American Journal of Transplantation 2013; 13: 3269–3273 Wiley Periodicals Inc.
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Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12471
Case Report
Totally Laparoscopic Right-Lobe Hepatectomy for Adult Living Donor Liver Transplantation: Useful Strategies to Enhance Safety F. Rotellar1,*, F. Pardo1, A. Benito2, P. Martı´-Cruchaga1, G. Zozaya1, L. Lopez3, F. Hidalgo3, B. Sangro4,5 and I. Herrero4,5 1
Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, Spain 2 Abdominal Radiology, Department of Radiology, University Clinic, Universidad de Navarra, Pamplona, Spain 3 Department of Anesthesiology, University Clinic, Universidad de Navarra, Pamplona, Spain 4 Liver Unit, Department of Internal Medicine, University Clinic, Universidad de Navarra, Pamplona, Spain 5 Centro de Investigacio´n Biome´dica en Red de Enfermedades Hepa´ticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain Corresponding author: Fernando Rotellar, [email protected]
The overriding concern in living donor liver transplantation is donor safety. A totally laparoscopic right hepatectomy without middle hepatic vein for adult living donor liver transplantation is presented. The surgical procedure is described in detail, focusing on relevant technical aspects to enhance donor safety, specifically the hanging maneuver and dynamic fluoroscopy-controlled bile duct division. Keywords: Adult, laparoscopy, live donor transplantation, liver transplantation, right lobe donor hepatectomy, right lobe graft Abbreviations: CT, computed tomography; DVT, deep venous thrombosis; GRWR, graft to recipient weight ratio; HCC, hepatocellular carcinoma; LDLT, living donor liver transplant; LFTs, liver function tests; LMWH, low-molecular-weight hepatin; LOS, length of stay; MELD, model for end-stage liver disease; MHV, middle hepatic vein; MRCP, magnetic resonance cholangiopancreatogram; NGT, nasogastric tube; RHV, right hepatic vein; WIT, warm isquemia time Received 21 June 2013, revised 31 July 2013 and accepted for publication 19 August 2013
Introduction Liver transplantation is nowadays the only curative option for several end-stage liver diseases. The demand for donor organs far exceeds supply, which has prompted surgeons to develop living donor liver transplant (LDLT) as an alternative organ source. At the same time, the totally laparoscopic approach has become standard practice for several hepatic conditions, and major liver resections and complex procedures are being increasingly performed in experienced centers (1,2). This approach has also been applied to LDLT, with the first totally laparoscopic graft procurement performed in 2002 for a pediatric recipient (3). Nevertheless, LDLT procedures are not free from complications (4,5), or even mortality (6), and thus the most important concern for the transplant community is donor safety. In this paper, a totally laparoscopic right hepatectomy for adult LDLT is presented, with attention focused on relevant technical aspects to enhance donor safety.
Case Description and Methods A 29-year-old male, weighing 74.4 kg, volunteered to donate part of his liver to his 69-year-old father who was suffering from cryptogenic cirrhosis with refractory ascites, episodes of encephalopathy and a history of two episodes of spontaneous bacterial peritonitis and type-1 hepatorrenal syndrome. He also had three hepatocellular carcinomas within Milan criteria. His ChildPugh class was B-9. Model for end-stage liver disease score was 15. Both donor and recipient were studied according to the protocol approved by the institutional review board of the Clinica Universidad de Navarra. Liver volume was estimated by computed tomography (CT) volumetry. Vascular anatomy was assessed by CT, and biliary anatomy by magnetic resonance cholangiopancreatogram. No preoperative liver biopsy was performed. The donor’s right liver volume, excluding middle hepatic vein (MHV), was 1046 cc, 60.6% of the total liver volume. With a recipient weight of 62 kg, graft to recipient weight ratio was 1.67%. The right liver had a single portal vein and a single artery. There were no significant retrohepatic veins. There were two bile ducts from the right lobe, with the right posterior duct draining into the left hepatic duct. The transplant team and transplant coordinator discussed the novelty of the procedure with the donor, recipient and family members, and stated that a full hemilobe graft procured in this manner had not previously been
3269
Rotellar et al performed in our center. A detailed proposal was given to the donor, who provided written consent. The ethics committee of the Clinica Universidad de Navarra revised the case and approved the donation. As dictated by the Spanish transplantation law 30/1979 revised in Royal Decrees 2070/1999 and 1723/2012, this consent was again provided before the presiding judge in the Civil Registry.
