Living Donor Hepatectomy Research Articles

The learning curve for robotic living donor right hepatectomy: Analysis of outcomes in two specialized centers.

Robotic surgery is an emerging minimally invasive option for living donor hepatectomy. Currently, there are no studies on the learning curve of robotic donor hepatectomy. Thus, we evaluated the learning curve for robotic donor right hepatectomy (RH). We retrospectively reviewed prospectively collected data from consecutive living donors who underwent robotic hepatectomy at two specialized centers between 2016 and 2022. We estimated the number of cases required to achieve stable operating times for robotic donor RH using cumulative sum (CUSUM) analysis. The complication rates were similar between the two centers (22.8% vs. 26.7%; p=0.74). Most complications were graded as minor (70.4%). Analysis of the total operative time demonstrated that the learning curves reached a peak at the 17th case in Center 1 and the 9th case in Center 2. The average operation times for cases 1-17 versus 18-99 in Center 1 were 603 versus 438 minutes (p<0.001), and cases 1-9 versus 10-15 in Center 2 were 532 versus 418 minutes (p=0.002). Complication rates were lower after the learning curves were achieved, although this did not reach statistical significance. A comparison of outcomes between centers suggests that a standardized approach to this complex operation can be successfully transferred.

Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients.

Analgesia in liver transplantation patients has been traditionally considered a secondary priority where perioperative management principally focused on survival rates in these critically ill patients. With recent advancements in both surgical and medical management, posttransplant survival rates have steadily improved. Outcome measurements are no longer limited to short-term mortality rates and hospital length of stay but are also measured by patient-centered outcomes, such as pain control and quality of life. As living donor liver transplantation has increased access to transplantation, it has also added a different patient population to manage in the perioperative period. For healthy patients undergoing living donor hepatectomies, it is important to reduce the impact of the surgery with proper perioperative pain management. We performed a literature search for articles related to perioperative pain management for liver transplantation living donors and recipients to identify current practices and recent advances. Neuraxial techniques, peripheral nerve blocks, and enteral and parenteral medications were all found to be feasible analgesia modalities for patients undergoing either liver transplant or donor hepatectomy. Patients may also benefit from nonpharmacological interventions and preoperative counseling. No particular perioperative analgesic modality was deemed superior to any other. For liver transplant living donors and recipients, perioperative pain management should emphasize the application of sustainable patient-centered pain control protocols.

301.5: Is white test of relevance in minimising bile leak in living donor hepatectomy: Experience from two LDLT centres across continents.

301.5: Is white test of relevance in minimising bile leak in living donor hepatectomy: Experience from two LDLT centres across continents.

P.195: The association of phase angle with in-hospital complication after laparoscopic living-donor hepatectomy.

P.195: The association of phase angle with in-hospital complication after laparoscopic living-donor hepatectomy.

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.

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

Complications of Laparoscopic and Open Donor Hepatectomy for Living Donor Liver Transplantation: Single Center Experience.

Donor hepatectomy is a major surgery with a relatively safeprofile anda reportedcomplication rate of ~20%. Most complications are non-life threatening and are resolved with conservative measures. However, rare complications may need invasive precautions, ranging from percutaneous interventions to surgeries. We retrospectively analyzed all living donor hepatectomies at our center. Donors were divided into 2 groups: laparoscopic and open procedures. We collected preoperative, intraoperative and postoperative data of donors.Donor complications were recorded separately intraoperatively and postoperatively according to the Clavien-Dindo postoperative complication classification system. Between July 2018 and April 2023, 215 living donors had hepatectomies, including 48 laparoscopic and 167 open donor hepatectomies. Among donors, 91 were female donors (42.3%) and 124 were male donors (57.7%).The meanage of alldonorswas 33.5±8.1 years, and the mean body mass index (in kilogram divided by meters squared) was 24.6 ± 3.8. Among donors, 124 underwent right and 91 underwent left or left lateral hepatectomies. The mean operative time for all donors was 301 ± 83 minutes, the mean hospital stay was 5.8 ± 1.4 days, and the mean follow-up was 31.9 ± 15.8 months. Four patients (1.8%) had intraoperative complications, including 2 cases of bleeding, 1 diaphragm perforation, and 1 portal vein stenosis. Fourteen patients (7.4%) had major postoperative complications, with 5 patients requiring surgical intervention. Donor hepatectomy is a complicated surgery that requires extensive preoperative preparation and appropriate donor selection. Postoperative donor complications can be diagnosed early with close follow-up, and a multidisciplinary approach is essential for complication management.

Current status and future perspectives of robotic liver surgery.

