Living Donor Hepatectomy Research Articles

Complete transition from open surgery to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomies.

This study was designed to review laparoscopic living donor liver transplantations (LDLTs) at a single center that achieved complete transition from open surgery to laparoscopy. LDLTs performed from January 2013 to July 2021 were reviewed. Comparisons between open and laparoscopic surgeries were performed according to periods divided into initial, transition, and complete transition periods. A total of 775 LDLTs, 506 laparoscopic and 269 open cases, were performed. Complete transition was achieved in 2020. Bile duct variations were significantly abundant in the open group both in the initial period (30.2% vs. 8.1%; p<0.001) and transition period (48.1% vs. 24.3%; p<0.001). Portal vein variation was more abundant in the open group only in the initial period (13.0% vs. 4.1%; p=0.03). Although the donor reoperation rate (0.0% vs. 4.1%; p=0.02) and Grade III or higher complication rate (5.6% vs. 13.5%; p=0.03) were significantly higher in the laparoscopy group in the initial period, there were no differences during the transition period as well as in overall cases. Median number of opioids required by the donor (three times [interquartile range, IQR, 1-6] vs. 1 time [IQR, 0-3]; p<0.001) was lower, and the median hospital stay (10 days [IQR, 8-12] vs. 8 days [IQR, 7-9]; p<0.001) was shorter in the laparoscopy group. Overall recipient bile leakage rate (23.8% vs. 12.8%; p<0.001) and overall Grade III or higher complication rate (44.6% vs. 37.2%; p=0.009) were significantly lower in the laparoscopy group. Complete transition to laparoscopic living donor hepatectomy was possible after accumulating a significant amount of experience. Because donor morbidity can be higher in the initial period, donor selection for favorable anatomy is required for both the donor and recipient.

The current and future role of robotic surgery in liver surgery and transplantation.

Minimally invasive surgery (MIS) is gaining interest in all surgical fields, especially in the hepatobiliary and liver transplant branch with excellent outcomes. However, its application especially in the living donation, is at the beginning and still controversial, with few published studies. A literature review was performed using the following keywords reviewing the current role of robotic donor hepatectomy in the literature and to evaluate the possible future implication in the transplant field: minimally invasive liver surgery, laparoscopic liver surgery, robotic liver surgery, robotic living donation, laparoscopic donor hepatectomy, robotic donor hepatectomy. 3-D imaging with high definition and stable view, a more rapid learning curve than the laparoscopic one and the lack of hand tremors and the freedom of movements are all important advantages claimed in favor of robotic surgery. Furthermore, most of the studies showed, compared to open surgery, less postoperative pain, less intraoperative blood loss, and a shorter period before returning to normal activity to the detriment of longer operation time. The excellent outcome can be explained thanks to the three-dimensional and magnification view that allows for better evaluation compared to the laparoscopic approach to the right plane of transection, vascular and biliary anatomy, and thanks to the precision of the movements a better bleeding control. Robotic approach, especially in living donor hepatectomy, is considered safe and feasible, even if its superiority compared to the open and laparoscopic approaches needs further evaluation.

Robotic surgery and liver transplantation: A single-center experience of 501 robotic donor hepatectomies

