J Hepatobiliary Pancreat Sci (2015) 22:779–788 DOI: 10.1002/jhbp.288

REVIEW ARTICLE

Laparoscopic living donor hepatectomy: a review of current status Jeong-Ik Park · Ki-Hun Kim · Sung-Gyu Lee Published online: 8 October 2015 © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery

Abstract Over the last two decades, laparoscopic surgery has been adopted in various surgical fields. Its advantages of reduced blood loss, reduced postoperative morbidity, shorter hospital stay, and excellent cosmetic outcome compared with conventional open surgery are well validated. In comparison with other abdominal organs, laparoscopic hepatectomy has developed relatively slowly due to the potential for massive bleeding, technical difficulties and a protracted learning curve. Furthermore, applications to liver graft procurement in living donor liver transplantation (LDLT) have been delayed significantly due to concerns about donor safety, graft outcome and the need for expertise in both laparoscopic liver surgery and LDLT. Now, laparoscopic left lateral sectionectomy in adult-to-pediatric LDLT is considered the standard of care in some experienced centers. Currently, the shift in application has been towards left lobe and right lobe graft procurement in adult LDLT from left lateral section in pediatric LDLT. However, the number of cases is too small to validate the safety and reproducibility. The most important concern in LDLT is donor safety. Even though a few studies reported the technical feasibility and comparable outcomes to conventional open surgery, careful validating through larger sample sized studies is needed to achieve standardization and wide application. Keywords Hepatectomy · Laparoscopy · Liver transplantation · Living donor · Minimally invasive Introduction Living donor liver transplantation (LDLT) has become an established treatment modality for patients with end-stage liver J.-I. Park Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea K.-H. Kim (✉) · S.-G. Lee Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, Ulsan University College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, Korea e-mail: [email protected]

disease because of the shortage of deceased donor organs. Since the first successful LDLT of a left lateral section graft from a mother to her son in 1989, this life-saving procedure has been applied to many adult patients [1]. Its safety and feasibility has been well documented over the past several decades and it is considered a valid and life-saving procedure, especially in countries where there are few or no options for deceased organ donation [2–6]. The most important concern in LDLT is donor safety, however, the permanent large abdominal incision scar following conventional open surgery may cause some living donors, especially young women, mental and physical stress, leading to hesitation with undergoing donor hepatectomy. Minimally invasive liver surgery, which has many advantages over the conventional open surgery, has been developed over the past two decades for the treatment of benign or malignant liver diseases [7, 8]. The application of minimally invasive liver surgery to graft procurement in LDLT can help to minimize the skin incision and related abdominal wall complications in donor hepatectomy while ensuring donor safety. Laparoscopic living donor left lateral sectionectomy (LDH-LLS) has revalidated by studies with larger numbers of cases since first reported in 2002, the procedure considered the standard of care in some experienced centers [9–11]. Since the complexity of laparoscopic hepatectomy was overcome in other indications, laparoscopic living donor hepatectomy (LDH) has also been investigated for major hepatectomy. However, only a small number of centers have performed LDH until now because the procedure can be performed only by surgical teams with extensive expertise in performing both minimally invasive surgery on the liver and donor hepatectomy in LDLT. In this review article we will evaluate the current status of LDH and provide balanced insights on the benefits and detriments of the laparoscopic approach in liver donors.

Methods A literature search was performed using PubMed, and English language articles were selected using the following

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combinations of keywords: (laparoscopic or laparoscopyassisted or minimally invasive or hybrid or hand-assisted) and (living donor or live donor) and (hepatectomy or liver resection). The final search was completed by April 2015. All titles and abstracts were screened and those related to LDH were retrieved. The references lists of the selected articles were also reviewed for additional reliable citations. Articles were excluded if they contained that data from animal studies or review articles without original data. All data were screened and apparent duplicated data were not included in the total number of patients.

Results Total number of published articles on laparoscopic living donor hepatectomy A PubMed search identified a total of 565 articles, of these, 32 articles [9–39] were selected for review after excluding duplicates, review articles, animal studies, and unrelated to donor hepatectomy. Additionally, one article [40] was retrieved from reference lists of the selected articles and one article [41] in submission by the authors was also selected. Most data have been reported as case series or case–control studies. There were 34 articles accounted for 22 centers and 480 cases worldwide.