Surgical Technique The patient was placed in the supine position, arms abducted and 308 anti-Trendelemburg with the surgeon standing between the patient’s legs. Deep venous thrombosis (DVT) prophylaxis included low-molecularweight hepatin and a sequential-compression device in the lower limbs. The pneumoperitoneum was established with a Veress needle at 12 mmHg pressure. Figure 1A shows trocar placement. A 5 mm 308 laparoscope was used. The procedure followed three phases. Vascular dissection, right liver mobilization and hanging-maneuver preparation After inspection of the abdominal cavity, the round and falciform ligaments were divided. The MHV and right
hepatic vein (RHV) were exposed, with dissection minimized in the vicinity of the left hepatic vein. An ultrasound examination defined the transection line along the right side of the MHV. Calot’s triangle was dissected and the cystic artery and duct were divided. The gallbladder was not removed as it was later used to mobilize the liver. With a delicate leftward traction from the cystic stump, the posterior right side of the hepatic pedicle was exposed and incised, identifying the main portal trunk and its bifurcation. The right portal vein was carefully dissected and taped. Attention was then turned to the artery, whose right trunk and branches were identified. A vessel loop was placed around the right hepatic artery in its trajectory along the anterior aspect of the right portal vein. All this time, the dissection was kept on the right side of the main biliary duct. The identification of the biliary branches was then postponed until the parenchymal transection reached the hepatic hilum, thereby offering better exposure.
Figure 1: Procedural steps: (A) trocar positions and planned suprapubic incision; (B) the right liver remains attached only by its vascular connections (artery outlined in red, portal vein in light blue and RHV in dark blue); (C) back table image showing V5 and V8 outflow veins; asterisks show anterior and posterior bile ducts; (D) implanted graft.
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American Journal of Transplantation 2013; 13: 3269–3273
Laparoscopic Living Donor Right Hepatectomy
The right liver was fully mobilized, dividing the peritoneum and coronary ligaments. The right side of the inferior caval vein was identified and carefully exposed, dividing venous branches between clips or (if less than 3 mm in diameter) with Ligasure V (Valleylab, CO). The hepatocaval ligament was similarly divided. Once the RHV was identified, the blunt end of a nasogastric tube (NGT) was pushed along its left side until it appeared above the liver, in between the anterior aspects of the RHV and MHV. The NGT was left behind the liver in readiness for the hanging maneuver to be performed later in the procedure. Parenchymal transection and fluoroscopy-controlled bile duct division An extracorporeal tourniquet for the Pringle maneuver was prepared. It was exteriorized at the planned suprapubic incision for removal of the graft. This extracorporeal tourniquet method has been reported elsewhere (7). The transection was performed with intermittent 15-min clamping and 5-min release periods. The first centimeter of the transection was performed with Ligasure, and then
with the combined use of a laparoscopic ultrasonic aspirator (CUSA Excel, Valleylab, CO) and Ligasure. The MHV tributary from segment V was identified and sectioned. The remnant side was ligated and secured with a locking clip. The graft stump was only secured with a clip that was later removed during back table reconstruction. Once reached the hilar plate, the opening of the parenchyma offered an optimal exposure and the right anterior hepatic duct was visually identified. A cholangiocatheter was inserted into the cystic stump, and a small vascular clamp placed in the right anterior hepatic duct to identify the optimal place for transection. A C-arm-shaped roentgenographic fluoroscope was brought into the surgical field (Figure 2A). Once fluoroscopic guidance confirmed the appropriate place to divide the anterior duct (Figure 2B), it was dissected, a Hem-o-lock (Weck, Teleflex Medical Europe, Athlone, co Westmeath, Ireland) was placed and, prior to its section, a new fluoroscopic check was done (Figure 2C). Parenchymal transection was continued, and the hilar plate between the two right ducts was sectioned
Figure 2: Intraoperative real-time fluoroscopic guidance for bile duct transection: (A) a C-arm-shaped roentgenographic fluoroscope is left in place during bile duct division process, (B) a vascular clamp precisely identifies where to cut the right anterior duct, (C) fluoroscopic control before anterior duct division, (D) anterior duct is divided and a vascular clamp identifies where to cut the right posterior duct (biliary branches from segments VIII and IVa are outlined in green), (E) final fluoroscopic control showing the integrity of the left biliary tree.