BackgroundOver the past two decades robotic surgery has been introduced to many areas including liver surgery. Laparoscopic liver surgery is an alternative minimally invasive approach. However, moving on to the complexity of living donor hepatectomies, the advantages of robotic versus laparoscopic approach have convinced us to establish the robotic platform as a standard for living donor hepatectomy. MethodsFrom November 2018 to January 2022, 501 fully robotic donor hepatectomies, including 177 left lateral donor lobes, 112 full left lobes and 212 full right lobes were performed. Grafts were donated to 296 adult recipients and 205 pediatric recipients. Donor age, sex, body weight, body mass index (BMI), graft weight, graft to body weight ratio (GBWR), operative time, blood loss, first warm ischemic time, pain score, length of intensive care unit (ICU) stay and hospital stay, and complications were retrospectively analyzed based on a prospectively kept database. Recipients were evaluated for graft and patient survival, age, sex, BMI, body weight, model of end-stage liver disease score, blood loss, transfusions, operative time, cold ischemic time, length of hospital stay and complications. ResultsThere was no donor mortality. Two cases needed to be converted to open surgery. The median blood loss was 60 mL (range 20-800), median donor operative time was 6.77 h (range 2.93-11.53), median length of hospital stay was 4 days (range 2-22). Complication rate in donors classified following Clavien-Dindo was 6.4% (n = 32) with one grade III complication. Three-year actual recipient overall survival was 91.4%; 87.5% for adult recipients and 97.1% for pediatric recipients. Three-year actual graft overall survival was 90.6%; 87.5% for adult recipients and 95.1% for pediatric recipients. In-hospital mortality was 6%, 9.1% (27/296) for adult recipients and 1.4% (3/205) for pediatric recipients. The recipients’ morbidity was 19.8% (n = 99). Twenty-eight recipients (5.6%) had biliary and 22 (4.4%) vascular complications. Six (12.0%) recipients needed to be re-transplanted. ConclusionsWith growing experience it is nowadays possible to perform any donor hepatectomy by robotic approach regardless of anatomical variations and graft size. Donor morbidity and quality for life results are encouraging and should motivate other transplant centers with interest in minimally invasive donor surgery to adopt this robotic technique.

Hepatic and portal vein transection by vascular stapler in open living donor hepatectomy – A retrospective cohort study

BackgroundIn an effort to increase donor safety in living donor liver transplantation, the utilization of vascular staplers for the division of the right portal and hepatic veins in patients undergoing right lobe liver donation for living donor liver transplantation (LDLT) was implemented. In here we report our experience with vascular staplers in patients undergoing LDLT and evaluate the subsequent feasibility and safety for donors. Material and methods17 cases of living donor liver transplant were retrospectively analyzed. The right portal vein was transected directly at the bifurcation of the main portal vein, the right hepatic vein was resected directly at the wall of the inferior vena cava using a vascular stapler device. ResultsWe registered a complication rate of 41.2% (7 donors). According to the Clavien-Dindo classification, grade II and grade III complications were each observed in 5.9% and grade IIIb complications in 29.4%, whereas catastrophic bleeding, complications with residual disability or the necessity of re-laparatomy did not occur. Upon 6 weeks, all donors were able to return to their previous occupation in fully recovered condition. ConclusionsThe utilization of vascular staplers in donors during open LDLT presents an encouraging alternative to manual over-sewing of vascular stumps. Apart from its timesaving aspect, the technique reduces the potential risk of life-threatening clamp slippage with subsequent uncontrolled blood loss.

Complete transition from open to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomy

Complete transition from open to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomy

The impact of liver steatosis on the postoperative evolution after right lobe living-donor hepatectomy.

Living donor liver transplantation has become a feasible treatment modality for end-stage liver disease. The obesity epidemic worldwide has made it increasingly common to encounter liver steatosis in living donor candidates. The aim of study was to analyze the impact of moderate hepatic steatosis on the postoperative evolutions after right lobe living-donor hepatectomy. Living donors who underwent donor hepatectomy during the period 2000 to 2020 in two medical centers were included in this study. We distinguished 3 groups based on the degree of steatosis: Group O - 0%, Group I - 1-10% and Group II >10%. A total number of 157 living donors underwent surgery, of whom 112 (71.34%) were right lobe liver donors. There were 62 without steatosis, 31 - with steatosis 1-10% and 19 with steatosis >10%. No difference has been found in proportion of men, median of age, body mass index and left lobe/total liver volume ration in compared groups. Total liver volume was significantly higher in the Group I than in the Group O (p=0.028). The moderate hepatic steatosis (HS) group presented significant higher volume of intraoperative hemorrhage than no-HS group (p=0.041). No differences were observed in the postoperative liver function between the groups. The minimal HS group comprised a significantly higher proportion of postoperative complications than no-HS group (67.7% vs 40.3%, p=0.043). The longer postoperative length of hospital stay in ICU was observed in Group I than in Group O (p=0.024). Moderate HS does not importantly impair living liver donors' safety.