Definition of the terms for laparoscopic liver procedures The Louisville Consensus Conference defined the terms for laparoscopic liver procedures. These three techniques have been used for laparoscopic major hepatectomy: pure laparoscopy (the pure or the totally laparoscopic method), hand-assisted laparoscopy (the hand-assisted method), and laparoscopy-assisted major hepatectomy (the laparoscopy-assisted method or the hybrid technique). To be brief, in the pure laparoscopic method, the entire resection of the liver is completed through laparoscopic ports; small incision may be made for specimen extraction. The hand-assisted method is defined by the elective placement of a hand port to facilitate the procedure, and the specimen is extracted from the hand-port incision. With the hybrid technique or the laparoscopy-assisted method, the liver is mobilized in a pure laparoscopic or hand-assisted procedure but the parenchymal transection is performed under direct vision through a 10- to 12-cm mini-laparotomy incision through which the specimen is extracted [42]. Various types of mini-laparotomy incisions like upper midline, right subcostal or right transverse incision are used depending on the surgeon’s preferences.

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Laparoscopic left lateral sectionectomy in living donors To date, many studies have reported that laparoscopic left lateral sectionectomy for benign and malignant liver lesions is superior to standard open surgery [17, 43, 44]. Moreover, left lateral section is one of the more appropriate uses of the laparoscopic approach for the procurement of liver grafts in living donors, because the left lateral section has well-defined anatomic surgical landmarks [10, 15]. LDH-LLS was first reported by Cherqui et al. [9] in 2002, confirming that this technique was feasible for pediatric LDLT. Subsequently, its safety and reproducibility were demonstrated by Soubrane et al. [10] in 2006, by Kim et al. [11] in 2011. According to these two studies, the laparoscopic approach has advantages of less blood loss, shorter hospital stay, rapid postoperative recovery and comparable donor morbidity over the open approach in addition to the cosmetic benefits. The results of the studies [9–14, 16, 17] on pure laparoscopic living donor left lateral sectionectomy (PLDH-LLS) except laparoscopyassisted method [19, 45] for pediatric LDLT are summarized in Table 1. Our team, Yu and Kim et al. [16] reappraised the safety and reproducibility of the procedure in a larger donor group than our first report. Scatton et al. [17] reported results obtained from 70 living donors, revalidating this laparoscopic procedure. Recently, Samstein et al. [12] also revalidated PLDH-LLS. Now, laparoscopic left lateral sectionectomy for graft procurement in living donors is considered primarily in some experienced centers. However, the development of graft hepatic artery thrombosis in pediatric LDLT is a matter for consideration. A report by Soubrane et al. [10] showed higher vascular complication rates (hepatic artery thrombosis) in the grafts compared to the open approach. Thereafter, it was explained that these complications resulted from the lack of anticoagulant use at the time of vessel division. Following these results, the authors would most likely modify the procedure to introduce a systematic protocol for anticoagulation before retrieval [17]. Though modifications to the inadequate sections of the procedure are required before wide application, LDH-LLS is a safe and reproducible approach in light of the results achieved so far. Laparoscopic major hepatectomy in living donors Since LDH-LLS for pediatric LDLT was successfully established with the evolution of minimally invasive liver surgery techniques, the laparoscopic approach has been applied to major donor hepatectomy in adult LDLT. As the number of deaths among patients on the waiting list increased, LDLT became considered as a valuable alternative for deceased donor liver transplantation in Western countries. The overall incidence of LDLT in the United States increased sharply

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Table 1 Results of the studies on pure laparoscopic living donor left lateral sectionectomy Authors

No.

OP time, min

Blood loss, ml

Comparative study (pure laparoscopic method vs. open surgery) Soubrane et al. [10] 16/14 320 ± 67 18.7 ± 44.2 /244 ± 55 /199.2 ± 185.4 P < 0.005 P < 0.005 Kim et al. [11] 11/11 330 ± 68 396 ± 72 /306 ± 29 /464 ± 78 P = NS P = NS 17/20 478 ± 68 177.3 ± 100.6 Samstein et al. [12]f /398 ± 42 /375.3 ± 190.9 P < 0.005 P < 0.005 Case series study (pure laparoscopic method) Cherqui et al. [9] 2 360–420 150–450 Troisi et al. [13] 1 – – Troisi et al. [14] 1 – – Yu et al. [16] 15 331.3 ± 63 410.0 ± 71.2 Scatton et al. [17]k 67 275 (175–520) 82 ± 79

