Left-Side Hepatectomy in Living Donors: Through a Reduced Upper-Midline Incision for Liver Transplantation M. Shinodaa,*, M. Tanabeb, O. Itanoa, H. Obaraa, M. Kitagoa, Y. Abea, T. Hibia, H. Yagia, A. Fujinoa, S. Kawachic, K. Hoshinoa, T. Kurodaa, and Y. Kitagawaa a Department of Surgery, Keio University School of Medicine, Tokyo, Japan; bDepartment of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan; and cDepartment of Digestive Surgery, Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
ABSTRACT Background. We present our attempts at reducing the length of incision in living donor left-side hepatectomy without laparoscopic approach. Methods. The chief surgeon initially made a 10-cm upper midline incision and performed all procedures through a minilaparotomy without abdominal wall lifting or pneumoperitoneum. For the procedures in the lateral and deep areas, we effectively applied traction to the wound in multiple directions using a wound retraction system so that the chief surgeon could obtain a good direct view. We also placed a fiberscope on the minilaparotomy so that the assistant surgeons could obtain an additional video view via a monitor. Surgeons lengthened the incision at their own discretion if the initial length was thought to be too short for the donor’s safety. Since February 2009, we have employed this operation for 19 living donors (12 lateral segmentectomies and 7 left hepatectomies) and compared parameters between the 19 donors and 34 previous donors who underwent the procedure with standard incision (11 lateral segmentectomies and 23 left hepatectomies). Results. The resultant length of incision was significantly reduced in operations with reduced incision length as compared with standard incision. Clinical outcomes such as operation time and length of hospital stay were comparable or significantly reduced with the reduced incision. The resultant incision length remained within 10 and 12 cm in lateral segmentectomy and left hepatectomy cases, respectively, whose body mass index was less than 22. Conclusion. It appears to be feasible to reduce the incision length for living donor leftside hepatectomy, especially in nonobese cases.
I
T IS EVIDENT that the laparoscopic approach has many benefits for patients, including a magnified intraoperative view, reduced postoperative pain, better cosmetic appearance, and fewer wound-related complications. In 2002, Cherqui and colleagues reported the first donor hepatectomy involving a laparoscopic procedure in which a left lateral lobectomy for liver transplantation was performed successfully on a child [1]. Since then, laparoscopic and laparoscopy-assisted donor hepatectomies have been performed at a few institutions [2e6], but the procedures have not been widely employed, in contrast with laparoscopic and laparoscopy-assisted nonedonor hepatectomy for hepatic neoplasm, the use of which has steadily increased [7e9]. Safety of the donor is of paramount importance for
living donor liver transplantation, and therefore, laparoscopic surgeons may be hesitant to apply laparoscopic techniques to living donors despite recent advances in laparoscopic device technology. Since 1995, we have performed 180 living donor hepatectomies using a standard incision. In 2002, we surveyed postoperative complaints of living donors who were operated on more than 3 months prior to the survey and found that more than half of them had complaints associated with *Address correspondence to Masahiro Shinoda, MD, PhD, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. E-mail: [email protected]
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.12.061
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LEFT-SIDE HEPATECTOMY IN LIVING DONORS
the incision. Subsequently, we successfully performed a laparoscopy-assisted lateral segmentectomy in 2004 and found that it is a viable option for living donors if the procedure is performed by laparoscopy experts. We also recognized that it is necessary to make a small incision to retrieve the graft even if the hepatectomy itself is performed laparoscopically in the abdominal cavity. Following these experiences, we became interested in exploring other procedural options for living donor hepatectomy (ie, making the smallest possible incision in the upper abdomen to retrieve the graft, utilizing a wound retraction system with fiberscope assistance, and performing the procedures through a minilaparotomy employing without abdominal wall lifting or CO2 pneumoperitoneum). These modifications should make the operation less invasive for the donor and result in less damage to the abdominal wall, and may be performed by any surgeon with hepatobiliary expertise. We began using this procedure in February 2009, and in the present study, we assessed its feasibility and clinical benefits. PATIENTS AND METHODS Patients and Parameters The subjects in this study were living donors who underwent left-side hepatectomies between October 2006 and June 2012. In October 2006, we organized the present donor operation team and performed living donor operations using a standard incision as described below. In February 2009, we introduced the living donor procedure using reduced incision for lateral segmentectomy and extended lateral segmentectomy. Since November 2010, we have performed the operation with reduced incision for left hepatectomy with and without the caudate lobe. In this study, we assessed and compared the following parameters between the standard and reduced incision methods: body mass index (BMI; calculated as body weight divided by height squared [kg/m2]); incision length (cm) at the time the operation was completed; graft weight (g); duration of operation (minutes); intraoperative blood loss (mL); postoperative peak values of blood parameters (lowest value for albumin and highest value for other parameters) including aspartate aminotransferase (IU/mL), alanine aminotransferase (IU/mL), alkaline phosphatase (IU/mL), gamma-glutamyl transferase (IU/mL), total bilirubin (mg/dL), prothrombin time-international normalized ratio, and albumin (mg/dL); hospital stay between operation and discharge (days); postoperative complications (more severe than grade III by Clavien-Dindo classification [10]); and hospital charges (1000 yen). We also compared the following recipient outcomes between the standard and reduced incision methods: postoperative peak values for blood parameters assessed in donors and the survival rates (%) at 3 months and 2 years. We also analyzed the relationship between BMI and final incision length in patients who underwent lateral segmentectomy and extended lateral segmentectomy and in patients who underwent left hepatectomy with and without the caudate lobe.