Living donor hepatectomy in medium volume liver transplant centre has comparable outcomes to high volume centres: validation of donabedian quality assurance framework.

Given the complexity of living donor hepatectomy, it is expected that high hospital volume will better outcomes. This study aims to evaluate post-operative outcomes for living donor hepatectomy in a medium volume liver transplant centre and compare to outcomes in high volume centres. Also, it serves as a validation tool for framework of structure-process-outcome model for safe living donor hepatectomy program. 204 donors who underwent donor hepatectomy between June 1996 to September 2019 were reviewed retrospectively and compared to outcomes in high volume centres. At 6 months, overall donor morbidity rate was 20/204 (9.8%). Wound complications were most common at 5/204 (2.5%). Majority of complications were either Clavien grade 1 or 2 and only 3 donors had Clavien grade 3 complications. There was zero donor mortality. Our centre's donor morbidity rate of 9.8% is the one of the lowest reported in the published literature. With increased experience, stringent donor selection and enhanced perioperative care by a multi-disciplinary team, outcomes in a medium volume centre can match the outcomes reported in high volume centres. The framework for quality in terms of structure, process and outcomes is presented which can be adopted for developing programs.

Complete transition from open to laparoscopic living donor hepatectomy: 8-year experience with more than 500 laparoscopy cases

Complete transition from open to laparoscopic living donor hepatectomy: 8-year experience with more than 500 laparoscopy cases

Lessons learned from 261 consecutive living donor hepatectomy in a single center

Lessons learned from 261 consecutive living donor hepatectomy in a single center

The outcomes of pure laparoscopic living donor hepatectomy at small volume center

The outcomes of pure laparoscopic living donor hepatectomy at small volume center

Laparoscopic donor and recipient hepatectomy followed by robot-assisted liver graft implantation in living donor liver transplantation

Minimally invasive surgery has been introduced for liver transplantations. Although laparoscopic or robot-assisted living donor hepatectomy is being used, minimally invasive surgery is rarely performed in recipients during liver transplantation. A 63-year-old patient (body mass index: 21.9kg/m2 ) with primary biliary cirrhosis underwent total laparoscopic explant hepatectomy, followed by robot-assisted liver engraftment using advanced technological innovations. The total operation time for the recipient was 12h 20min, including laparoscopic explant hepatectomy (140min) and robot-assisted engraftment (220min). Achieving hepatic and portal vein anastomoses consumed 35 and 28min, respectively. The hepatic artery anastomosis and bile duct reconstruction took 83 and 66min, respectively. The estimated blood loss was 3600ml. The warm and cold ischemic times were 87 and 220min, respectively. The patient received 10 units each of red blood cells and fresh frozen plasma during the surgery and recovered from early allograft dysfunction after liver transplantation. This case study suggests that laparoscopic explant hepatectomy followed by robot-assisted engraftment is feasible in selected recipients only. We obtained informed consent for this innovative procedure from the patient and from her living donor.

Transcystic biliary drainage after living donor hepatectomy prevents biliary complications

Transcystic biliary drainage after living donor hepatectomy prevents biliary complications

Comparison of Continuous Thoracic Epidural With Erector Spinae Block for Postoperative Analgesia in Adult Living Donor Hepatectomy.

