Laparoscopic living donor hepatectomy: a review of current status

Over the last two decades, laparoscopic surgery has been adopted in various surgical fields. Its advantages of reduced blood loss, reduced postoperative morbidity, shorter hospital stay, and excellent cosmetic outcome compared with conventional open surgery are well validated. In comparison with other abdominal organs, laparoscopic hepatectomy has developed relatively slowly due to the potential for massive bleeding, technical difficulties and a protracted learning curve. Furthermore, applications to liver graft procurement in living donor liver transplantation (LDLT) have been delayed significantly due to concerns about donor safety, graft outcome and the need for expertise in both laparoscopic liver surgery and LDLT. Now, laparoscopic left lateral sectionectomy in adult‐to‐pediatric LDLT is considered the standard of care in some experienced centers. Currently, the shift in application has been towards left lobe and right lobe graft procurement in adult LDLT from left lateral section in pediatric LDLT. However, the number of cases is too small to validate the safety and reproducibility. The most important concern in LDLT is donor safety. Even though a few studies reported the technical feasibility and comparable outcomes to conventional open surgery, careful validating through larger sample sized studies is needed to achieve standardization and wide application.     

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.     

Analysis of surgical and perioperative complications in seventy-five right hepatectomies for living donor liver transplantation

AIM： To present an analysis of the surgical and perioperative complications in a series of seventyfive right hepatectomies for living-donation （RHLD） performed in our center. METHODS： From January 2002 to September 2007, we performed 75 RHLD, defined as removal of a portion of the liver corresponding to Couinaud segments 5-8, in order to obtain a graft for adult to adult living-related liver transplantation （ALRLT）. Surgical complications were stratified according to the most recent version of the Clavien classification of postoperative surgical complications. The perioperative period was defined as within 90 d of surgery. RESULTS： No living donor mortality was present in this series, no donor operation was aborted and no donors received any blood transfusion. Twenty- three （30.6%） living donors presented one or more episodes of complication in the perioperative period. Seven patients （9.33%） out of 75 developed biliary complications, which were the most common complications in our series.CONCLUSION： The need to define, categorize and record complications when healthy individuals, such as living donors, undergo a major surgical procedure, such as a right hepatectomy, reflects the need for prompt and detailed reports of complications arising in this particular category of patient. Perioperative complications and post resection liver regeneration are not influenced by anatomic variations or patient demographic.     

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. Reducedwound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a minilaparotomy 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.     

Laparoscopic versus open left lateral hepatectomy

Laparoscopic liver surgery is becoming more popular, and many high-volume liver centers are now gaining expertise in this area. Laparoscopic left lateral hepatectomy (LLLH) is a standardized and anatomically well-defined resection and may transform into a primarily laparoscopic procedure for cancer surgery or living donor hepatectomy for transplantation. Five case–control series were identified comparing a total of 167 cases (86 cases of LLLH plus 81 cases of open left lateral hepatectomy). Groups were matched by age and sex, with broadly similar indications for surgery and resection techniques. LLLH is associated with shorter hospital stays and less blood loss without compromising the margin status or increasing complication rates. Donors of LLLH grafts did not have higher graft-related morbidity. Prospective studies are required to define the safety in terms of disease-free and overall survival in this new avenue in laparoscopic liver surgery.     

Pushing the frontiers of living donor right hepatectomy

Living donor right hepatectomy(LDRH)is currently the most common donor surgery in adult-to-adult living donor liver transplantation although the morbidity and mortality reported in living donors still contradicts the Hippocratic tenet of"do no harm".Achieving low complication rates in LDRH remains a matter of major concern.Living donor surgery is performed worldwide as an established solution to the donor shortage.The aim of this study was to assess the current status of LDRH and comment on the future of the procedure;assessment was made from the stand point of optimizing the donor selection criteria and reducing morbidity based on both the authors’8-year institutional experience and a literature review.New possibilities have been explored regarding selection criteria.The safety of living donors with unfavorable conditions,such as low remnant liver volume,fatty change,or old age,should also be considered.Abdominal incisions have become shorter,even without laparoscopic assistance;upper midline laparotomy is the primary incision used in more than 400 consecutive LDRHs in the authors’institution.Various surgical techniques based on preoperative imaging technology of vascular and biliary anomalies have decreased the anatomicalbarriers in LDRH.Operative time has been reduced,with low blood loss.Laparoscopic or robotic LDRH has been tried in only a few selected donors.The LDRHspecific,long-term outcomes remain to be addressed.The follow-up duration of these studies should be long enough to address possible late complications.Donor safety,which is the highest priority,is ensured by three factors:preoperative selection,intraoperative surgical technique,and postoperative management.These three focus areas should be continuously refined,with the ultimate goal of zero morbidity.     