Donor Operation With Standard Incision The patient was placed in a dorsal position and occasionally rotated to the left or right in accordance with the procedures. The chief surgeon was positioned at the right side of the donor, and an assistant surgeon and a laparoscopic surgeon were positioned at the left side of the donor. A 10-cm midline incision was initially made in the upper abdomen for liver biopsy. This “zero biopsy” of the liver
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Fig 1. Operative field from the shorter incision. The minilaparotomy wound is spread using an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, Calif, United States; small black triangles) and Thompson wound retraction system (Thompson Surgical Instruments, Traverse City, Mich, United States; white triangles and white arrows). By attaching multiple spatulas (black arrows) to the suspension rod (white arrows) around the wound and pulling the wound in multiple directions, the minilaparotomy wound goes above the lateral working areas. Neither trocars nor a pneumoperitoneum system were used. A12-cm incision in a case of left hepatectomy with the caudate lobe is shown.
was routinely performed to determine whether the liver was pathologically normal and qualified for grafting. After confirming the pathologic status, the incision was lengthened from the xiphoid process to the bottom of the umbilicus. A Kent retractor (Takasago Medical Industries Co Ltd, Tokyo, Japan) was applied to the wound. In the lateral and extended lateral segmentectomy, the left lobe was mobilized by dissecting the ligament around the liver and the Arantius duct. For left hepatectomy with and without the caudate lobe, the right lobe was also mobilized to an extent by which the Cantlie line came toward the midline. For left hepatectomy with the caudate lobe, the caudate lobe was mobilized from the inferior vena cava with dissection of the short hepatic veins. For the hanging maneuver, semicircular Kelly forceps were inserted into the tunnel between the middle and right hepatic veins, and the common trunk of the middle and left hepatic veins was encircled using a Penrose drain tube. After cholecystectomy, a catheter was inserted from the cystic duct to the common bile duct, and intraoperative cholangiography was performed to confirm the optimal transection line of the left bile duct. The left hepatic artery and the left portal vein were isolated. Liver parenchymal transection was performed using a CUSA (Cavitron Ultrasonic Surgical Aspirator, Tyco Healthcare, Mansfield, Mass, United States) without interruption of inflow to the liver. The liver parenchymal transection line was on the right side of the umbilical portion for lateral segmentectomy, the right side of one of the hepatic veins in the medial segment for extended lateral segmentectomy, and the right side of the middle hepatic vein for left lobectomy with and without the caudate lobe. In the left lobectomy with and without the caudate lobe, a hanging maneuver was applied for liver parenchymal transection using the Penrose drain. The left hepatic duct was dissected
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Fig 2. Direct view and video view of the dissection of ligaments around the liver. Procedures in a case of left hepatectomy with the caudate lobe are shown. (A, B, C) View from the overhead video camera. This represents nearly the full direct view from the chief surgeon’s perspective. (D, E, F) View from the fiberscope on the wound. This video view was mainly watched by the assistant surgeons via a monitor placed to the left and rear of the chief surgeon. The pictures show mobilization of the lateral segment (A, D), right lobe (B, E), and caudate lobe (C, F). (A, D) A Thompson retraction system (Thompson Surgical Instruments, Mich, United States) was used to apply traction to the wound toward the left cranial side (white arrows), and a spatula is pushing the left lobe toward the medial and caudal side (black arrows). Dissection of the left triangular ligament is shown. (B, E) Thompson retraction system was used to apply traction to the wound toward the right cranial side (white arrows), and a spatula is pushing the right lobe toward the left side (black arrows). The coronary ligament and right triangular ligament are being dissected. (C, F) A spatula is pushing the caudate lobe toward the right side (black arrows). The inferior vena cava is being exposed. Lt, left lobe of the liver; Rt, right lobe of the liver; Cd, caudate lobe of the liver; Lg, ligament around the liver; Dp, diaphragm; IVC, inferior vena cava; FS, fiberscope; PS, Powerstar bipolar scissors (Ethicon Japan, Tokyo, Japan); LS, LigaSure vessel sealing system (Covidien Japan, Tokyo, Japan).
at the optimal line confirmed by intraoperative cholangiography. After insertion of a perfusion catheter into the left portal vein, the left hepatic artery, left portal vein, and hepatic vein were dissected, followed by ex situ perfusion. We used a curved atraumatic clamp (Cooley Coarctation clamp, Aesculap, Inc, Center Valley Pa, United States) to clamp the inferior vena cava side of the hepatic vein.