Background: Thoracic epidural analgesia (TEA) is commonly used for pain management in donor hepatectomy. Erector spinae plane block (ESPB) is a newer ultrasound-guided block described for the management of thoracic and abdominal pain. There is limited literature available comparing the two techniques. The objective of this study was to compare the postoperative analgesic efficacy and adverse effects of continuous ESPB to continuous TEA in donor hepatectomy.Methodology: The randomized controlled trial (RCT) was registered on ClinicalTrials.gov (NCT04151511). A total of 82 patients undergoing donor hepatectomy between January 2020 and December 2020 were recruited, of whom 41 received TEA and 41 received ESPB. Randomization was done by the sealed opaque envelope method.Results: The mean visual analog scale (VAS) scores in donors who received TEA and ESPB in post-anesthesia care unit (PACU) (2.7 + 0.9 vs. 2.4 + 0.5; P = 0.02) at one hour (2.7 + 0.9 vs. 2.2 + 0.6; P = 0.008), six hours (1.8 + 0.9 vs. 0.8 + 0.5; P < 0.001), 12 hours (0.9 + 0.7 vs. 0.2 + 0.7; P < 0.001), and 24 hours (0.48 + 0.5 vs. 0.08 + 0.3; P < 0.001) were significantly different. Mean opioid consumption was 3.38 ± 6.24 mg in the ESPB group and 10.75 ± 9.64 mg in the TEA group (P < 0.001). Mean lung volume (MLV) at 24 hours in the TEA group and ESPB group was 1543 ml and 1815 ml (P < 0.001). MLV was 2545 ml in the TEA group and 2820 ml in the ESPB group at 48 hours (P < 0.001). Mean nausea and vomiting score at six hours was 0.1 vs. 0.03 (P = 0.02).Conclusion: ESPB improves pain control after donor hepatectomy with an enhanced safety profile and reduced opioid consumption.

Anaphylactic shock during living donor hepatectomy: An anaesthesiologist's nightmare and the recipient's too?

Anaphylactic shock during living donor hepatectomy: An anaesthesiologist's nightmare and the recipient's too?

Change of Anesthetic Management From Open to Laparoscopic Living Donor Right Hepatectomy After Learning Curve

In our hospital, open living donor hepatectomy (OLDH) began in 1996 and laparoscopic living donor hepatectomy (LLDH) began in 2013. In this study, we focus on the change of anesthetic management from OLDH to LLDH. Under the approval of the Institutional Review Board of our hospital, medical records of the last 2 years (2011 and 2012 vs 2019 and 2020) of each OLDH and LLDH era were collected. Left hepatectomy in any period and OLDH during the LLDH era were excluded. There were 175 OLDHs and 213 LLDHs. We performed 836 cases of OLDH before 2011 and 206 cases of LLDH before 2019. Laryngeal mask airway replaced intubation in half of LLDH cases. Erector spinae plane block was performed in a quarter of LLDH cases. Lung-protective ventilation with low tidal volume and positive end-expiratory pressure were applied for LLDH. Additional peripheral venous line was decreased, and there was no central venous catheterization. Anesthesia duration time was reduced and crystalloid infusion per hour was also decreased. There was no intraoperative transfusion and there was no difference in postoperative transfusion incidence. Reoperation rate was not different. Only 1 donor in OLDH transferred to the intensive care unit after the operation because of uncontrolled hypertension. Length of hospital stay was decreased. As the surgical tactics for living liver donors become less invasive, the anesthetic strategy also becomes less invasive. In addition, new types of airway management, ventilation method, and analgesic technique have been introduced.

Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.

Use of a Mini-subcostal Incision for Living Donor Right Hepatectomy: A Series of 189 Consecutive Cases