American Journal of Transplantation 2013; 13: 3269–3273
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between clips. The right posterior duct was managed in the same manner (Figure 2D–E). Once the second duct was divided, a final fluoroscopic control confirmed the integrity of the left liver biliary tree and the C-arm fluoroscope was removed from the surgical field. The caudate lobe was then divided, and the NGT passed above the right vessels. Pulling from both ends of the NGT, a hanging maneuver of the liver was performed. This allowed the transection to continue securely, avoiding risk of damage to the MHV; V8 was identified and sectioned between Hem-o-locks for later back table reconstruction. Removal of the graft Once the division of the liver was completed, the right liver depended only on the vascular structures (Figure 1B). The tourniquet was removed and a Pfannestiel incision was prepared, except for the peritoneum that was minimally opened; through it an Endocatch II (Covidien, Norwalk, CT) was inserted and left intra-abdominally. The right artery was ligated with a 2/0 silk tie; two clips were additionally placed before division; the right portal vein was transected with an endostapler (endoGIA 45-2.5; Covidien) as well as the RHV. The graft was placed in the endobag and carefully extracted through the suprapubic incision, which was then closed. Hemostasis was checked, and the falciform ligament sutured to avoid torsion of the remnant liver. No drain was left. The graft was immediately taken to the back table, where staple lines were removed from the portal and RHV stumps (Figure 1C), and flushed with 3 L of Celsior solution (SangStat–Genzyme; Genzyme Germany, Neu-Isenburg, Germany). V5 and V8 outflow was reconstructed with a cryopreserved vascular iliac vein graft. The right lobe graft was then implanted in the recipient in the standard fashion (Figure 1D) (see Video S1 for a detailed presentation of the technique).
Results Total operative time was 480 min. The required clamping time for parenchymal transection was five periods of 15 min. Blood loss was
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Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12471
Case Report
Totally Laparoscopic Right-Lobe Hepatectomy for Adult Living Donor Liver Transplantation: Useful Strategies to Enhance Safety F. Rotellar1,*, F. Pardo1, A. Benito2, P. Martı´-Cruchaga1, G. Zozaya1, L. Lopez3, F. Hidalgo3, B. Sangro4,5 and I. Herrero4,5 1
Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, Spain 2 Abdominal Radiology, Department of Radiology, University Clinic, Universidad de Navarra, Pamplona, Spain 3 Department of Anesthesiology, University Clinic, Universidad de Navarra, Pamplona, Spain 4 Liver Unit, Department of Internal Medicine, University Clinic, Universidad de Navarra, Pamplona, Spain 5 Centro de Investigacio´n Biome´dica en Red de Enfermedades Hepa´ticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain Corresponding author: Fernando Rotellar, [email protected]
The overriding concern in living donor liver transplantation is donor safety. A totally laparoscopic right hepatectomy without middle hepatic vein for adult living donor liver transplantation is presented. The surgical procedure is described in detail, focusing on relevant technical aspects to enhance donor safety, specifically the hanging maneuver and dynamic fluoroscopy-controlled bile duct division. Keywords: Adult, laparoscopy, live donor transplantation, liver transplantation, right lobe donor hepatectomy, right lobe graft Abbreviations: CT, computed tomography; DVT, deep venous thrombosis; GRWR, graft to recipient weight ratio; HCC, hepatocellular carcinoma; LDLT, living donor liver transplant; LFTs, liver function tests; LMWH, low-molecular-weight hepatin; LOS, length of stay; MELD, model for end-stage liver disease; MHV, middle hepatic vein; MRCP, magnetic resonance cholangiopancreatogram; NGT, nasogastric tube; RHV, right hepatic vein; WIT, warm isquemia time Received 21 June 2013, revised 31 July 2013 and accepted for publication 19 August 2013
Introduction Liver transplantation is nowadays the only curative option for several end-stage liver diseases. The demand for donor organs far exceeds supply, which has prompted surgeons to develop living donor liver transplant (LDLT) as an alternative organ source. At the same time, the totally laparoscopic approach has become standard practice for several hepatic conditions, and major liver resections and complex procedures are being increasingly performed in experienced centers (1,2). This approach has also been applied to LDLT, with the first totally laparoscopic graft procurement performed in 2002 for a pediatric recipient (3). Nevertheless, LDLT procedures are not free from complications (4,5), or even mortality (6), and thus the most important concern for the transplant community is donor safety. In this paper, a totally laparoscopic right hepatectomy for adult LDLT is presented, with attention focused on relevant technical aspects to enhance donor safety.