Donor Operation With Reduced Incision Common Procedures and Policy. The patient was placed in a dorsal position and rotated in accordance with the procedures. The
positioning was the same as for the operation with standard incision; the chief surgeon was on the right side of the donor, and the assistant and laparoscopic surgeons were on the left side. A midline incision with a maximum length of 10 cm was initially made in the upper abdomen, and the zero biopsy was performed. A wound retractor (Alexis wound retractor, Applied Medical, Calif, United States) was applied to the incision. We applied traction to the wound toward the lateral working space using a wound retraction system (Thompson Retractor, Thompson Surgical Instruments, Traverse City, Mich, United States), which has multiple retractors and enables traction in multiple directions (Fig 1), so that a good direct view of the working area is created for the
LEFT-SIDE HEPATECTOMY IN LIVING DONORS chief surgeon (Fig 2A, B, C). We also placed a 5-mm or 10-mm flexible fiberscope (Olympus, Tokyo, Japan) at the margin of the wound without inserting trocars or employing CO2 pneumoperitoneum. The fiberscope provided a video view of the deep and lateral working space for the assistant surgeons (Fig 2D, E, F). A monitor was placed at the upper right of the donor (to the left and rear of the chief surgeon) so that the assistant surgeons could view the procedure. Energy-based devices such as Powerstar bipolar scissors (Ethicon Japan, Tokyo, Japan) and LigaSure vessel sealing system (Covidien Japan, Tokyo, Japan) were used for dissecting ligaments and tiny vessels in the deep or lateral working space. Midline procedures (ie, cholecystectomy, inserting a biliary tube, cholangiography, and dividing hilar vessels) and procedures from liver parenchymal transection to removal of the graft were performed in the same way as with the standard method through the reduced incision (Fig 3). We used the Satinsky Vena Cava clamp (Aesculap) to securely grasp the hepatic vein (Fig 3B). Surgeons lengthened the incision during the operation at their own discretion when they recognized that the initial incision length was insufficient to perform the operation safely. Lateral Segmentectomy and Extended Lateral Segmentectomy Procedures. First, after confirming the pathologic status of the zero biopsy, lateral procedures (ie, mobilization of the left lobe) were performed under a combination of direct view and video view as follows. The wound was pulled toward the upper left using a Thompson retraction system so that the wound came over the lateral segment (Fig 2A). The chief surgeon directly watched the left-lateral working area and dissected the ligament around the left lobe and the Arantius duct, while the other surgeons assisted with the procedures while watching the video view in a monitor (Fig 2D). Next, the chief surgeon performed midline procedures (ie, cholecystectomy, inserting a tube into the cystic duct, cholangiography, and dividing the hepatic artery and portal vein) under direct view, while the other surgeons watched mainly the direct view and partially the video view. Finally, procedures from liver parenchymal transection to removing the graft were performed through the reduced incision under direct view without fiberscope assistance, in the same way as with the standard method. Procedures for Left Hepatectomy With and Without the Caudate Lobe. First, after mobilizing the left lobe as described above, the right lobe was also mobilized to an extent by which the Cantlie line came to the midline. The wound was pulled toward the right, and the chief surgeon directly watched the right lateral working area and
1403 dissected the ligament around the right lobe, while the other surgeons watched the video view in the monitor (Fig 2B, E). The common trunk of the middle and left hepatic veins was encircled using a Penrose drain tube under the combination view. The tube was used for the hanging maneuver during liver parenchymal transaction (Fig 3A). For left hepatectomy with the caudate lobe, the caudate lobe was mobilized while pushing to the cranial side with a spatula and dissecting the short hepatic veins with energy devices under the combination view (Fig 2C, F). Next, midline procedures (ie, cholecystectomy, inserting a biliary tube, cholangiography, and dividing hilar vessels) and finally procedures from liver parenchymal transection to removal of the graft were performed in the same way as the lateral segmentectomy and extended lateral segmentectomy through the reduced incision.
Statistical Analysis Results are expressed as means standard deviations (SDs). For parametric data, differences between groups were evaluated using Student t test for unpaired data, based on the assumption that the data were derived from populations with equal SDs. Differences were considered significant at P values less than .05.
RESULTS Comparison Between Operations With Standard and Reduced Incisions
The numbers of living donors who underwent left side hepatectomies between October 2006 and June 2012 are shown in Table 1. Clinical parameters of the operations with standard and reduced incisions are shown in Table 2. Incision length and duration of operation were significantly lower for the operations performed with reduced incision length compared to those with standard incision in the lateral segmentectomy and extended lateral segmentectomy patients. Incision length, duration of operation, aspartate aminotransferase level, alkaline phosphatase level, gamma-glutamyl transferase level, and length of hospital stay were significantly lower in the reduced-incision operations compared with standard incision in patients who underwent left hepatectomy with and without the caudate lobe. With respect to postoperative complications, bile leakage, corresponding to grade
Fig 3. Direct view of dissection of the liver parenchyma and left hepatic vein. Midline procedures in a case of left hepatectomy with the caudate lobe are shown. (A) Liver parenchymal dissection with hanging maneuver. The cut line shown is the right side of the middle hepatic vain. A Penrose drain (PD) was used. Lt, left lobe of the liver; Rt, right lobe of the liver. (B) Clamp of the left hepatic vein (HV). The Satinsky vena cava clamp (CL) is used in the deep area.