Problems in adult living donor liver transplantation using the right hepatic lobe

BACKGROUND: Adult living donor liver transplantation (LDLT) is now widely applied to patients, children or adults, and the graft extends from the left hepatic lobe to the right hepatic lobe. Harvesting the right hepatic lobe would mean putting the donor at high risk. The congestion of a graft may cause small-for-size syndrome. The safety of the donor and its evaluation, which are related to the outcome for the recipient,play an important role in LDLT. How to decrease the congestion of the graft is another challenge to transplant experts. DATA SOURCES: A literature search from MEDLINE about adult LDLT in recent years was made to analyze the safety of the living donor and the innovation of surgical techniques for preventing small-for-size syndrome. RESULTS: The top priority for adult LDLT is donor safety. Preoperative donor evaluation consists of three stages: phase 1 for general evaluation, phase 2 for laboratory tests, and phase 3 for radiological evaluation of graft volume and vessel anatomy. The potential pathogenic mechanisms of small-for-size syndrome seem to be related to persistent portal hypertension and portal overperfusion. Improved surgical techniques for decreasing portal hypertension and preventing congestion of a graft may reduce the incidence of small-for-size syndrome. The improved techniques include reconstruction of the tributaries of the middle hepatic vein, end-to-side portocaval shunting, ligation of the splenic artery, dual-graft transplantation, and modified reconstruction of hepatic veins. CONCLUSION: With the careful preoperative assessment and the safety of the living donor, as well as improved surgical techniques, adult LDLT using the right lobe is safe.     

Living donor hepatectomy in a pregnant woman

Liver transplantation with a live donor is an effective way to expand the donor pool. Restrictive selection of living donors may assure donor safety but limit the utility of this resource. A 12-month-old recipient with biliary atresia was rapidly deteriorating with hepatic encephalopathy, massive ascites and coagulopathy. Her mother, the only possible living donor, expressed a strong desire to donate part of liver to her baby, although she was found to be pregnant. The donor hepatectomy was then undertaken at 18 weeks of gestation. A left lateral segmentectomy was performed. Her postoperative course was uneventful and she was discharged 7 days after the operation. She gave birth to a healthy term baby without any complications 5 months later. Both recipient and her younger brother are well 12 months after the operation. Despite the limited experience reported herein, pregnancy may no longer be considered an absolute contraindication for live liver donation.     

Total laparoscopic liver resection in 78 patients

AIM: To summarize the clinical experience of laparoscopic hepatectomy at a single center.METHODS: Between November 2003 and March 2009, 78 patients with hepatocellular carcinoma ( n = 39), metastatic liver carcinoma ( n = 10), and benign liver neoplasms ( n = 29) underwent laparoscopic hepatectomy in our unit. A retrospective analysis was done on the clinical outcomes of the 78 patients.RESULTS: The lesions were located in segments Ⅰ ( n = 3), Ⅱ ( n = 16), Ⅲ ( n = 24), Ⅳ ( n = 11), Ⅴ ( n = 11),Ⅵ ( n = 9), and Ⅷ ( n = 4). The lesion sizes ranged from 0.8 to 15 cm. The number of lesions was three ( n = 4),two ( n = 8) and one ( n = 66) in the study cohort. The surgical procedures included left hemi-hepatectomy ( n = 7), left lateral lobectomy ( n = 14), segmentectomy ( n = 11), local resection ( n = 39), and resection of metastatic liver lesions during laparoscopic surgery for rectal cancer ( n = 7). Laparoscopic liver resection was successful in all patients, with no conversion to open procedures. Only four patients received blood transfusion (400-800 mL). There were no perioperative complications, such as bleeding and biliary leakage. The liver function of all patients recovered within 1 wk, and no liver failure occurred.CONCLUSION: Laparoscopic hepatectomy is a safe and feasible operation with minimal surgical trauma. It should be performed by a surgeon with sufficient experience in open hepatic resection and who is proficient in laparoscopy.     

Liver transplantation for polycystic liver with massive hepatomegaly： A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease.Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008.The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack).Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and finally, right hepatectomy was performed. OLT was performed successfully.The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed first during OLT if the liver is over enlarged.     

