invasive living-donor hepatectomy is a relatively new surgical technique that can improve donor safety and expedite donor rehabilitation. Following an early stage of research where donor safety was not adequately established, the minimally invasive approach nowadays yields better outcomes when carried out by experienced surgeons. Important factors include donor selection criteria, hospital equipment, and surgeon’s learning curve. This review describes the current status of laparoscopic and robotic living-donor hepatectomy, along with the challenges facing the advancement of these surgical techniques.

Outcomes of Adult Right Graft Living Donor Liver Transplantation Utilizing the Robotic Platform-integrated Real-time Indocyanine Green Fluorescence Cholangiography Compared to the Open Approach

OBJECTIVE

This study aimed to assess short-term biliary outcomes in adult living donor liver transplants using right grafts, comparing robotic surgery with real-time indocyanine green fluorescence cholangiography for optimal hilar plate transection, against the conventional open approach.

BACKGROUND

Determining the optimal transection plane through the hilar plate is crucial in donor hepatectomies, impacting outcomes significantly.

METHODS

From 2011 to 2023, a total of 839 right graft living donor hepatectomies were performed, with 414 (49%) performed via the open approach and 425 (51%) utilizing the robotic platform.

RESULTS

The magnetic resonant cholangiopancreatography predictions correlated moderately with the actual count of graft ducts ( r =0.57, P <0.001). Out of all 839 right donor hepatectomies, 321 (44%) were single duct grafts, of which 193/425 (49%) were retrieved with the robotic while 128/414 (38%) were with the open approach (OR: 1.58, 95% CI: 1.16-2.14), P =0.003). Overall, 50 (6%) of the donors developed a biliary complication during their hospital stay, of whom 38 (9%) were grafts retrieved with the open, while 13 (3%) with the robotic approach (OR: 0.31, 95% CI: 0.15-0.61, P <0.001). Similarly, 63 (15%) of the adult recipients developed a biliary complication of any severity when grafts were retrieved with the open approach compared to 35 (8%) with the robotic approach (OR: 0.50, 95% CI: 0.31-0.79), P =0.002).

CONCLUSIONS

The robotic platform with integrated real-time indocyanine green fluorescence cholangiography during right donor hepatectomy offers improved safety for the donor by accurately addressing the right hilar corridor, resulting in fewer graft ducts and fewer complications for the donor and recipient when compared to the standard open approach.

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.

Minimally invasive tools are necessary for the modern practice of liver surgery

INTRODUCTION

Minimally invasive liver resection (MILR) is performed for other gastrointestinal applications. At our centre, all liver resections are systematically performed using a minimally invasive approach. This study aimed to describe our experience in minimising open surgery and emphasised the importance of minimally invasive surgery.

PATIENTS AND METHODS

We retrospectively reviewed 260 patients who underwent liver surgery and compared the surgical outcomes between the open and MILR groups.

RESULTS

A total of 154 patients (68%) underwent MILR. The proportion of patients who underwent prior abdominal surgery and resection was higher in the open surgery group. However, the proportion of patients with liver cirrhosis was similar between the two groups. The MILR group was superior in terms of operative time, blood loss, Pringle manoeuvre rate and mean hospital stay. In addition, major complication and bile leak rates were lower in the MILR group. No significant differences in the tumour size, number of lesions or underlying liver pathology were observed between the two groups.

CONCLUSION

Acceptable outcomes can be achieved even when the minimally invasive approach is considered the primary option for all patients who require liver resection. Minimally invasive tools are necessary for the modern practice of liver surgery; therefore, laparoscopic or robotic surgery should be included in the armamentarium of liver surgeons.

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.

Systematic review and meta-analysis of open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy

The value of minimally invasive approaches for living donor hepatectomy remains unclear. Our aim was to compare the donor outcomes after open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy (OLDH vs. LALDH vs. PLLDH vs. RLDH). A systematic literature review of the MEDLINE, Cochrane Library, Embase, and Scopus databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (up to December 8, 2021). Random-effects meta-analyses were performed separately for minor and major living donor hepatectomy. The risk of bias in nonrandomized studies was assessed using the Newcastle-Ottawa Scale. A total of 31 studies were included. There was no difference in donor outcomes after OLDH versus LALDH for major hepatectomy. However, PLLDH was associated with decreased estimated blood loss, length of stay (LOS), and overall complications versus OLDH for minor and major hepatectomy, but also with increased operative time for major hepatectomy. PLLDH was associated with decreased LOS versus LALDH for major hepatectomy. RLDH was associated with decreased LOS but with increased operative time versus OLDH for major hepatectomy. The scarcity of studies comparing RLDH versus LALDH/PLLDH did not allow us to meta-analyze donor outcomes for that comparison. There seems to be a marginal benefit in estimated blood loss and/or LOS in favor of PLLDH and RLDH. The complexity of these procedures limits them to transplant centers with high volume and experience. Future studies should investigate self-reported donor experience and the associated economic costs of these approaches.