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Table 1. Patient Number for Standard and Reduced Incision Operations
Lateral segmentectomy Extended lateral segmentectomy Left hepatectomy Left hepatectomy with caudate lobe Total
Standard Incision
Reduced Incision
9 2 8 15 34
10 2 5 2 19
The liver parenchymal transection line was on the right side of the umbilical portion for lateral segmentectomy, the right side of one of the hepatic veins in the medial segment for extended lateral segmentectomy, and the right side of the middle hepatic vein for left lobectomy with and without the caudate lobe.
IIIa according to the Clavien-Dindo classification [10], was observed in 2 cases of left hepatectomy (1 from the standard incision group and 1 from the reduced incision group), and both were treated uneventfully by conservative methods. In the case with reduced incision, the bile leakage was associated with technical issues pertaining to the bile duct transection but not with the incision length. There were no complications of grade IIIb or higher. With respect to outcomes in recipient, a statistically significant difference was detected only in the comparison of total bilirubin levels in recipients who received the left lobe with or without the caudate lobe. Analyses of Incision Length and BMI
In the group of patients who underwent lateral segmentectomy and extended lateral segmentectomy, BMI was less than 22 in 7 cases and greater than 22 in 5 cases (Fig 4). The incision length was 10 cm or less in all 7 cases in which BMI less than 22 and was greater than 10 cm in all 5 cases in which BMI was greater than 22. In the group of patients who underwent left hepatectomy with and without the caudate lobe, BMI was less than 22 in 4 cases and greater than 22 in 3 cases. The incision length was 12 cm or less in all of the 4 cases in which BMI was less than 22, and was 12 cm or more in all of the 3 cases in which BMI was greater than 22. DISCUSSION
Laparoscopic and laparoscopy-assisted approaches are beneficial for magnifying the intraoperative view, improving cosmetic appearance, and reducing postoperative pain and wound complications, as reported previously [2e6]. However, these procedures are sometimes complex and require considerable expertise with the technique. Consequently, there have been attempts to reduce incision length without employing laparoscopic procedures for donor operations. Lee and coworkers successfully performed 143 consecutive living donor hepatectomies, including both right- and left-side hepatectomies, through an 18-cm upper midline incision and found that a reduced upper-midline incision without laparoscopic assistance can be safely used for living donor hepatectomy [11]. Kasahara and associates performed 70 living donor hepatectomies via lateral segmentectomy through a 7-cm upper midline incision and reported that the duration of operation and hospital stay were significantly shorter for
donors who underwent the procedure with reduced incision versus standard incision [12]. We recognized that the attempts by Lee and Kasahara presented a third option, using neither a full open nor a pure laparoscopic approach, for donor operations. In February 2009, we began using a similar nonlaparoscopic procedure for left hepatectomy and lateral segmentectomy, in which the chief surgeon performed the entire procedure through an upper-midline minilaparotomy without abdominal wall lifting or pneumoperitoneum, but we introduced some modifications. Left hepatectomy and lateral segmentectomy are essentially performed as a 2-step procedure (ie, the lateral procedure and the midline procedure). The lateral portion is performed in the early part of the operation and includes mobilization of the left lobe and right lobe, while the midline portion includes all the other procedures (eg, cholecystectomy, dividing the hepatic artery and portal vein, and dissecting the liver parenchyma). The lateral procedures are usually difficult to perform through a minilaparotomy and are instead done under laparoscopic observation for laparoscopy-assisted lateral segmentectomy and left hepatectomy [5,8]. In this study, we effectively applied traction to the wound toward the lateral working area using the traction system and pushed the liver toward the midline using a spatula. It was feasible to place the minilaparotomy nearly above the working area in the lateral region, enabling the chief surgeon to obtain a good direct view of the area. We also placed a fiberscope above the wound to obtain