LOS, day

WIT, min

Donor Cxa

Recipient Cxb

11.0 ± 2.7 /12.8 ± 4.9 P = NS 6.9 ± 0.3 /9.8 ± 0.9 P = 0.001 4.27 ± 1.5 /5.95 ± 1.5 P < 0.005

10 (6–12) /5 (2–7) P = NS 6±2 /5 ± 1 P = NS –

3 (18.7%)c /5 (35.7%) P = NS 0 /1 (0.09%)

6 (37.5%)d /6 (42.8%) 2 (18.1%)e /2 (18.1%)

2 (9.0%)g /6 (30.0%)

2 (9.0%)h /

5–7 7 2 7.1 ± 0.8 –

4–10 6 4 5.8 ± 1.6 9 ± 4.1

0 0 0 0 6 (8.5%)l

1 (50%)i 0 0 2 (13.3%)j 18 (25.7%)m

a

Defined higher than grade II Clavien classification Defined vascular and biliary Cx c Bile leak required reoperation (n = 1) and suprapubic incision hematoma (n = 2) d Hepatic artery thrombosis (n = 2), graft necrosis due to portal vein thrombosis required retransplant (n = 1), and biliary strictures (n = 3) e Portal vein stenosis treated with intraoperative portal vein stent (n = 1) and biliary stricture treated with PTBD (n = 1) f The results included five left hepatectomies g Hernia (n = 1) and bile leak (n = 1) h Hepatic artery thrombosis (n = 1) and portal vein thrombosis (n = 1) i Hepatic artery thrombosis (n = 1) j Portal vein stenosis (n = 1) and biliary stricture (n = 1) k The results were not described separately, included three left hepatectomies; l Bile leak (n = 2), biliary stricture (n = 1), suprapubic incision hematoma (n = 1), bladder injury (n = 1), and ulcer (n = 1) m Hepatic artery thrombosis (n = 5), portal vein thrombosis (n = 3), and biliary Cx (n = 10) Cx complications, LOS length of stay, WIT warm ischemic time b

during the late 1990s; however, expansion of LDLT was restricted following reports of fatal donor complications in the literature and the worldwide media [46–48]. In this setting, the application of the laparoscopic approach for major donor hepatectomy is likely to help potential donors who hesitate to donate in LDLT reach a positive decision, and subsequently contribute to the increased number of LDLT.

Laparoscopic left hepatectomy in living donors Until now, the reports of laparoscopic living donor left hepatectomy (LDH-LL) have been relatively limited in contrast with left lateral section or right hepatectomy in living donors. We found 11 articles [9–14, 16, 17] (10 centers: 142 cases) for LDH-LLS, nine articles [12, 18–25] (six centers: 94 cases) for LDH-LL, and 21 articles [18, 20–23, 26–41] (14 centers: 252 cases) for LDH-RL from literature search in present study. From the viewpoint of the surgical technique, left lobe graft procurement is simpler than right lobe graft because left

lobe graft usually has a single hepatic vein, a single portal vein and a single bile duct although multiple hepatic artery reconstructions are sometimes needed. On the other hand, right lobe graft requires additional reconstructions of the middle hepatic vein tributaries and multiple bile duct reconstructions [49]. It is believed that the low number of reports is not associated with the difficulty of the surgical technique but rather, to the preference for right lobe graft in terms of recipient recovery [48, 50]. If the donor safety is warranted, right lobe graft is often selected in many transplant centers to prevent smallfor-size syndrome. The expansion of LDLT programs in Western countries has been restricted by donor safety concerns in contrast with the stable establishment of LDLT in Eastern countries where cadaveric organs are scarce. Due to this concern about donor safety, some groups prefer left lobe graft in adult LDLT [21, 24, 49, 51]. Soejima et al. [49] suggested that the left lobe graft is an appropriate option that can sustain the metabolic demands of the adult recipients, and could be considered first for ideal patients with a Model for End-Stage Liver Disease (MELD) score < 30 as well as for