Left Lobe First With Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation

OBJECTIVE

Evaluate outcome of left-lobe graft (LLG) first combined with purely laparoscopic donor hemihepatectomy (PLDH) as a strategy to minimize donor risk.

BACKGROUND

An LLG first approach and a PLDH are 2 methods used to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). But the risk associated with application LLG first combined with PLDH is not known.

METHODS

From 2012 to 2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a 4-month adoption process, all donor hepatectomies, since December 2019, were performed laparoscopically.

RESULTS

There was one intraoperative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs 371 minutes). PLDH provided shorter hospital stays, lower blood loss, and lower peak aspartate aminotransferase. Peak bilirubin was lower in LLG donors compared with right-lobe graft donors (1.4 vs 2.4 mg/dL, P < 0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs 1.6 mg/dL, P < 0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs 22%, P = 0.007) and late complications, including incisional hernia (0% vs 13.7%, P < 0.001), compared with open cases. LLG was more likely to have a single duct than a right-lobe graft (89% vs 60%, P < 0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between the type of graft and surgical approach.

CONCLUSIONS

The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.

Risk Factors Associated With Surgical Morbidities of Laparoscopic Living Liver Donors

OBJECTIVE

This study analyzed the incidence and risk factors for surgical morbidities of laparoscopic living donors.

BACKGROUND

Although laparoscopic living donor programs have been established safely in leading centers, donor morbidities have not been discussed sufficiently.

METHODS

Laparoscopic living donors operated on from May 2013 to June 2022 were reviewed. Donor complications were reviewed, and factors related to bile leakage and biliary stricture were analyzed using the multivariable logistic regression method.

RESULTS

A total of 636 donors underwent laparoscopic living donor hepatectomy. The open conversion rate was 1.6%, and the 30-day complication rate was 16.8% (n=107). Grade IIIa and IIIb complications occurred in 4.4% (n=28) and 1.9% (n=12) of patients, respectively. The most common complication was bleeding (n=38, 6.0%). Fourteen donors (2.2%) required reoperation. Portal vein stricture, bile leakage, and biliary stricture occurred in 0.6% (n=4), 3.3% (n=21), and 1.6% (n=10) of cases, respectively. The readmission rate and reoperation rate were 5.2% (n=33) and 2.2% (n=14), respectively. Risk factors related to bile leakage were 2 hepatic arteries in the liver graft (OR=13.836, CI=4.092-46.789, P <0.001), division-free margin<5 mm from the main duct (OR=2.624, CI=1.030-6.686, P =0.043), and estimated blood loss during operation (OR=1.002, CI=1.001-1.003, P =0.008), while the Pringle maneuver (OR=0.300, CI=0.110-0.817, P =0.018) was protective against leakage. Regarding biliary stricture, bile leakage was the only significant factor (OR=11.902, CI=2.773-51.083, P =0.001).

CONCLUSIONS

Laparoscopic living donor surgery showed excellent safety for the majority of donors, and critical complications were resolved with proper management. To minimize bile leakage, cautious surgical manipulation is needed for donors with complex hilar anatomy.

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.

Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy (MIDH) is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors. After an initial period in which donor safety was not effectively validated, MIDH currently seems to provide improved results, provided that it is conducted by experienced surgeons. Appropriate selection criteria are crucial to achieve better outcomes in terms of complications, blood loss, operative time, and hospital stay. Beyond a pure laparoscopic technique, various approaches have been recommended such as hand-assisted, laparoscopic-assisted, and robotic donation. The latter has shown equal outcomes compared to open and laparoscopic approaches. A steep learning curve seems to exist in MIDH, mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding. This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination. Surgeons need expertise in liver transplantation, hepatobiliary surgery, and minimally invasive techniques to perform MIDH. Barriers can be categorized into surgeon-related, institutional-related, and accessibility. More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

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.