an additional video view for the assistant surgeons. Although the direct view of the lateral region through the minilaparotomy was fully available to only the chief surgeon, the additional video view was useful for assistant surgeons to create the working area without a direct view. We inserted no ports and employed neither abdominal wall lifting nor CO2 pneumoperitoneum; nonetheless, the lateral procedures for the left hepatectomy and lateral segmentectomy were performed uneventfully through the minilaparotomy. As for the midline portion, we uneventfully performed procedures through the minilaparotomy without fiberscope assistance. It has already been shown that the midline procedure can be performed through a minilaparotomy using an open approach in laparoscopy-assisted lateral segmentectomy and left hepatectomy, in which laparoscopic procedures are employed only for the lateral portion, by some laparoscopic expert surgeons [5,8]. Nitta, one of the pioneer surgeons of laparoscopic hepatectomy, and associates also showed that it is useful to employ the hanging maneuver for transection of the liver through the minilaparotomy [8], because the maneuver lifts the working area toward the ventral side. We introduced some of these reported techniques to our procedures for the midline portion through the minilaparotomy. An important difference between our techniques and those used by Nitta et al is that we dissected the hepatic vein leaving a margin for anastomosis, because Nitta’s involved hepatectomy for neoplasms for which endolinear stapling devices can be used on the hepatic vein. We needed to use an appropriate clamp and leave a margin
Standard Incision (n ¼ 11)
Left Hepatectomy and Left Hepatectomy þ S1
Mean SD
Age Sex (Male/Female) Body mass index (kg/m2) Incision length (cm) Graft weight (g) Duration of operation (min) Blood loss (mL) Postoperative blood parametes AST (IU/L) ALT (IU/L) ALP (IU/L) gGTP (IU/L) TB (mg/dL) PT-INR Alb (g/dL) Hospital stay (d) Hospital charge (x1000 yen) Recipient’s outcomes AST (IU/L) ALT (IU/L) ALP (IU/L) gGTP (IU/L) TB (mg/dL) PT-INR Alb (g/dL) 3-month survival rate (%) 2-year survival rate (%)
32.5 4.6 4/7 21.8 2.9 19.0 2.8 251 64 486 51 144 127
(MinimumMaximum)
Reduced Incision (n ¼ 12) Mean SD
(MinimumMaximum)
MeanSD
(18.0e26.2) (17.0e21.0) (140e358) (412e558) (50e400)
37.8 7.7 4/8 21.3 2.7 11.4 3.1 251 58 413 76 98 100
(16.9e25.4) (7.5e17.0) (180e375) (310e543) (50e400)
NS NS NS P < .05 NS P < .05 NS
(168e642) (175e821) (230e716) (26e228) (0.9e3.8) (1.1e1.4) (2.4e3.4) (8e21) (138e228)
NS NS NS NS NS NS NS NS NS
(281e9652) (277e6634) (675e1978) (36e353) (2.2e15.6) (1.8e3.2) (2.0e3.5)
NS NS NS NS NS NS NS NS NS
(25e39)
168 191 298 99 1.0 0.1 0.3 2.3 9
(179e688) (162e763) (63e1049) (41e356) (1.0e3.8) (1.1e1.5) (2.4e3.3) (10e17) (143e173)
365 436 401 84 1.8 1.3 2.9 11.8 173
845 612 1281 300 9.7 2.7 2.7 91 91
976 618 775 315 5.6 1.0 0.3
(137e3514) (121e2255) (375e3135) (67e916) (2.6e23.4) (1.8e5.2) (2.2e3.1)
1389 2615 1084 1767 1286 385 162 114 7.0 4.7 2.3 0.4 2.8 0.4 100 100
348 361 456 141 1.9 1.3 2.8 12.6 158
Standard Incision (n ¼ 23)
151 222 128 57 0.9 0.1 0.3 3.7 26
(29e56)
(MinimumMaximum)
Reduced Incision (n ¼ 7) MeanSD
37.1 11.2 8/15 22.9 2.6 27.5 5.1 425 85 560 93 223 196
(16.2e27.4) (23e33) (311e616) (409e812) (30e650)
33.69.3 4/3 21.3 2.4 12.3 2.1 385 96 391 78 229 204
436 450 438 147 2.4 1.2 2.9 14.5 164
194 164 294 134 1.4 0.1 0.2 4.4 12
(176e948) (279e923) (132e1358) (24e500) (1.1e6.3) (1.0e1.5) (2.5e3.1) (8e30) (138e184)
303 377 244 69 1.9 1.4 2.8 10 171
498 548 891 302 15.8 2.3 2.5
669 827 436 284 8.3 0.6 0.4 87 78
(119e3121) (106e3216) (336e1873) (37e1187) (5.5e38.1) (1.5e3.6) (1.8e3.4)
413 631 317 401 695 322 314 300 8.4 6.8 2.3 0.9 2.5 0.4 100 100
(20e57)
82 107 54 57 0.9 0.2 0.3 2.1 10
(MinimumMaximum)
(21e49) (18.2e24.5) (10.0e16.0) (256e534) (248e485) (50e600)
NS NS NS P < .05 NS P < .05 NS
(222e436) (230e507) (162e322) (26e190) (1.1e3.7) (1.2e1.6) (2.5e3.3) (7e13) (160e183)
P < .05 NS P < .05 P < .05 NS P < .05 NS P < .05 NS
(127e1833) (97e1213) (322e1214) (57e924) (3.1e23.1) (1.5e4.1) (2.0e3.1)
NS NS NS NS P < .05 NS NS NS NS
LEFT-SIDE HEPATECTOMY IN LIVING DONORS
Table 2. Comparison of Operations Performed With Standard and Reduced Incisions Lateral Segmentectomy and Extended Lateral Segmentectomy
Abbreviations: AST, aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; gGTP, gamma-glutamyl transferase; TB, total bilirubin; PT-INR, prothrombin time-international normalized ratio; NS, not significant.