Robotic liver resection has been reported in case series since the early 2000s. The surgical robot is capable of precise operation using articulated forceps with seven degrees of freedom. The robot also eliminates tremors and provides a good surgical field with highly detailed 3D high-definition images. The clinical results demonstrating their usefulness have been increasing year by year. Initially, a shorter hospital stay was observed in comparison with open hepatectomy. Recent reports have also shown lower conversion and complication rates in comparison with laparoscopic hepatectomy. The clamp and crush method with bipolar forceps, sealing devices, ultrasonic shears, and the combined procedure of Cavitron ultrasonic surgical aspirator and robotic forceps as hybrid procedures have been reported as effective methods of parenchymal transection in robotic surgery. Theoretically, the advantages of the robotic platform allow for more complex liver resection around hilar structures and major blood vessels, as well as for vascular reconstruction or biliary reconstruction. The application of robotic liver surgery for hilar cholangiocarcinoma, living donor hepatectomy, and living donor liver transplantation has been reported. Robotic liver surgery is becoming more popular for certain indications; however, it is important to further evaluate its long-term surgical and oncological outcomes and costs in comparison with conventional laparoscopic and open liver surgery, based on accumulated experience.

An Elbow Patch Reconstruction Technique for Narrowed Remnant Portal Veins during Right Lobe Living Donor Hepatectomy: A Rescue Surgery.

Background: Treatment of established portal vein narrowing after living donor hepatectomy is challenging. We aimed to present a new approach termed the "elbow patch reconstruction technique" to correct the narrowed remnant portal vein just or late after right lobe living donor hepatectomy. Methods: Demographic and clinical data of 12 living liver donors with narrowed remnant portal veins and treated with the "elbow patch reconstruction technique" were prospectively collected and retrospectively evaluated. Anatomic variation of the portal vein was defined in accordance with the Nakamura classification; six of the living liver donors had type A, three had type B, and the remaining three had type C. In eight of the living liver donors with a narrowed remnant portal vein, diagnosis was detected by intraoperative Doppler ultrasonography and visual inspection by experienced transplant surgeons in the living donor hepatectomy procedure. In the remaining four living liver donors, diagnosis was performed postoperatively when elevation of liver enzymes was noticed during the routine liver function test and Doppler US. The diagnosis was confirmed by multidetector computed tomography. Results: Data from nine males and three females aged 18 to 54 years were analyzed. All of the living liver donors were followed up for a median of 1710 days (min-max: 1178-4447 days; IQR: 1516 days), and none of the living liver donors had any structural or functional complications in the portal vein. Conclusions: Narrowing remnant portal veins are rare, but they are a life-threatening complication in living liver donors, and this condition requires urgent management. Image guided interventions and narrowed segment resection with end-to-end anastomosis using a vascular graft carried a potential risk for thrombosis and restenosis. To avoid these complications, we shared a technique named "elbow patch reconstruction technique". This technique can be very effective in relieving the narrowing of the remnant portal vein after right lobe living donor hepatectomy.

Defining Surgical Difficulty During Open Right Lobe Donor Hepatectomy and its Prediction Using Preoperative Donor Computed Tomography Morphometry

BackgroundThere is no accepted way to define difficult donor hepatectomy (DiffDH) during open right living donor hepatectomy (ORLDH). There are also no studies exploring association between DiffDH and early donor outcomes or reliable pre-operative predictors of DiffDH. MethodsConsecutive ORLDH performed over 18 months at a single center were included. Intra-operative parameters were used to develop an objective definition of DiffDH. The impact of DiffDH on early postoperative outcomes and achievement of textbook outcome (TO) was evaluated. Donor morphometry data on axial and coronal sections of donor CT at the level of portal bifurcation were collected. Donor and graft factors predictive of DiffDH were evaluated using univariate and multivariate logistic regression. ResultsOne hundred and eleven donors (Male-40.5%, Age-34± 9.5 years) underwent ORLDH during the study period. Difficulty score was constructed using five intra-operative parameters i.e. operating time, transection time, estimated blood loss, need for intra-operative vasopressors and need for Pringle maneuver. Donors were classified as DiffDH (score ≥ 2) or Standard DH (score<2). Twenty nine donors (26%) were classified as DiffDH. DiffDH donors suffered greater all cause morbidity (p=0.004) but not major morbidity (Clavien-Dindo score>2; p=0.651), more peri-operative transfusion (p=0.013), increased post-operative SIRS (p=0.034), delay in achieving full oral diet (p=0.047) and a 70% reduced chance of achieving TO as compared to StDH (p=0.007). On logistic regression analysis, increasing right lobe antero-posterior depth (RLdepth) was identified as an independent predictor of DiffDH (Odds ratio- 2.0(95% ci =1.2,3.3), p<0.006). ROC curve analysis identified RLdepth>14 cms as the best predictor of DiffDH (Sensitivity-79%, specificity-66%, Area under curve=0.803, p<0.001). ConclusionWe report a novel definition of DiffDH and show that it is associated with worse post-operative outcomes, including a lesser chance of achieving TO. We also report that DiffDH can be predicted from readily available donor CT parameters.