Case Description and Methods A 29-year-old male, weighing 74.4 kg, volunteered to donate part of his liver to his 69-year-old father who was suffering from cryptogenic cirrhosis with refractory ascites, episodes of encephalopathy and a history of two episodes of spontaneous bacterial peritonitis and type-1 hepatorrenal syndrome. He also had three hepatocellular carcinomas within Milan criteria. His ChildPugh class was B-9. Model for end-stage liver disease score was 15. Both donor and recipient were studied according to the protocol approved by the institutional review board of the Clinica Universidad de Navarra. Liver volume was estimated by computed tomography (CT) volumetry. Vascular anatomy was assessed by CT, and biliary anatomy by magnetic resonance cholangiopancreatogram. No preoperative liver biopsy was performed. The donor’s right liver volume, excluding middle hepatic vein (MHV), was 1046 cc, 60.6% of the total liver volume. With a recipient weight of 62 kg, graft to recipient weight ratio was 1.67%. The right liver had a single portal vein and a single artery. There were no significant retrohepatic veins. There were two bile ducts from the right lobe, with the right posterior duct draining into the left hepatic duct. The transplant team and transplant coordinator discussed the novelty of the procedure with the donor, recipient and family members, and stated that a full hemilobe graft procured in this manner had not previously been
3269
Rotellar et al performed in our center. A detailed proposal was given to the donor, who provided written consent. The ethics committee of the Clinica Universidad de Navarra revised the case and approved the donation. As dictated by the Spanish transplantation law 30/1979 revised in Royal Decrees 2070/1999 and 1723/2012, this consent was again provided before the presiding judge in the Civil Registry.
Surgical Technique The patient was placed in the supine position, arms abducted and 308 anti-Trendelemburg with the surgeon standing between the patient’s legs. Deep venous thrombosis (DVT) prophylaxis included low-molecularweight hepatin and a sequential-compression device in the lower limbs. The pneumoperitoneum was established with a Veress needle at 12 mmHg pressure. Figure 1A shows trocar placement. A 5 mm 308 laparoscope was used. The procedure followed three phases. Vascular dissection, right liver mobilization and hanging-maneuver preparation After inspection of the abdominal cavity, the round and falciform ligaments were divided. The MHV and right
hepatic vein (RHV) were exposed, with dissection minimized in the vicinity of the left hepatic vein. An ultrasound examination defined the transection line along the right side of the MHV. Calot’s triangle was dissected and the cystic artery and duct were divided. The gallbladder was not removed as it was later used to mobilize the liver. With a delicate leftward traction from the cystic stump, the posterior right side of the hepatic pedicle was exposed and incised, identifying the main portal trunk and its bifurcation. The right portal vein was carefully dissected and taped. Attention was then turned to the artery, whose right trunk and branches were identified. A vessel loop was placed around the right hepatic artery in its trajectory along the anterior aspect of the right portal vein. All this time, the dissection was kept on the right side of the main biliary duct. The identification of the biliary branches was then postponed until the parenchymal transection reached the hepatic hilum, thereby offering better exposure.
Figure 1: Procedural steps: (A) trocar positions and planned suprapubic incision; (B) the right liver remains attached only by its vascular connections (artery outlined in red, portal vein in light blue and RHV in dark blue); (C) back table image showing V5 and V8 outflow veins; asterisks show anterior and posterior bile ducts; (D) implanted graft.
