Another Tool in the Quest for the Perfect Living Liver Donor Operation.

Abstract

Living donor surgeons must balance donor safety with regard to bleeding, vascular injury, and biliary complications while minimizing short-term pain and long-term abdominal wall function. At the same time, living donor patients are usually deeply concerned about the recipient’s outcomes. Reduced donor morbidity at the cost of increased recipient complications is not acceptable. In this issue, Park et al report their experience with 448 consecutive donors who underwent living donor right hepatectomy by a single surgeon over the course of 5 y.1 One hundred eighty-seven of these donors underwent a mini-incision compared with the conventional J-shaped incision. The team functions within a center that performed more than 1600 donor right hepatectomies over the 5-y period. Right hepatectomy is a physiologically significant operation with risks related to loss of hepatic parenchyma. Many donor surgeons have argued that due to the risks of the surgery including hepatic failure, vascular injury, and biliary complications, the open approach should remain the primary approach.2 However, minimally invasive approaches have been introduced starting with Cherqui et al in 20023 and for right hepatectomies in 2013.4 Although a few centers have embraced the full laparoscopic approach for near donors, adoption broadly in the community of donor surgeons has been slow. Ten years after the initial right hepatectomy reports, fully laparoscopic donor hepatectomy surgery remains isolated to a few centers.5,6 As the authors mention, mini-incision, laparoscopy-assisted and hand-assisted approaches, have been introduced to minimize abdominal wall injury while reducing the learning curve associated with fully laparoscopic approach. Park et al show that excellent outcomes can be achieved for the donors and the recipients using an 8.5- to 13-cm right subcostal incision. They demonstrated low rates of biliary and vascular complications for both donors and recipients. Authors note that when they started mini-incision living donor right hepatectomy, they avoided larger liver and higher body mass index patients or patients with large inferior right hepatic veins. Later in their experience, they develop increased comfort with higher body mass index patients. Interestingly, at the authors’ institution, only 5% of the right hepatectomies are performed laparoscopically, and 3 of the 5 performing donor hepatectomies only perform mini-incision on selected patients. This rigorous selection of patients highlights challenges for broader application of smaller incisions even at the most experienced centers in the world. Making a minimally invasive donor operation safer, more easily reproducible, and with a shortened learning curve is the ideal all donor surgeons should be striving toward. Park et al have shown that mini-incision right donor hepatectomy can be part of that toolbox but likely the perfect operation is still out there waiting to be developed.