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Extended criteria donors for Robotic Right Hepatectomy- A Propensity Score matched Analysis

BACKGROUND

Robotic right donor hepatectomy (RDH) has been reported from experienced centers with reduced morbidity when compared to open RDH. However, outcomes in donors with large grafts/ complex biliovascular anatomy are unknown.

METHODS

Out of 170 robotic RDH, 100 had one or more of the following: graft weight ≥ 800gms, type 2/3 portal vein, >1 bile duct or hepatic artery and inferior hepatic veins >5mm requiring reconstruction (extended criteria donors- ExRDH), while the remaining 70 had standard anatomy (SRDH). After propensity score matching, 66 ExRDH were compared with 66 SRDH. Additionally, all robotic RDH performed were analysed in 3 temporal phases (60, 60 and 50).

RESULTS

Peak AST and ALT were higher among donors and recipients in the ExRDH arm compared to SRDH. Other intraoperative parameters and post-operative complications were similar between the two groups. During the last phase, donors demonstrated reduction in duration of surgery, postoperative complications and hospital stay while recipients showed decreased blood loss and hospital stay.

CONCLUSION

Robotic right hepatectomy performed in donors with extended criteria have similar perioperative outcomes as standard donors. However, a significant learning curve needs to be traversed. Further studies are required before safely recommending robotic RDH for all donors.

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.

World Survey on Minimally Invasive Donor Hepatectomy: A Global Snapshot of Current Practices in 2370 Cases

BACKGROUND

Having little evidence on the real extent of the minimally invasive donor hepatectomy (MIDH), a world survey was conducted aiming to picture the spread of MIDH and to identify geographical, institutional, and individual differences.

METHODS

A web-based survey was created with 5 sections (general, institutional, surgeon's experience, technical, and spread and dissemination), comprising up to a total of 47 questions. A thorough search was carried out to identify all possible centers and surgeons performing MIDH.

RESULTS

A global MIDH experience of 2370 cases was collected: 1587 right hepatectomies (RHs; 48.9% pure laparoscopic), 471 left lateral sectionectomies (LLS; 81.1% pure laparoscopic), and 366 left hepatectomies (LHs; 77.6% laparoscopic-assisted). LLS and adult MIDH conversion rates were 5.4% and 3.9%, respectively. Median blood loss was 250 mL (100-600), 100 mL (50-250), and 150 mL (50-500) for RH, LLS, and LH, respectively. Intra- and postoperative transfusion rates were 0.5%, 0%, and 0.3%; and 1.3%, 1.6%, and 0% for RH, LLS, and LH, respectively. Geographically, Asia accounts up to 1730 cases (73% of the global experience, 49.6% pure lap), of which 1374 cases are RH; Europe and Middle East-395 cases-stands out for its experience in left lateral sectionectomy: 289 cases (93% pure lap). Finally, America accounts for 245 cases, using a laparoscopic-assisted technique in 72.6% of the cases (178).

CONCLUSIONS

This world survey provides evidence and data on the global spread of MIDH and anticipates how in a near future a large-scale adoption of these techniques may be observed.

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.

Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis

Laparoscopic donor hepatectomy (LDH), accepted as a minimally invasive approach, has become increasingly popular for living donor liver transplant. However, the outcomes of LDH remain to be fully clarified when compared with open living donor hepatectomy. Thus, our meta-analysis was designed to assess the efficacy of laparoscopic in comparison with conventional open donor hepatectomy.The PubMed, Cochrane, and Embase electronic databases were searched to identify the articles concerning the comparison of the efficacy of laparoscopic versus open surgery in treatment of living donor liver transplantation updated to March, 2020. The main search terms and medical Subject Heading terms were: "living donor," "liver donor," "minimally invasive," "laparoscopic surgery," and "open surgery." After rigorous evaluation on quality, the data was extracted from eligible publications. The outcomes of interest included intraoperative and postoperative results.The inclusion criteria were met by a total of 20 studies. In all, 2001 subjects involving 633 patients who received laparoscopic surgery and 1368 patients who received open surgery were included. According to the pooled result of surgery duration, the laparoscopic surgery was associated with shorter duration of hospital stay (MD = -1.07, 95% CI -1.85 to -0.29; P = .007), less blood loss (MD = -57.57, 95% CI -65.07 to -50.07; P < .00001), and less postoperative complications (OR = 0.61, 95% CI 0.44-0.85; P = .003). And the open donor hepatectomy achieved a trend of shorter operation time (MD = 30.31, 95% CI 13.93-46.69; P = .0003) than laparoscopic group. Similar results were found in terms of ALT (P = .52) as well as the AST (P = .47) peak level between the 2 groups.LDH showed the better perioperative outcomes as compared with open donor hepatectomy. The findings revealed that LDH may be a feasible and safe procedure for the living donor liver transplantation.

