New methods in liver transplantation

Abstract

Pancreas transplant recipients continue to suffer high surgical morbidity. Current robotic technology provides a unique opportunity to test whether laparoscopy can improve the postoperative course of pancreas transplantation (PT). Current knowledge on robotic pancreas and renal transplantation was reviewed to determine feasibility and safety of robotic PT. Information available from literature was included in this review, together with personal experience including three PT, and two renal allotransplants. As of April 2011, the relevant literature provides two case reports on robotic renal transplantation. The author's experience consists of one further renal allotransplantation, two solitary PT, and one simultaneous pancreas–kidney transplantation. Information obtained at international conferences includes several other renal allotransplants, but no additional PT. Preliminary data show that PT is feasible laparoscopically under robotic assistance, but raises concerns regarding the effects of increased warm ischemia time on graft viability. Indeed, during construction of vascular anastomoses, graft temperature progressively increases, since maintenance of a stable graft temperature is difficult to achieve laparoscopically. There is no proof that progressive graft warming produces actual damage to transplanted organs, unless exceedingly long. However, this important question is likely to elicit a vibrant discussion in the transplant community. BackgroundBecause cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection. MethodsLeft hepatic lobectomy (resection of segments 2 and 3) was done by laparoscopy in one woman aged 27 years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalized through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia. FindingsDonor operations lasted 7 hours for the woman and 6 hours for the man, and warm ischemia times were 4 minutes and 10 minutes, respectively. Blood loss was 150 mL and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after surgery; and hospital stay was 7 days and 5 days, respectively. Both recipients are alive and have excellent graft function. InterpretationWe have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasibility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for pediatric living donor liver transplantation.