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Fig 4. Relationship between body mass index (BMI) and incision length. The relationships between BMI and final incision length in (A) patients with lateral segmentectomy and extended lateral segmentectomy and (B) patients with left hepatectomy with and without the caudate lobe are shown.
at the hepatic vein for anastomosis to the recipient side of the hepatic vein. We used a Cooley coarctation clamp in the operation with standard incision, but the clamp’s grip interfered with the wound. Therefore, we used a Satinsky vena cava clamp to securely grasp the hepatic vein from the minilaparotomy. Donor safety is an absolute requirement for living donor liver transplantation. When we introduced the new operation in February 2009, we recognized that surgeons should lengthen the incision when the initial incision length appeared insufficient to ensure safety. In fact, an incision greater than 10 cm was used in 8 of the 19 cases. We retrospectively assessed the relationship between BMI and incision length in lateral segmentectomy and extended lateral segmentectomy and found that the boundary between an incision length greater than 10 cm and 10 cm or less was a BMI of 22, which is the average BMI in the Japanese population according to Japan Society for the Study of Obesity [13]. The BMI of 22 was also the boundary between an incision length greater than 12 cm and 12 cm or less in left hepatectomy with and without the caudate lobe. It is therefore reasonable that surgeons lengthened the incision in cases with above average BMI. It is also noteworthy that the average incision length was still much shorter in the reduced incision group than in the standard incision group even after the incision was lengthened in some of the cases. The duration of operation, blood parameters, length of hospital stay, and adverse events may vary depending on the skill of the surgeon. It is difficult to estimate the actual duration of the operation, because the living donor operation sometimes includes waiting time to coordinate the operation with the recipient. However, it is very likely that reducing incision length has a beneficial impact on some clinical outcomes especially for left hepatectomy with and without the caudate lobe. We confirmed that introduction of this procedure produced no unfavorable outcomes in recipients. Since the number of cases was relatively small in this study, a greater number of patients should be evaluated in the future to more precisely determine the benefits of this operation. Great attention should also be paid to the prevention of postoperative complications, such as bile leakage, irrespective of the incision length.
In conclusion, it appears to be feasible to reduce the incision length for living donor left-side hepatectomy by applying wound retraction and obtaining an additional video view. The devices used for the modified procedure were all commercially available. We believe that the procedures presented herein can be performed uneventfully if the surgeon is a hepatobiliary expert and that the procedures are a suitable option for living donor operations. REFERENCES [1] Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392. [2] Baker TB, Jay CL, Ladner DP, et al. Laparoscopy-assisted and open living donor right hepatectomy: a comparative study of outcomes. Surgery 2009;146:817. [3] Choi HJ, You YK, Na GH, et al. Single-port laparoscopy-assisted donor right hepatectomy in living donor liver transplantation: sensible approach or unnecessary hindrance? Transplant Proc 2012;44: 347. [4] Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522. [5] Kurosaki I, Yamamoto S, Kitami C, et al. Video-assisted living donor hemihepatectomy through a 12-cm incision for adultto-adult liver transplantation. Surgery 2006;139:695. [6] Soyama A, Takatsuki M, Hidaka M, et al. Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision. Transplant Proc 2012;44:353. [7] Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009;250:825. [8] Nitta H, Sasaki A, Fujita T, et al. Laparoscopy-assisted major liver resections employing a hanging technique: the original procedure. Ann Surg 2010;251:450. [9] Wakabayashi G, Nitta H, Takahara T, et al. Standardization of basic skills for laparoscopic liver surgery towards laparoscopic donor hepatectomy. J Hepatobiliary Pancreat Surg 2009;16:439. [10] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205. [11] Lee KW, Kim SH, Han SS, et al. Use of an upper midline incision for living donor partial hepatectomy: a series of 143 consecutive cases. Liver Transpl 2011;17:969. [12] Kasahara M, Sakamoto S, Shigeta T, et al. A 7-cm upper midline incision for living donor left lateral hepatectomy: singe-center consecutive 70 donor experience. Transplantation 2012;93:e33. [13] JASSO - Japan Society for the Study of Obesity, http://www. jasso.or.jp/contents/english/index.html; 2014. Accessed on May 18, 2014.
ABSTRACT Background. We present our attempts at reducing the length of incision in living donor left-side hepatectomy without laparoscopic approach. Methods. The chief surgeon initially made a 10-cm upper midline incision and performed all procedures through a minilaparotomy without abdominal wall lifting or pneumoperitoneum. For the procedures in the lateral and deep areas, we effectively applied traction to the wound in multiple directions using a wound retraction system so that the chief surgeon could obtain a good direct view. We also placed a fiberscope on the minilaparotomy so that the assistant surgeons could obtain an additional video view via a monitor. Surgeons lengthened the incision at their own discretion if the initial length was thought to be too short for the donor’s safety. Since February 2009, we have employed this operation for 19 living donors (12 lateral segmentectomies and 7 left hepatectomies) and compared parameters between the 19 donors and 34 previous donors who underwent the procedure with standard incision (11 lateral segmentectomies and 23 left hepatectomies). Results. The resultant length of incision was significantly reduced in operations with reduced incision length as compared with standard incision. Clinical outcomes such as operation time and length of hospital stay were comparable or significantly reduced with the reduced incision. The resultant incision length remained within 10 and 12 cm in lateral segmentectomy and left hepatectomy cases, respectively, whose body mass index was less than 22. Conclusion. It appears to be feasible to reduce the incision length for living donor leftside hepatectomy, especially in nonobese cases.