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those with estimated graft volume to standard liver volume (GV/SLV) ratio > 35%. The representative reports [18–20] for LDH-LL use the laparoscopy-assisted method. The reports of laparoscopyassisted living donor left hepatectomy (LADH-LL) showed less pain, improved postoperative symptoms, and faster recovery in comparison with conventional open surgery. The studies [18–23] on LADH-LL are summarized in Table 2. A study by Kurosaki et al. [18] showed that the operative time, blood loss and length of stay with LADH-LL were comparable to those of open surgery, but postoperative pain, duration and use of supplemental analgesics were significantly reduced (3.2 ± 0.4 vs. 3.7 ± 0.6 days, P = 0.014; 1.2 ± 1.2 vs. 3.8 ± 2.8 times, P = 0.039, respectively). Another study by Marubashi et al. [19] showed that operative time was significantly longer with LADH-LL than with open surgery (435 ± 103 vs. 383 ± 73 min, P = 0.005), but the hospital stay was significantly shorter with LADH-LL (10.3 ± 3.3 vs. 18.3 ± 16.7 days, P = 0.019). There was no significant donor morbidity in both studies. Recent studies on pure laparoscopic living donor left hepatectomy (PLDH-LL) by Troisi et al. [24] and Samstein et al. [12, 25] indicated that the procedure took longer to complete but offered advantages of lower blood loss and shorter length of stay in addition to significantly reducing the number of days taken off work (Table 3). However, the

number of cases is too small to validate the safety and reproducibility; therefore, more reports by experienced teams are needed. LDH-LL has been shown to be technically feasible, and comparable to open surgery with regard to the donor outcome, so the procedure can have positive effects on the postoperative quality of life for donors. However, larger sample sized studies are needed to further establish its safety and reproducibility.

Laparoscopic right hepatectomy in living donors Adult LDLT typically requires a right lobe graft to provide sufficient graft size for the recipient. Even though open donor right hepatectomy (ODH-RL) is well described and characterized as a safe procedure, approximately 40% of the donors in LDLT experienced complications, according to some reviews of living donor complications [52–54]. In a review of donor hepatectomy in Japan [54], the morbidity risk generally increased as the hepatectomy mass increased from left lateral section donation (8.2%) to left lobe donation (12.0%), and to the right lobe donation (19.0%). For this reason, the laparoscopic approach has been used with the aim of reducing postoperative pain, recovery time and surgical morbidity in major donor hepatectomy [29]. However, LDH-RL has been

Table 2 Results of the studies on laparoscopy-assisted living donor left hepatectomy Authors

No.

OP time, min

Comparative study (laproscopy-assisted method vs. open surgery) Kurosaki et al. [18]b 10/13 363 ± 32.7 /320 ± 67.9 P = NS 14/79 435 ± 103 Marubashi et al. [19]c /383 ± 73 P = 0.005 Soyama et al. [20] 41/137 398 (286–671) /400 (310–802) P = NS Case series study (laproscopy-assisted method) 9 456 (328–581) Soyama et al. [21]f Oya et al. [22] 4 529–645 Takahara et al. [23] 13 – a

Blood loss, ml

LOS, day

Donor Cxa

302 ± 191 /283 ± 371 P = NS 353 ± 396 /456 ± 347 P = NS 475 (50–3350) /610 (170–3150) P = NS

11.0 ± 2.7 /12.8 ± 4.9 P = NS 10.3 ± 3.3 /18.3 ± 16.7 P = 0.019 –

0/0

2 (6.5%)d /9 (11.4%) P = NS 3(4.4%)e

520 (230–1000) 100–1100 –

– 9–22 –

1 (6.6%)g 0 3 (23.0%)h

Defined higher than grade II Clavien classification The results were not described separately, included three right hepatectomies c The results were not described separately, included 17 left lateral sectionectomies d Delayed gastric emptying required endoscopy (n = 2) e Duodenal ulcer (n = 1), portal vein thrombosis (n = 1) and ileus (n = 1) : Cx was not reported separately, included 25 right hepatectomy group f The results were not described separately, included six right hepatectomies g Portal vein thrombosis required relaparotomy h Biliary Cx. Cx complications, LOS length of stay b

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Table 3 Results of the studies on pure laparoscopic living donor major hepatectomy Authors

Type

No.