Robotic living donor hepatectomy is associated with superior outcomes for both the donor and the recipient compared with laparoscopic or open - A single-center prospective registry study of 3448 cases

Minimally invasive donor hepatectomy is an emerging surgical technique in living donor liver transplantation (LDLT). We examined outcomes across open, laparoscopic, and robotic LDLT using a prospective registry. We analyzed 3448 cases (1724 donor-recipient pairs) from January 2011 to March 2023 (NCT06062706). Among donors, 520 (30%) were female. Adult-to-adult LDLT comprised 1061 (62%) cases. A total of 646 (37%) of the donors underwent open, 165 (10%) laparoscopic, and 913 (53%) robotic hepatectomies. Primary outcomes: donor overall morbidity was 4% (35/903) for robotic, 8% (13/165) laparoscopic, and 16% (106/646) open (P < .001) procedures. Pediatric and adult recipient mortality was similar among the 3 donor hepatectomy approaches: robotic 1.5% and 7.0%, compared with 2.3% and 8.3% laparoscopic, and 1.6% and 5.5% for open donor surgery, respectively (P = .802, P = .564). Secondary outcomes: pediatric and adult recipients major morbidity after robotic hepatectomy was 15% and 23%, compared with 25% and 44% for laparoscopic surgery and 19% and 31% for open surgery, respectively (P = .033, P < .001). Graft and recipient 5-year survival were 90% and 93% for pediatrics and 79% and 80% for adults, respectively. In conclusion, robotic LDLT was associated with superior outcomes when compared with the laparoscopic and open approaches. Both donors and, for the first time reported, recipients benefitted from lower morbidity rates in robotic surgery, emphasizing its potential for further advancing this field.

The Effect of Pringle Maneuver Applied during Living Donor Hepatectomy on the Ischemia-Reperfusion Injury Observed in the Donors and Recipients.

Background and Objectives: The aim of this study is to evaluate the clinical and laboratory changes of ischemia and reperfusion injury in the remnant livers of donors with and without Pringle maneuver. Furthermore, we evaluated the recipients who have been transplanted with liver grafts from these donors. Methods and Materials: A total of 108 patients (54 living liver donors and 54 liver recipients) who underwent donor hepatectomy and recipients who living donor liver transplantation, were included in this randomized double-blind study between February 2021 and June 2021. The donors were divided into two groups: Pringle maneuver applied (n = 27) and Pringle maneuver not applied (n = 27). Similarly, recipients with implanted liver obtained from these donors were divided into two groups as the Pringle maneuver was performed (n = 27) and not performed (n = 27). Blood samples from donors and recipients were obtained on pre-operative, post-operative 0 h day (day of surgery), post-operative 1st day, post-operative 2nd day, post-operative 3rd day, post-operative 4th day, post-operative 5th day, and liver tissue was taken from the graft during the back table procedures. Liver function tests and complete blood count, coagulation tests, IL-1, IL-2, IL-6, TNF-α, and β-galactosidase measurements, and histopathological findings were examined. Results: There was no statistically significant difference in the parameters of biochemical analyses for ischemia-reperfusion injury at all periods in the donors with and without the Pringle maneuver. Similarly, there was no statistically significant difference between in the recipients in who received liver grafts harvested with and without the Pringle maneuver. There was no statistically significant difference between the two recipient groups in terms of perioperative bleeding and early bile duct complications (p = 0.685). In the histopathological examinations, hepatocyte damage was significantly higher in the Pringle maneuver group (p = 0.001). Conclusions: Although the histological scoring of hepatocyte damage was found to be higher in the Pringle maneuver group, the Pringle maneuver did not augment ischemia-reperfusion injury in donors and recipients that was evaluated by clinical and laboratory analyses.

