Pure Laparoscopic Donor Right Hepatectomy for Rare Non-Bifurcation Portal Vein Variation Donor and Reconstruction Technique

BACKGROUND

Pure laparoscopic donor right hepatectomy (PLDRH) is a technical demanding procedure, and many centers have strict selection criteria especially an anatomical variation. Portal vein variation is considered as a contra-indication for this procedure in most centers. We presented a case of PLDRH in donor who had rare non-bifurcation portal vain variation. The donor was 45-year-old female. Pre-operative imaging showed a rare non-bifurcation portal vain variation. The procedure was following the routine step of laparoscopic donor right hepatectomy except the hilar dissection phase. All portal branches should not be dissected before division of bile duct to prevent vascular injury. Regarding bench surgery, all portal branches were reconstructed together. Finally, the explanted portal vein bifurcation was used to reconstruct all portal vein branches as a single orifice. The liver graft was successfully transplanted. The graft was well functioned, and all portal branches were patented.

CONCLUSION

This technique facilitated identification and safely divided all portal branches. PLDRH in donor with this rare portal vein variation can be performed safely by a highly experienced team and good reconstruction technique. Pure laparoscopic donor right hepatectomy (PLDRH) is a technical demanding procedure, and many centers have strict selection criteria especially an anatomical variation. Portal vein variation is considered as a contra-indication for this procedure in most centers. Lapisatepun and colleagues report PLDRH in rare non-bifurcation portal vein variation, and reconstruction technique was scanty reported.

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.

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).

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Living Donor Liver Transplantation: Technical Innovations

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Laparoscopic donor hepatectomy

Laparoscopic liver resection has been applied to treat most indications for liver resection during the past two decades. According to the literature, patient numbers have increased exponentially as a result, and surgical difficulty has increased as well. In expert centers, laparoscopic anatomical hemihepatectomy and major liver resection more than 3 segments have become the acceptable treatment. Moreover, with surgical innovations and accumulated experience, living donor liver transplantation has become an established treatment choice for patients on the transplant waiting list. It is even considered an inevitable choice in regions with limited access to organs from deceased donors. However, significant morbidity and rare but catastrophic mortality are associated with donor hepatectomy and remain major concerns. Therefore, to decrease the incidence of complications, a minimally invasive approach in donor hepatectomy was adopted in the early 2000s. Initially, a minimally invasive approach was used for left lateral sectionectomy for pediatric liver transplant, then for laparoscopy-assisted hemihepatectomy and pure laparoscopic/robotic right donor hepatectomy, and more recently, for adult living donor liver transplantation. The extent of procedure complexity and potential complications depends on the approach and the size of the graft to be harvested. Early results from expert teams have seemed promising in terms of shortened donor recovery and improved perioperative outcomes. However, the combination of these two highly sophisticated surgical procedures raise more concerns about donor safety, especially with regard to unexpected events during the operation. A high level of evidence is very difficult to achieve in this highly specialized surgical practice with limited penetration. Therefore, an international registry has been suggested to determine the risks and benefits before the use of laparoscopic right donor hepatectomy spreads.

Totally laparoscopic living donor left hepatectomy for liver transplantation in a child

BACKGROUND

Minimally invasive surgery has been validated to be a new standard in living donor hepatectomy for adult-to-pediatric transplantation with less morbidity [1]. Laparoscopic donor hepatectomy can reduce the major concerns about pain and morbidity associated with open surgery and a slow return to daily activities of donors [2]. Herein, we present one case of totally laparoscopic living donor left hepatectomy including the middle hepatic vein (MHV).

DONOR AND METHOD

A 37-year-old mother volunteered to donate to her 3-year-old son with biliary atresia (PELD score 7). Total donor liver volume was 833 cm³ and left liver, including MHV, was 290 cm³. Graft to recipient body weight ratio was 2.07. Our operative technique has been published previously [2]. The left hepatic artery and portal vein were dissected and encircled with two vessel loops. Pringle's maneuver was used during parenchymal transection. The transection of the liver was performed using an alternating combination of laparoscopic ultrasonic aspirator (CUSA) and THUNDERBEAT™ (Olympus, Japan). The MHV was identified and parenchymal transection was performed right side to it. Several small tributaries from segment V and VIII were identified and divided. Finally, left bile duct was identified and divided after performing intraoperative cholangiography using a mobile C-arm.

RESULTS

Totally laparoscopic living donor left hepatectomy was performed successfully without intraoperative complications and transfusion. The operation time was 300 min, the estimated blood loss was less than 125 ml and Graft weight was 314 g. Oral intake was resumed on the first postoperative day (POD). On POD 4, CT scan showed no pathological findings. The patient was discharged on POD 8 without complications.

CONCLUSION

The authors conclude that the laparoscopic living donor left hepatectomy is a safe and feasible procedure but should be performed in selected patients with a favorable anatomy.