OP time, min

Blood loss, ml

LOS, day

WIT, min

Donor Cxa

Troisi et al. [24] Samstein et al. [25] Samstein et al. [12]c Soubrane et al. [37] Rotellar et al. [38] Han et al. [39] Takahara et al. [23] Kim et al. [41]

LL LL LL RL RL RL LL/RL RL

4 2 5 1 1 2 3/3 3

487.5 (370–560) 368.5 (358–379) 478 ± 68 480 480 – 482 ± 81.5 458.6 (427–502)

50 (50–80) 125 177.3 ± 100.6 100 100 – 69.5 ± 60.1 240 (200–270)

5±1 4±1 4.27 ± 1.5 7 4 9 (8–10) 8.5 ± 1.7 7.8 (7–8)

4.7 (4.3–6.5) – – 12 3 – – 4.8 (4.5–5.0)

1 (25%)b 0 2 (9.0%)d 0 0 0 1/1 (33.3%)e 0

a

Defined higher than grade II Clavien classification Isolated right posterior duct treated with Roux-en-Y hepaticojejunostomy c The results were not reported separately, included 17 left lateral sectionectomy group d Hernia (n = 1) and bile leak (n = 1) e Biliary fistula required ERBD and PCD (n = 2) Cx complications, LOS length of stay, WIT warm ischemic time b

scarcely reported up to recent times, in contrast with LDH-LLS for pediatric LDLT. In fact, laparoscopic right hepatectomy is difficult to perform even for the treatment of benign tumors according to a report by Suh et al. [28]. This difficulty is related to (1) extensive mobilization of the heavy right liver, which is deeply seated below the rib cage, (2) ligation of the short hepatic veins, and (3) the deep parenchymal transection needed to retain both inflow and outflow of the liver. Furthermore, in living donors, the vascular and biliary pedicles must be distinctly divided at an adequate level without the use of linear staplers or an electric coagulator; these vessels are very short and small. This is why the first minimally invasive approach to donor right hepatectomy was a mini-incision procedure in contrast with laparoscopic left lateral sectionectomy. There have been some reports recently on the feasibility and safety of using the laparoscopy-assisted approach for donor right hepatectomy. Kurosaki et al. [18] first reported LDH-RL using the laparoscopy-assisted method, Koffron et al. [26] also successfully performed laparoscopy-assisted living donor right hepatectomy (LADH-RL) using a similar method at the same time in 2006. This hybrid technique was later reported by Baker et al. [29] in the United States and by Wakabayashi et al. [40] in Japan. Several case series studies [18, 20, 21, 23, 26–36, 40] of LADH-RL are summarized in Table 4. In Table 4, the laparoscopic procedure in LADH-RL is classified into two groups based on the presence of hand-assistance. There are three types of mini-laparotomy incisions: 9- to 12-cm midline incision, 10- to 15-cm right subcostal incision and 9-cm right transverse incision; depending on the surgeon’s preference. In these reports, there was no donor mortality or comparable complications greater than grade II Clavien classification (3.8–20.0%) [55]. There are some case-matched comparative studies [29, 33, 34] between

LADH-RL and conventional ODH-RL (Table 5). Baker et al. [29] reported shorter operative time (265 ± 48 vs. 316 ± 61 min, P < 0.001), comparable blood loss, length of stay and equivalent donor complication rate and recipient outcomes for 33 LADH-RL cases compared with 33 ODH-RL cases. Zhang et al. [33] reported significantly shorter hospital stay and periods of analgesic use (7.0 ± 1.4 vs. 8.7 ± 2.4 days, P = 0.003; 2.4 ± 1.0 vs. 3.2 ± 1.0 days, P = 0.011, respectively), comparable blood loss, operative time and donor complications for 25 LADH-RL cases compared with 25 ODH-RL cases. The three main case-matched comparative studies [30, 31, 35] involving LADH-RL and mini-incision donor right hepatectomy are summarized in Table 6. Ha et al. [31] reported that there were no significant differences in blood loss, hospital stay and incidence of postoperative complications, with the exception of an additional 30 min required for the preparation of laparoscopic devices in the LADH-RL group. However, the laparoscopic-assisted method was useful for the dissection of the retrohepatic vena cava compared with mini-incision right hepatectomy. Nagai et al. [30] reported no significant differences between the two procedures in terms of postoperative liver function tests and length of hospital stay, but the estimated blood loss tended to be lower in the miniincision group than in the hybrid method group (177 ± 89 vs. 350 ± 174 ml, P = 0.09). Suh et al. [35] reported the clinical outcomes and donor satisfaction with different incision methods, and divided the donors into three groups: conventional inverted L incision, upper midline incision, and transverse incision with laparoscopy. The operative time and the length of hospital stay were lowest in the upper midline incision group but the donor satisfaction with the cosmetic results and self-confidence were higher in the upper midline incision and hybrid method groups than in the conventional open method group. Recently, some groups [23, 37–39] in

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Table 4 Results of the studies on laparoscopy-assisted living donor right hepatectomy (hybrid technique) Authors

No.