3270
American Journal of Transplantation 2013; 13: 3269–3273
Laparoscopic Living Donor Right Hepatectomy
The right liver was fully mobilized, dividing the peritoneum and coronary ligaments. The right side of the inferior caval vein was identified and carefully exposed, dividing venous branches between clips or (if less than 3 mm in diameter) with Ligasure V (Valleylab, CO). The hepatocaval ligament was similarly divided. Once the RHV was identified, the blunt end of a nasogastric tube (NGT) was pushed along its left side until it appeared above the liver, in between the anterior aspects of the RHV and MHV. The NGT was left behind the liver in readiness for the hanging maneuver to be performed later in the procedure. Parenchymal transection and fluoroscopy-controlled bile duct division An extracorporeal tourniquet for the Pringle maneuver was prepared. It was exteriorized at the planned suprapubic incision for removal of the graft. This extracorporeal tourniquet method has been reported elsewhere (7). The transection was performed with intermittent 15-min clamping and 5-min release periods. The first centimeter of the transection was performed with Ligasure, and then
with the combined use of a laparoscopic ultrasonic aspirator (CUSA Excel, Valleylab, CO) and Ligasure. The MHV tributary from segment V was identified and sectioned. The remnant side was ligated and secured with a locking clip. The graft stump was only secured with a clip that was later removed during back table reconstruction. Once reached the hilar plate, the opening of the parenchyma offered an optimal exposure and the right anterior hepatic duct was visually identified. A cholangiocatheter was inserted into the cystic stump, and a small vascular clamp placed in the right anterior hepatic duct to identify the optimal place for transection. A C-arm-shaped roentgenographic fluoroscope was brought into the surgical field (Figure 2A). Once fluoroscopic guidance confirmed the appropriate place to divide the anterior duct (Figure 2B), it was dissected, a Hem-o-lock (Weck, Teleflex Medical Europe, Athlone, co Westmeath, Ireland) was placed and, prior to its section, a new fluoroscopic check was done (Figure 2C). Parenchymal transection was continued, and the hilar plate between the two right ducts was sectioned
Figure 2: Intraoperative real-time fluoroscopic guidance for bile duct transection: (A) a C-arm-shaped roentgenographic fluoroscope is left in place during bile duct division process, (B) a vascular clamp precisely identifies where to cut the right anterior duct, (C) fluoroscopic control before anterior duct division, (D) anterior duct is divided and a vascular clamp identifies where to cut the right posterior duct (biliary branches from segments VIII and IVa are outlined in green), (E) final fluoroscopic control showing the integrity of the left biliary tree.
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between clips. The right posterior duct was managed in the same manner (Figure 2D–E). Once the second duct was divided, a final fluoroscopic control confirmed the integrity of the left liver biliary tree and the C-arm fluoroscope was removed from the surgical field. The caudate lobe was then divided, and the NGT passed above the right vessels. Pulling from both ends of the NGT, a hanging maneuver of the liver was performed. This allowed the transection to continue securely, avoiding risk of damage to the MHV; V8 was identified and sectioned between Hem-o-locks for later back table reconstruction. Removal of the graft Once the division of the liver was completed, the right liver depended only on the vascular structures (Figure 1B). The tourniquet was removed and a Pfannestiel incision was prepared, except for the peritoneum that was minimally opened; through it an Endocatch II (Covidien, Norwalk, CT) was inserted and left intra-abdominally. The right artery was ligated with a 2/0 silk tie; two clips were additionally placed before division; the right portal vein was transected with an endostapler (endoGIA 45-2.5; Covidien) as well as the RHV. The graft was placed in the endobag and carefully extracted through the suprapubic incision, which was then closed. Hemostasis was checked, and the falciform ligament sutured to avoid torsion of the remnant liver. No drain was left. The graft was immediately taken to the back table, where staple lines were removed from the portal and RHV stumps (Figure 1C), and flushed with 3 L of Celsior solution (SangStat–Genzyme; Genzyme Germany, Neu-Isenburg, Germany). V5 and V8 outflow was reconstructed with a cryopreserved vascular iliac vein graft. The right lobe graft was then implanted in the recipient in the standard fashion (Figure 1D) (see Video S1 for a detailed presentation of the technique).
Results Total operative time was 480 min. The required clamping time for parenchymal transection was five periods of 15 min. Blood loss was