Convenience of a tape-guiding technique in different types of hepatectomy

BACKGROUND/AIMS: The liver hanging maneuver is widely used in right lobectomy to resect huge tumors and harvest living donors. The convenience of tape assistance in other types of hepatectomy is not well known. METHODOLOGY: Tape-guiding technique (TGT) was applied in 30 hepatectomies of different type between April 2003 and April 2006. The indications were liver carcinoma in 22 and living-donor in 8. Hepatectomies included right lobectomy, 14; left lobectomy with caudate lobectomy, 8; left lobectomy without caudate lobectomy, 2; lateral segmentectomy, 3; central bisegmentectomy, posterior segmentectomy, and superior dorsal partial resection, 1 each. A tape was placed in front of the inferior vena cava for right hepatectomy and left hepatectomy with caudate lobectomy. In other hepatectomies, the tape was positioned to be the target of parenchymal dissection. RESULTS: TGT was successfully performed in all 30 cases. Tape facilitated dissection by helping the surgeon maintain orientation, and traction on the tape flattened the parenchyma, making it easier to identify and manage vessels and ducts. With an assistant holding the tape, the surgeon's left hand was free, and ligation and suturing was easier and more secure. CONCLUSIONS: The TGT is a convenient technique that is applicable to different types of liver resection.     

Donor experience and outcome of pediatric living-related liver transplantation in Saudi Arabia

Background/Purpose. The purpose of this article is to present the first series of living donation of liver grafts in Saudi Arabia, as well as in the Arab World, and to report the morbidity and mortality of the living donors after such procedures. Methods. A retrospective review of the medical charts of 37 living donors who were involved in the procedure of living-related liver transplantation (LRLT), that took place in Riyadh Armed forces Hospital in the period between November 1998 and July 2002, is conducted. Results. The age of living donors ranged between 21 and 41 years, and there were 22 women and 15 men. All donors are first-degree relatives, apart from 2 donors who were the cousins of the recipients. There was no mortality among the donors. The morbidity was minimal, including 3 cases of biliary leakage and 1 of incisional hernia. Of 39 pediatric liver transplantations that have been done over the above period, only 2 cases had cadaveric liver transplantation and these were excluded from this study. All donors had left lateral segment donation, apart from one who had right lobe, segments V–VIII donation to a 14-year-old recipient. Conclusion. Living donation of hepatic graft is a safe procedure for the donors with an excellent outcome. Living-related liver transplantation is the optimal treatment for end-stage liver disease and the solution for the scarcity of cadaveric liver grafts. The level of acceptance of living donation of hepatic grafts among the Saudi people is favorable.     

Liver function impairment in liver transplantation and after extended hepatectomy

Extended hepatectomy,or liver transplantation of reduced-size graft,can lead to a pattern of clinical manifestations,namely"post-hepatectomy liver failure"and"small-for-size syndrome"respectively,that can range from mild cholestasis to irreversible organ non-function and death of the patient.Many mechanisms are involved in their occurrence but in the recent past,high portal blood flow through a relatively small liver vascular bed has taken a central role.Therefore,several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation,such as portocaval shunt,mesocaval shunt,splenorenal shunt,splenectomy or ligation of the splenic artery.However,high portal flow is not the only factor responsible,and before major liver resections,preoperative assessment of the residual liver function is necessary.Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume,preventing posthepatectomy liver failure.More recently,a new surgical procedure,that combines in situ splitting of the liver and portal vein ligation,has gradually come to light,inducing remarkable hypertrophy of the healthy liver in just a few days.Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.     

Safety evaluation of donors for living-donor liver transplantation in Chinese mainland： A single-center report

AIM:To discuss the safety of donors during living donor liver transplantation (LDLT) and the authors' experience with 50 cases. METHODS:Between January 1995 and March 2006,50 patients with end-stage liver disease received LDLT in our department. Donors (at the age of 27-58 years) were healthy and antibody (ABO)-compatible. The protocol of evaluation and selection of donors,choice of surgical methods and strategy applied in the safety evaluation of donors were analyzed. RESULTS:A total of 115 candidate donors were evaluated for LDLT at our center. Of these,50 underwent successful hepatectomy for living donation. The elimination rate for donors was 43.5%. Positive hepatitis serology and ABO incompatibility were the main factors for excluding candidates. All donors recovered uneventfully. The follow-up time ranged from 3 to 135 mo. The incidence of major and minor medical complications was 12.0% and 28.0%,respectively. CONCLUSION:LDLT provides an excellent approach to the problem of donor shortage in China. With a thorough and complete preoperative workup and meticulous intra-and postoperative management,LDLT can be performed with minimal donor morbidity.     