Hybrid method with hand-assistance Kurosaki et al. [18]b 3 4 Koffron et al. [26]c Koffron et al. [27] 20 Suh et al. [28] 7 Baker et al. [29] 33 Wakabayashi et al. [40] 7 f Soyama et al. [21] 6 Nagai et al. [30] 4 Ha et al. [31] 20 Choi et. al. [32] 11 Zhang et al. [33] 25 Makki et al. [34] 26 Suh et al. [35] 14 Takahara et al. [23] 25 Soyama et al. [20] 25 Hybrid method without hand-assistance Choi et al. [36]l 20/40

OP time, min

Blood loss, mL

LOS, day

Incision (→ extension)

Donor Cxa

363 ± 32.7 235 – 489 ± 87.3 265 ± 48 – 456 (328–581) 389 ± 69 335 ± 93.6 483.9 ± 103.7 385 ± 47.4 702 ± 124.1 333.8 ± 61.7 – 411 (324–581)

302 ± 191 150 – – 417 ± 217 – 520 (230–1000) 350 ± 174 290.1 ± 66 307.8 ± 133.0 378 ± 112.5 336.5 ± 89.4 298.3 ± 118.8 – 600 (130–1900)

11.0 ± 2.7 3±1 – 10.2 ± 3.2 4.3 – – 6.3 ± 1.3 10.7 ± 2.6 9 (8–18) 7.0 ± 1.4 – 10.2 ± 4.4 – –

12 cm, midline 5 cm, midline – 9 cm, transverse 5 cm → ND, midline 10 cm, subcostal 12 cm, midline 10 cm, midline 8 → 10-12 cm, subcostal 9 cm, transverse 5 → 12 cm, midline 6 → 9 cm, midline 9 cm, transverse – 12 cm, midline

0 0 – 1 (14.2%)d 2 (6.1%)e – 1 (6.6%)g – 0 – 1 (4%)h 1 (3.8%)i 0 2 (8%)j 3 (4.4%)k

383.5 ± 41.7/ 278.5 ± 72.2

870.0 ± 653.0/ 450.0 ± 316.4

12.1 ± 2.8/ 11.8 ± 4.4

5 → 15 cm, subcostal

4 (20%)m/6 (15%)n

a

Defined higher than grade II Clavien classification The results were not described separately, included 10 left hepatectomies c After submission, three additional cases were performed d Fluid collection required percutaneous drainage e Small bowel injury (n = 1) and biloma due to wound dehiscence (n = 1) f The results included nine left hepatectomies g Portal vein thrombosis h Bleeding i Pleural effusion needed drainage j Biliary Cx (n = 2) k Duodenal ulcer (n = 1), portal vein thrombosis (n = 1) and ileus (n = 1) : Cx was not reported separately, included 41 left hepatectomy group l 40 cases were performed using single port m Diaphragmatic hernia (n = 1), pleural effusions required percutaneous drainage (n = 2) and biliary stricture treated with ERBD (n = 1) n Pleural effusion (n = 1), biliary Cx (n = 3) and bleeding (n = 2) Cx complications, LOS length of stay, ND not described b

experienced centers reported successful pure laparoscopic living donor right hepatectomy (PLDH-RL). Although the manuscript has not yet been published, we performed three PLDH-RLs in which three young donors with a single and longer segments in the right portal vein, hepatic artery, and bile duct were selected for no compromise operations [41]. There was no graft-related complication but one donor complication, which is biliary fistula that required an endoscopic biliary drainage and a percutaneous abdominal drainage catheter among the 10 reported PLDH-RL cases until now (Table 3). We believe that the strict indication should be recommended for PLDH to reduce donor morbidity. PLDH is the closest technique to the concept of minimally invasive surgery but there is concern about the influence of the additional warm ischemia and prolonged exposure to carbon dioxide pressure on the graft function [24]. To our knowledge,

there are no reported surgical, vascular, immunological or infectious complications resulting from laparoscopic organ retrieval in studies of PLDH. In addition, evolutions of the minimally invasive surgery technique in various attempts have been reported such as single port LADH-RL [36] or robot-assisted donor right hepatectomy [56]. At present, we need to consider balanced insights regarding the benefits and potential risks of development towards pure laparoscopic right lobe graft procurement. PLDH-RL apparently leads to less wound-related morbidity and faster recovery as well as the best cosmetic results, but the technical procedure is somewhat limited in situations involving sudden blood loss during liver transection [57, 58]. We should also consider that there have been reports of difficulties in controlling vascular injuries from failure of vascular clips and stapler that have had unfortunate results despite the procedures being