I
T IS EVIDENT that the laparoscopic approach has many benefits for patients, including a magnified intraoperative view, reduced postoperative pain, better cosmetic appearance, and fewer wound-related complications. In 2002, Cherqui and colleagues reported the first donor hepatectomy involving a laparoscopic procedure in which a left lateral lobectomy for liver transplantation was performed successfully on a child [1]. Since then, laparoscopic and laparoscopy-assisted donor hepatectomies have been performed at a few institutions [2e6], but the procedures have not been widely employed, in contrast with laparoscopic and laparoscopy-assisted nonedonor hepatectomy for hepatic neoplasm, the use of which has steadily increased [7e9]. Safety of the donor is of paramount importance for
living donor liver transplantation, and therefore, laparoscopic surgeons may be hesitant to apply laparoscopic techniques to living donors despite recent advances in laparoscopic device technology. Since 1995, we have performed 180 living donor hepatectomies using a standard incision. In 2002, we surveyed postoperative complaints of living donors who were operated on more than 3 months prior to the survey and found that more than half of them had complaints associated with *Address correspondence to Masahiro Shinoda, MD, PhD, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. E-mail: [email protected]
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.12.061
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LEFT-SIDE HEPATECTOMY IN LIVING DONORS
the incision. Subsequently, we successfully performed a laparoscopy-assisted lateral segmentectomy in 2004 and found that it is a viable option for living donors if the procedure is performed by laparoscopy experts. We also recognized that it is necessary to make a small incision to retrieve the graft even if the hepatectomy itself is performed laparoscopically in the abdominal cavity. Following these experiences, we became interested in exploring other procedural options for living donor hepatectomy (ie, making the smallest possible incision in the upper abdomen to retrieve the graft, utilizing a wound retraction system with fiberscope assistance, and performing the procedures through a minilaparotomy employing without abdominal wall lifting or CO2 pneumoperitoneum). These modifications should make the operation less invasive for the donor and result in less damage to the abdominal wall, and may be performed by any surgeon with hepatobiliary expertise. We began using this procedure in February 2009, and in the present study, we assessed its feasibility and clinical benefits. PATIENTS AND METHODS Patients and Parameters The subjects in this study were living donors who underwent left-side hepatectomies between October 2006 and June 2012. In October 2006, we organized the present donor operation team and performed living donor operations using a standard incision as described below. In February 2009, we introduced the living donor procedure using reduced incision for lateral segmentectomy and extended lateral segmentectomy. Since November 2010, we have performed the operation with reduced incision for left hepatectomy with and without the caudate lobe. In this study, we assessed and compared the following parameters between the standard and reduced incision methods: body mass index (BMI; calculated as body weight divided by height squared [kg/m2]); incision length (cm) at the time the operation was completed; graft weight (g); duration of operation (minutes); intraoperative blood loss (mL); postoperative peak values of blood parameters (lowest value for albumin and highest value for other parameters) including aspartate aminotransferase (IU/mL), alanine aminotransferase (IU/mL), alkaline phosphatase (IU/mL), gamma-glutamyl transferase (IU/mL), total bilirubin (mg/dL), prothrombin time-international normalized ratio, and albumin (mg/dL); hospital stay between operation and discharge (days); postoperative complications (more severe than grade III by Clavien-Dindo classification [10]); and hospital charges (1000 yen). We also compared the following recipient outcomes between the standard and reduced incision methods: postoperative peak values for blood parameters assessed in donors and the survival rates (%) at 3 months and 2 years. We also analyzed the relationship between BMI and final incision length in patients who underwent lateral segmentectomy and extended lateral segmentectomy and in patients who underwent left hepatectomy with and without the caudate lobe.
Donor Operation With Standard Incision The patient was placed in a dorsal position and occasionally rotated to the left or right in accordance with the procedures. The chief surgeon was positioned at the right side of the donor, and an assistant surgeon and a laparoscopic surgeon were positioned at the left side of the donor. A 10-cm midline incision was initially made in the upper abdomen for liver biopsy. This “zero biopsy” of the liver
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Fig 1. Operative field from the shorter incision. The minilaparotomy wound is spread using an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, Calif, United States; small black triangles) and Thompson wound retraction system (Thompson Surgical Instruments, Traverse City, Mich, United States; white triangles and white arrows). By attaching multiple spatulas (black arrows) to the suspension rod (white arrows) around the wound and pulling the wound in multiple directions, the minilaparotomy wound goes above the lateral working areas. Neither trocars nor a pneumoperitoneum system were used. A12-cm incision in a case of left hepatectomy with the caudate lobe is shown.