Introduction: Living donor hepatectomy is now a well-established surgical procedure. However, a large abdominal incision is still required, which results in a large permanent scar, especially for a right liver graft. Minimally invasive surgery has been widely used for donor operations. This study aimed to determine the safety and feasibility of mini- subcostal incision for living donor right hepatectomy. Methods: We reviewed 1456 patients who underwent living donor right hepatectomy (LDRH) between January 2015 and December 2019 at Asan Medical Center. We performed 1:1 propensity score matching of the LDRH with mini- subcostal incision and the LDRH with conventional incision (J-shape), with 144 patients subsequently included in each group. Results: The total operation time (P =0.018) were longer in the mini- subcostal incision group. None of the donors required intraoperative transfusion or experienced any irreversible disabilities or mortalities. The length of postoperative hospital stay was significantly shorter in the mini- subcostal incision group (P =0.043). The rate of complications in donors was similar between the 2 groups. Graft steatosis were independent predictors of postoperative morbidity after LDRH with mini- subcostal incision on multivariable analysis. Vascular and biliary complication rates in recipients were similar between the 2 groups. Conclusions: LDRH with mini- subcostal incision is feasible when performed at an experienced living donor liver transplantation center. Donor safety is paramount in living donor liver transplantation. In centers with difficulties in performing pure laparoscopic donor right hepatectomy, LDRH with mini-subcostal incision can be an alternative to pure laparoscopic donor right hepatectomy.

Pure laparoscopic living donor liver transplantation: Dreams come true

Minimally invasive approaches are increasingly being applied in surgeries and have recently been used in living donor hepatectomy. We have developed a safe and reproducible method for minimally invasive living donor liver transplantation, which consists of pure laparoscopic explant hepatectomy and pure laparoscopic implantation of the graft, which was inserted through a suprapubic incision. Pure laparoscopic explant hepatectomy without liver fragmentation was performed in a 60-year-old man with alcoholic liver cirrhosis and hepatocellular carcinoma. The explanted liver was retrieved through a suprapubic incision. A modified right liver graft, procured from his 24-year-old son using the pure laparoscopic method, was inserted through a suprapubic incision, and implantation was performed intracorporeally throughout the procedure. The time required to remove the liver was 369min, and the total operative time was 960min. No complications occurred during or after the surgery. The patient recovered well, and his hospital stay was of 11days. Pure laparoscopic living donor liver transplantation from explant hepatectomy to implantation was performed successfully. It is a feasible procedure when performed by a highly experienced surgeon and transplantation team. Further studies with larger sample sizes are needed to confirm its safety and feasibility.

Indocyanine Green Near-Infrared Fluorescence Cholangiogram During Pure Laparoscopic Living Donor hepatectomy For Optimal Bile Duct Division

Introduction: Biliary complications in living donor liver transplantation are most common and troubled problem to liver transplant surgeons, various method to decease biliary complications has been studied and determining the optimal bile duct division point is important to decrease complication rate. Intraoperative cholangiogram has been standard method to determine the optimal bile duct division point for conventional donor hepatectomy, but in laparoscopic donor hepatectomy, indocyanine green(ICG) near-infrared fluorescence cholangiogram is alternative option of intraoperative cholangiogram. We compared conventional cholangiogram and ICG near-infrared fluorescence cholangiogram to determine optimal bile duct division point in pure laparoscopic living donor hepatectomy. Method: From May 2016 to October 2019, 80 cases of pure laparoscopic donor hepatectomy has been performed in Kyungpook national university hospital. Conventional cholangiogram was used in 45 cases, ICG near-infrared fluorescence cholangiogram was used in 35 cases. We compared two groups in preoperative bile duct anomaly of donor, operative time and postoperative complications. Result: In bile duct anomaly of donors, there were no differences between two groups. Operative time was much longer in conventional cholangiogram group because conventional cholangiogram procedure itself was time consuming. In one donor of conventional group, biliary complication occurred. Bile leakage from the cutting edge of the remnant right hepatic duct was identified, resolved by ERBD insertion. Conclusion: ICG near-infrared fluorescence cholangiogram is more easier and convenient method to determine proper bile duct division point and is helpful to decrease biliary complications by confirming the real time fluorescence image of bile duct.

Donor Outcomes after a Split Policy Implementation at a Dual Pediatric-Adult Transplant Center

Introduction: Minimally-invasive hepatectomy has been associated with reduced length of stay (LOS) and recovery time compared to open hepatectomy. Minimally-assisted living donor hepatectomy (MLDH, laparoscopic or robotic) is performed in a small number of centers in the US. Herein, we reviewed our experience of MLDH.