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Table 5 Results of the comparative studies on laparoscopy-assisted donor right hepatectomy with case-matched open donor hepatectomy Authors

No.

OP time, min

Blood loss, ml

LOS, day

Donor Cxa

Recipient Cxb

Baker et al. [29]

33/33

Zhang et al. [33]

25/25

Makki et al. [34]

26/24

265 ± 48 /316 ± 61 P < 0.001 385.9 ± 47.4 /378.1 ± 59.0 P = NS 702.5 ± 124.1 /675.2 ± 117.5 P = NS

417 ± 217 /550 ± 305 P = NS 378.4 ± 112.5 /422.6 ± 139.3 P = NS 336.5 ± 89.4 /395.8 ± 125.7 P = NS

4.3 /3.9 P = NS 7.0 ± 1.4 /8.7 ± 2.4 P = 0.003 -

2 (6.1%)c /2 (6.1%) P = NS 1 (4%)e /1 (4%) P = NS 1 (3.8%)g /4 (16.6%) P = NS

17 (51.5%)d /19 (57.5%) P = NS 3 (12%)f /1 (4%) P = NS 2 (7.6%)h /2 (8.3%) P = NS

a

Defined higher than grade II Clavien classification Defined vascular and biliary Cx c Small bowel injury (n = 1) and biloma due to wound dehiscence (n = 1) d Hepatic artery thrombosis (n = 2), portal vein thrombosis (n = 1), and biliary Cx (n = 12) e Bleeding required reoperation f Hepatic artery thrombosis (n = 1), biliary stricture (n = 1) and bleeding (n = 1) g Pleural effusion required drainage h Biliary stricture (n = 1) and bile leak (n = 1) Cx complications, LOS length of stay b

Table 6 Results of the comparative studies on laparoscopy-assisted donor right hepatectomy with case-matched mini-incision donor hepatectomy Authors

No.

OP time, min

Blood loss, mL

LOS, day

Donor Cxa

Recipient Cxb

Ha et al. [31]

20/20

7 (25%)c

6 (35.7%)d

Suh et al. [35]e

14/147

10.7 ± 2.6 /10.9 ± 2.5 P = NS 6.3 ± 1.3 /6.0 ± 1.5 P = NS 10.2 ± 4.4 /8.4 ± 1.6 P = 0.01

–

4/9

290.1 ± 66 /250 ± 111.3 P = NS 350 ± 174 /177 ± 89 P = NS 298.3 ± 118.8 /319.9 ± 200.4 P = NS

0/0

Nagai et al. [30]

335.5 ± 93.6 /305.4 ± 88.1 P = NS 389 ± 69 /359 ± 54 P = NS 333.8 ± 61.7 /258.3 ± 43.3 P = 0.000

0 /5 (3.4%)

5 (35.7%)f /48 (32.6%)

a

Defined higher than grade II Clavien classification Defined vascular and biliary Cx c Not classified separately, anticoagulation for deep vein thrombosis (n = 1), treatment with antibiotics for phlebitis (n = 1), readmission for ileus (n = 2), bile leak required ERCP (n = 1), fluid collection required drainage (n = 1) and bleeding required reoperation (n = 1) d Not classified separately, hepatic artery thrombosis (n = 2) and biliary Cx in the others e The results of mini-laparotomy were not described separately, included 10 left hepatectomy f Vascular Cx (n = 2), biliary Cx (n = 2), and bleeding (n = 1) Cx complications, LOS length of stay b

performed by experienced hands in other laparoscopic surgery [59–61]. Moreover, there are some important issues that need further development, certainly in donors with some vascular or biliary anatomical variation for pure laparoscopic graft procurement, which are small sized hepatic artery, and the exact transection site of the bile duct and maintaining the right plane of transection. The short and small sized hepatic artery can increase the risk of intima damage during dissection, and difficulty of transection of the bile duct can induce late biliary stricture in the donors, especially in case of anatomical variations [24, 62]. Living donor mortality in ODH