Ethical issues in living donor liver transplantation

The cadaveric organ shortage and the high mortality rate while patients wait for an organ have driven the medical community to develop alternative strategies for treating patients with end-stage liver disease. Adult living donor liver transplantation (ALDT) has evolved in response to the cadaveric organ shortage. Although there are benefits for recipients of ALDT, donors may incur substantial risk, including death. In contrast to pediatric living donation, in which the left lateral segment of the liver is resected from a donor, ALDT generally requires right hepatectomy, which is associated with greater morbidity and mortality. Because ALDT places a healthy individual at risk for substantial morbidity and mortality, debate over the ethics of this procedure is ongoing. Two donor deaths have occurred in the United States, adding to the concern over donor safety. Despite the risks associated with ALDT, many individuals elect to proceed with living donation with the hope of improving the life of a relative or friend. When considering whether we as a society should support and encourage ALDT, we should examine the perspective of the donor, recipient, and medical community as well. The medical community has an obligation to study carefully the risks and outcomes associated with ALDT so that we can deliver the highest quality of care that is not at the expense of healthy individuals.     

Laparoscopic hepatectomy: indications and outcomes

We outline the indications, evaluate the degree of invasiveness, and analyze the outcomes of laparoscopic hepatectomy, mainly in the treatment of hepatocellular carcinoma (HCC). The important considerations in determining indications for laparoscopic hepatectomy include tumor size, type, and location. Nodular tumors smaller than 4 cm or pedunculated tumors smaller than 6 cm are suitable candidates. Concerning location, tumors in the lower segment or the left lateral segment are suitable. Regarding operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral segmentectomy is a feasible, less invasive procedure. Operative time in our recent laparoscopic hepatectomy patients has decreased, with less bleeding. Furthermore, laparoscopic hepatectomy is less invasive than conventional hepatectomy on evaluation by the Estimation of Physiolic Ability and Surgical Stress (E‐PASS) scoring system. Patients recovered more quickly after laparoscopic hepatectomy, which allowed shorter hospitalization. Both the 5‐year survival rate for HCC and the survival rate without recurrence were nearly identical to those of open conventional hepatectomy, although further analysis will be necessary to reach definitive conclusions. In conclusion, laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy in properly selected patients and is beneficial for patient quality of life, because it is a minimally invasive procedure when indications are strictly followed.     

Laparoscopic liver resection for posterosuperior tumors using caudal approach and postural changes: A new technical approach

Laparoscopic liver resection(LLR) for tumors in the posterosuperior liver [segment(S) 7 and deep S6] is a challenging clinical procedure. This area is located in the bottom of the small subphrenic space(rib cage), with the large and heavy right liver on it when the patient is in the supine position. Thus, LLR of this area is technically demanding because of the handling of the right liver which is necessary to obtain a fine surgical view, secure hemostasis and conduct the resection so as to achieve an appropriate surgical margin in the cage. Handling of the right liver may be performed by the hand-assisted approach, robotic liver resection or by using spacers, such as a sterile glove pouch. In addition, the operative field of posterosuperior resection is in the deep bottom area of the subphrenic cage, with the liver S6 obstructing the laparoscopic caudal view of lesions. The use of intercostal ports facilitates the direct lateral approach into the cage and to the target area, with the combination of mobilization of the liver. Postural changes during the LLR procedure have also been reported to facilitate the LLR for this area, such as left lateral positioning for posterior sectionectomy and semi-prone positioning for tumors in the posterosuperior segments. In our hospital, LLR procedures for posterosuperior tumors are performed via the caudal approach with postural changes. The left lateral position is used for posterior sectionectomy and the semi-prone position is used for S7 segmentectomy and partial resections of S7 and deep S6 without combined intercostal ports insertion. Although the movement of instruments is restricted in the caudal approach, compared to the lateral approach, port placement in the para-vertebra area makes the manipulation feasible and stable, with minimum damage to the environment around the liver.     

Hanging maneuver in left hepatectomy

The liver hanging maneuver in right hepatectomy introduced by Belghiti in 2001, is a safe and effective method for right hepatectomy in cases of large hepatoma and living donor liver transplantation. In this article, we first introduce the hanging maneuver in extended left hepatectomy (left hepatectomy including middle hepatic vein). Extended left hepatectomy is a more difficult procedure than right hepatectomy because in the deeper part of the transection, the plane sharply turns to the left above the caudate lobe. Using the hanging maneuver, the horizontal transection plane becomes vertical, and the extended left hepatectomy can be performed easier and safer. This technique can be applied effectively in all kinds of left-sided hepatectomies.     

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.     

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

Introduction

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties.

Methods

We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy.

Conclusion

Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.