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.

Laparoscopic living-donor hepatectomy: Review of its current status

The laparoscopic living-donor hepatectomy procedure has been developing rapidly. Although its use has increased worldwide, it is still only performed by experienced surgeons at a limited number of institutions. However, technical innovations have improved the feasibility of more widespread use of laparoscopic living-donor hepatectomy. The advantages of laparoscopic living-donor hepatectomy should not be overemphasized, and the fundamental principle of "living-donor safety first" cannot be neglected. This review aims to summarize the current status of laparoscopic living-donor hepatectomy and to emphasize that, while this procedure may soon be used as a reliable, donor-friendly substitute for traditional open donor hepatectomy, its safety and efficacy require further substantiation first.

Donor wound satisfaction after living-donor liver transplantation in the era of pure laparoscopic donor hepatectomy

BACKGROUND

Donor safety and cosmetic outcome are the main concerns raised by most living-donors. Pure laparoscopic living-donor hepatectomy (PLLDH) can provide the balance between those concerns. No studies evaluated the donors' satisfaction after PLLDH. The aim of this study is to evaluate the donors' satisfaction after PLLDH compared with donors who underwent open approach.

METHODS

We randomly assigned a questionnaire (Donor satisfaction questionnaire) to the donors, operated between 2011 and 2017, during their follow-up visits in the outpatient clinic. Donors who responded to the questionnaire were included in our study. Donors were divided into 3 groups: L group (conventional inverted L incision), M group (midline incision), and PL group (laparoscopic approach).

RESULTS

149 donors were included in our study. L group included 60 donors (40.3%), M group included 39 patients (26.2%), and PL group included 50 patients (33.5%). There were no significant differences between the groups regarding preoperative and perioperative outcomes apart from shorter operation time in PL group and higher wound infection in M group. Body image scale was significantly better in PL group (p = 0.001). Cosmetic scale was significantly higher in PL group (p = 0.001). Regarding self-confidence scale, it was significantly higher in PL group (p = 0.001). There was no significant difference between the groups regarding the sense of dullness or numbness on the scar (p = 0.113).

CONCLUSION

PLLDH is safe and feasible for living-donor hepatectomy. Donors operated by pure laparoscopic approach have better satisfaction scores compared to conventional open approach.

Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long-term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO-compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow-up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long-term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

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.

Robotic Versus Open Right Lobe Donor Hepatectomy for Adult Living Donor Liver Transplantation: A Propensity Score-Matched Analysis

Robotic right lobe donor hepatectomy (RRLDH) is rarely performed, and data concerning its safety and efficacy are lacking. Here we compare our series of RRLDHs with a similar cohort undergoing open right lobe donor hepatectomy (ORLDH) with a propensity score-matched (PSM) analysis. Among 263 consecutive adult patients undergoing right lobe living donor hepatectomy from January 2015 until July 2019, 35 RRLDHs were matched to 70 ORLDHs. A 1:2 PSM analysis was performed to make the groups comparable for donor sex, age, and body mass index (BMI) and for recipient sex, age, BMI, Model for End-Stage Liver Disease score, and indication for transplant. Operative time was longer in RRLDHs compared with ORLDHs (504 ± 73.5 versus 331 ± 65.1 minutes; P < 0.001) but significantly decreased with the number of patients (P < 0.001). No conversions occurred. First warm ischemia time was longer and blood loss significantly less in RRLDHs (P = 0.001 and 0.003, respectively). Overall donor complications were similar: 2 (6%) in RRLDHs versus 12 (17%) in ORLDHs (P = 0.13). Biliary leak occurred in 1 (3%) patient receiving a robotic procedure and 2 (3%) patients receiving the conventional approach. Donors undergoing robotic surgery required less patient-controlled analgesia and had a shorter hospital stay compared with the open surgery group (P < 0.001 and P = 0.001, respectively). No significant differences in graft anatomical data and recipient outcomes were recorded. RRLDH is feasible, safe, and reproducible, with significantly decreased blood loss and a shorter hospital stay compared with the open procedure. The first 35 patients receiving the robotic procedure showed a substantial reduction in operative time, reflecting a rapid shortening of the learning curve.

Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients

OBJECTIVE

To define the current status of "difficult" LLR, a global database was created and investigated.

BACKGROUND

In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available.

METHODS

A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses.

RESULTS

Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes.

CONCLUSIONS

Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.

Minimally invasive donor hepatectomy, systemic review

Liver transplantation is a life-saving therapy for patients with end-stage liver disease. Living donation is a critical source of organs throughout the world. Reducing donor morbidity and mortality is of utmost importance while maintaining access to liver transplantation for recipients. While laparoscopy was more rapidly utilized in donor nephrectomy, laparoscopy has been slower to develop for living donor hepatectomies due to the concerns about hemostasis, safety of the donor and quality of the graft. Pure minimal invasive approach has become a standard of care for left lateral sectionectomy (LLS) for pediatric recipients. In the past few years, a number of centers with significant laparoscopic and living donor experience have reported fully minimally invasive approach to hemi-hepatectomies. In this manuscript we discuss the experiences, lessons learned and path forward for laparoscopic and minimal invasive surgery(MIS) in donor hepatectomies (DH).

Comparison of perioperative outcomes between pure laparoscopic surgery and open right hepatectomy in living donor hepatectomy: Propensity score matching analysis

Pure laparoscopic donor right hepatectomy (PLDRH) is not a standard procedure for living donor liver transplantation but is safe and reproducible in the hands of experienced surgeons. However, the perioperative outcomes of PLDRH have not been fully evaluated yet. We used propensity score matching to compare the perioperative complications and postoperative short-term outcomes of donors undergoing PLDRH and open donor right hepatectomy (ODRH). A total of 325 consecutive donors who underwent elective, adult-to-adult right hepatectomy were initially screened. After propensity score matching, all patients were divided into two groups: PLDRH (n = 123) and ODRH (n = 123) groups. Perioperative complications and postoperative outcomes were compared between the two groups. Postoperative pulmonary complications were significantly more common in the ODRH than in the PLDRH group (54.5 vs. 31.7%, P < 0.001). The biliary complications (leak and stricture) were higher in PLDRH group than in the ODRH group (8% vs. 3%), but it failed to reach statistical significance (P = 0.167). Overall, surgical complication rates were similar between the two groups (P = 0.730). The opioid requirement during the first 7 postoperative days was higher in the ODRH group (686 vs. 568 mg, P < 0.001). The hospital stay and time to the first meal were shorter in the PLDRH than in the ODRH group (P = 0.003 and P < 0.001, respectively). PLDRH reduced the incidence of postoperative pulmonary complications and afforded better short-term postoperative outcomes compared to ODRH. However, surgical complication rates were similar in both groups.

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.

Pure 3D laparoscopy versus open right hemihepatectomy in a donor with type II and III portal vein variations

BACKGROUNDS/AIMS

Pure laparoscopic living donor right hemihepatectomy (PLDRH) has been performed in many experienced centers. However, portal vein variations still remain challenging thus disturbing the widespread of PLDRH in many centers. PLDRH when integrated with 3-dimensional laparoscopy and indocyanine green (ICG) near-infrared fluorescence cholangiography is safe and feasible.

METHODS

We reviewed 19 donors with separated right anterior and right posterior portal veins who underwent living donor right hemihepatectomy between January 2014 and December 2016. We compared the clinical outcomes of PLDRH and conventional open right hemihepatectomy (CDRH).

RESULTS

6 donors (31.6%) underwent PLDRH while 13 donors (68.4%) underwent CDRH. There was no intraoperative complications, transfusions and open conversions in the PLDRH donors. The total operative time was longer in PLDRH (356.5 vs. 244.5 minutes, p=0.003). However, the length of hospital stay (8.5 vs. 9.0 days, p=0.703), blood loss (450.0 vs. 393.6 ml, p=0.557) and complication rate (16.6% vs.27.3%; p=0.327) did not differ between the two groups.

CONCLUSIONS

PLDRH is safe and feasible in donors with type II and III portal vein variations. Further prospective comparative studies are needed to prove the safety and efficacy of PLDRH.