occurred in 23 donors (0.20%, 23/11,553). Nineteen of these 23 deaths were related to the surgical procedure [47]. In addition, potentially life-threatening near-miss events have been reported, with an incidence not less than 1.1%, even in ODH [47]. If donor mortality is likely a little bit higher after application of laparoscopic surgery, surgeons should not use a laparoscopic approach for donor hepatectomy, because any harm to the donors cannot be justified with any reason. Some liver transplant surgeons concerned that laparoscopic surgery has been too rapidly extended to a living donor candidate without sufficient concerns for donor safety [63], and the

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aim of the development of laparoscopic liver surgery was not with aesthetic result or less pain but with a decrease in the rate of complications [64]. Koffron et al. [26] suggested that LADH-RL for right lobe graft procurement is the better option at this time for the following reasons. First, vascular and biliary anatomical variations greatly increase the difficulty of dissection in the hepatic hilum; however, these variants may not be problematic since hilar dissection can be performed through the hand-assist/extraction incision in a fashion similar to the open technique. Second, parenchymal transection was performed under direct vision with the standard instruments used in the conventional open hepatectomy. Therefore, no incremental risk related to the parenchymal transection was added. Besides, for large right lobe grafts, a sizable incision is needed for retrieval without damages. Due to these concerns, Ha et al. [31] reported that an incision larger than 10-cm is necessary to extract a small-sized right lobe graft smaller than 500 g, but a large-sized graft greater than 700 g requires a slightly larger incision of up to 12-cm in length. Owing to this inevitable limit of the skin incision, a pure laparoscopic approach is a little bit difficult when harvesting larger right lobe grafts. At present, we agree with Lin et al. [58] that LADH-RL is the safe and appropriate minimally invasive procedure for right lobe procurement in LDLT and could provide the benefits of minimally invasive surgery without interfering with donor safety. The Second International Consensus Conference on Laparoscopic Liver Resection evaluated the current status of laparoscopic liver surgery and provided recommendations to aid its future development [64]. The stage of development of LDH was categorized using the Balliol classification of “IDEAL” paradigm: I: idea, D: development, E: exploration, A: assessment, and L: long-term evaluation [65]. LDH-LLS for pediatric LDLT was classified as IDEAL 2b: exploration phase, requires institutional oversight and a registry to determine short and long term outcomes in both donor and recipient. On the other hand, LDH for adult LDLT was classified as IDEAL 2a: development phase, requires both ongoing institutional ethical approval and a reporting registry of all cases in place before beginning to perform this procedure. Long-term outcomes in donors and recipient needed. To conclude, according to this suggestion of the International Consensus Conference, on the basis of potential and unknown risk to donor and level of surgical skills required, laparoscopic donor major hepatectomy in LDLT cannot be recommended for wide introduction at this time [64]. Development of the laparoscopic approach for liver graft procurement towards right-side lobe and pure laparoscopy methods for minimizing donor morbidity has undeniable worth. Nevertheless, by carefully validating the procedure,

J Hepatobiliary Pancreat Sci (2015) 22:779–788

we will have to proceed slowly with the understanding that the donor is not a patient but a healthy individual. Conclusions Laparoscopic living donor left lateral sectionectomy has been well validated and is considered the standard of care in some experienced centers. However, other types of laparoscopic techniques for left or right lobe graft procurement are technically feasible but do not meet the standards for wide application due to lack of evidence. We know that laparoscopic living donor hepatectomy has definite advantages such as less wound morbidity and faster recovery over conventional open surgery. We believe that the benefits will increase the willingness of potential donors to donate in LDLT. More studies with larger sample sizes are needed before laparoscopic major hepatectomy for graft procurement will be ready for broad acceptance. The most important concern in LDLT is donor safety. If the donor is endangered by a new approach attempting to overcome shortcomings of the conventional procedure, the new approach should not be accepted. We should keep in mind that the pure laparoscopic approach for graft procurement in living donors should be performed in selected individuals with favorable anatomy as well as by teams with expertise in both laparoscopic liver surgery and LDLT [24, 62]. Conflict of interest

None declared.

Author contributions KH Kim designed the article; JI Park searched the literatures and wrote the article; SG Lee reviewed the article; KH Kim revised the article and supervised.

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