Liver resection volume-dependent pancreatic strain following living donor hepatectomy

The liver and pancreas work together to recover homeostasis after hepatectomy. This study aimed to investigate the effect of liver resection volume on the pancreas. We collected clinical data from 336 living liver donors. They were categorized into left lateral sectionectomy (LLS), left lobectomy, and right lobectomy (RL) groups. Serum pancreatic enzymes were compared among the groups. Serum amylase values peaked on postoperative day (POD) 1. Though they quickly returned to preoperative levels on POD 3, 46% of cases showed abnormal values on POD 7 in the RL group. Serum lipase levels were highest at POD 7. Lipase values increased 5.7-fold on POD 7 in the RL group and 82% of cases showed abnormal values. The RL group’s lipase was twice that of the LLS group. A negative correlation existed between the remnant liver volume and amylase (r = − 0.326)/lipase (r = − 0.367) on POD 7. Furthermore, a significant correlation was observed between POD 7 serum bilirubin and amylase (r = 0.379)/lipase (r = 0.381) levels, indicating cooccurrence with liver and pancreatic strain. Pancreatic strain due to hepatectomy occurs in a resection/remnant liver volume-dependent manner. It would be beneficial to closely monitor pancreatic function in patients undergoing a major hepatectomy.

Deep learning for 3D biliary anatomy for living liver donor hepatectomy planning.

Deep learning for 3D biliary anatomy for living liver donor hepatectomy planning.

Donor Complications Following Living Donor Hepatectomy: 17-Year Experience of a Single Team in One Institution of Japan.

Donor safety is paramount in living donor liver transplantation. However, there remains a risk of postoperative complications for some donors. Here, we provide a comprehensive assessment of donor morbidity by a single team with 17 years of experience at a single center. We retrospectively reviewed 453 donor hepatectomies of living donor liver transplants at Kumamoto University from August 2000 to March 2017. Posterior segment graft cases were excluded in this study. The donors were classified by graft type as follows: right lobe (n = 173), left lobe (n = 149), and left lateral segment (n = 131). The overall complication rate was 29.8%, and the severe complication (Clavien-Dindo grade IIIa or higher) rate was 9.1%. The most frequent complication was bile leakage, with an overall incidence of 13.9% and severe incidence of 4.6%. Among the 3 types of graft, there were no significant differences in bile leakage with any Clavien-Dindo grade. However, upper gastrointestinal complications, such as a duodenal ulcer and gastric stasis, were related to left lobe donation. There were no significant differences in the incidence of postoperative donor complications, except upper gastrointestinal complications, among the 3 types of graft.

Robotic surgery: Moving the needle in living donor hepatectomy.

Robotic surgery: Moving the needle in living donor hepatectomy.

Histopathological Analysis of Gallbladder Specimens Obtained During Living Donor Hepatectomy

Histopathological Analysis of Gallbladder Specimens Obtained During Living Donor Hepatectomy

Diaphragmatic hernia after living-donor hepatectomy: case series of single center

Diaphragmatic hernia after living-donor hepatectomy: case series of single center

Early drain removal after live liver donor hepatectomy is safe - A randomized control trial

Early drain removal after live liver donor hepatectomy is safe - A randomized control trial

Hepatic Duct Division During Robotic Living Donor Hepatectomy: A Comparison Between the Novel Triple C (Clip-Clamp-Cut) and the Cut-Suture Techniques.

Background: In robotic donor hepatectomy (RDH), hepatic duct division (HDD) and its stump closure technique are of paramount importance in avoiding postoperative biliary complications in both donors and recipients. We describe our novel triple C ("clip-clamp-cut") technique of HDD. Methods: Out of 4016 living donor liver transplant (LDLT) (2004-October 2023), we have performed 208 RDH cases since December 2019. This study is a retrospective analysis of the first 160 RDH cases. After excluding the first 20 RDH cases (learning curve) and 3 left-sided RDH cases, 137 cases with no exclusion criteria were included. We divided these 137 donors into the "cut and suture" (CS) group (n = 33) and the "triple C" technique group (n = 104). We compared intraoperative details and postoperative outcomes. Results: All 137 robotic donors and 128/137 recipients are currently well. Donor biliary leak rate was significantly lower among the triple C group (n = 3, 2.9%) compared to the CS group (n = 5, 15.2%) (p=0.009). No other differences in postdonation morbidity were observed among the two groups. Recipient biliary complication rate was lower in the triple C group than in the CS group although not statistically significant (10.6% vs. 15.1%; p=0.537), despite more multiple biliary anastomoses in the former. No significant differences in post-transplant recipient morbidity and mortality were observed. Conclusions: Our simple yet novel triple C technique enables clean, precise, bloodless HDD resulting in lower donor and potentially recipient biliary complication rates. The ease and reproducibility make it ideal for widespread adoption.

A learning curve for laparoscopic living donor hepatectomy using cusum analysis

A learning curve for laparoscopic living donor hepatectomy using cusum analysis