was routinely performed to determine whether the liver was pathologically normal and qualified for grafting. After confirming the pathologic status, the incision was lengthened from the xiphoid process to the bottom of the umbilicus. A Kent retractor (Takasago Medical Industries Co Ltd, Tokyo, Japan) was applied to the wound. In the lateral and extended lateral segmentectomy, the left lobe was mobilized by dissecting the ligament around the liver and the Arantius duct. For left hepatectomy with and without the caudate lobe, the right lobe was also mobilized to an extent by which the Cantlie line came toward the midline. For left hepatectomy with the caudate lobe, the caudate lobe was mobilized from the inferior vena cava with dissection of the short hepatic veins. For the hanging maneuver, semicircular Kelly forceps were inserted into the tunnel between the middle and right hepatic veins, and the common trunk of the middle and left hepatic veins was encircled using a Penrose drain tube. After cholecystectomy, a catheter was inserted from the cystic duct to the common bile duct, and intraoperative cholangiography was performed to confirm the optimal transection line of the left bile duct. The left hepatic artery and the left portal vein were isolated. Liver parenchymal transection was performed using a CUSA (Cavitron Ultrasonic Surgical Aspirator, Tyco Healthcare, Mansfield, Mass, United States) without interruption of inflow to the liver. The liver parenchymal transection line was on the right side of the umbilical portion for lateral segmentectomy, the right side of one of the hepatic veins in the medial segment for extended lateral segmentectomy, and the right side of the middle hepatic vein for left lobectomy with and without the caudate lobe. In the left lobectomy with and without the caudate lobe, a hanging maneuver was applied for liver parenchymal transection using the Penrose drain. The left hepatic duct was dissected
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Fig 2. Direct view and video view of the dissection of ligaments around the liver. Procedures in a case of left hepatectomy with the caudate lobe are shown. (A, B, C) View from the overhead video camera. This represents nearly the full direct view from the chief surgeon’s perspective. (D, E, F) View from the fiberscope on the wound. This video view was mainly watched by the assistant surgeons via a monitor placed to the left and rear of the chief surgeon. The pictures show mobilization of the lateral segment (A, D), right lobe (B, E), and caudate lobe (C, F). (A, D) A Thompson retraction system (Thompson Surgical Instruments, Mich, United States) was used to apply traction to the wound toward the left cranial side (white arrows), and a spatula is pushing the left lobe toward the medial and caudal side (black arrows). Dissection of the left triangular ligament is shown. (B, E) Thompson retraction system was used to apply traction to the wound toward the right cranial side (white arrows), and a spatula is pushing the right lobe toward the left side (black arrows). The coronary ligament and right triangular ligament are being dissected. (C, F) A spatula is pushing the caudate lobe toward the right side (black arrows). The inferior vena cava is being exposed. Lt, left lobe of the liver; Rt, right lobe of the liver; Cd, caudate lobe of the liver; Lg, ligament around the liver; Dp, diaphragm; IVC, inferior vena cava; FS, fiberscope; PS, Powerstar bipolar scissors (Ethicon Japan, Tokyo, Japan); LS, LigaSure vessel sealing system (Covidien Japan, Tokyo, Japan).
at the optimal line confirmed by intraoperative cholangiography. After insertion of a perfusion catheter into the left portal vein, the left hepatic artery, left portal vein, and hepatic vein were dissected, followed by ex situ perfusion. We used a curved atraumatic clamp (Cooley Coarctation clamp, Aesculap, Inc, Center Valley Pa, United States) to clamp the inferior vena cava side of the hepatic vein.
Donor Operation With Reduced Incision Common Procedures and Policy. The patient was placed in a dorsal position and rotated in accordance with the procedures. The
positioning was the same as for the operation with standard incision; the chief surgeon was on the right side of the donor, and the assistant and laparoscopic surgeons were on the left side. A midline incision with a maximum length of 10 cm was initially made in the upper abdomen, and the zero biopsy was performed. A wound retractor (Alexis wound retractor, Applied Medical, Calif, United States) was applied to the incision. We applied traction to the wound toward the lateral working space using a wound retraction system (Thompson Retractor, Thompson Surgical Instruments, Traverse City, Mich, United States), which has multiple retractors and enables traction in multiple directions (Fig 1), so that a good direct view of the working area is created for the
LEFT-SIDE HEPATECTOMY IN LIVING DONORS chief surgeon (Fig 2A, B, C). We also placed a 5-mm or 10-mm flexible fiberscope (Olympus, Tokyo, Japan) at the margin of the wound without inserting trocars or employing CO2 pneumoperitoneum. The fiberscope provided a video view of the deep and lateral working space for the assistant surgeons (Fig 2D, E, F). A monitor was placed at the upper right of the donor (to the left and rear of the chief surgeon) so that the assistant surgeons could view the procedure. Energy-based devices such as Powerstar bipolar scissors (Ethicon Japan, Tokyo, Japan) and LigaSure vessel sealing system (Covidien Japan, Tokyo, Japan) were used for dissecting ligaments and tiny vessels in the deep or lateral working space. Midline procedures (ie, cholecystectomy, inserting a biliary tube, cholangiography, and dividing hilar vessels) and procedures from liver parenchymal transection to removal of the graft were performed in the same way as with the standard method through the reduced incision (Fig 3). We used the Satinsky Vena Cava clamp (Aesculap) to securely grasp the hepatic vein (Fig 3B). Surgeons lengthened the incision during the operation at their own discretion when they recognized that the initial incision length was insufficient to perform the operation safely. Lateral Segmentectomy and Extended Lateral Segmentectomy Procedures. First, after confirming the pathologic status of the zero biopsy, lateral procedures (ie, mobilization of the left lobe) were performed under a combination of direct view and video view as follows. The wound was pulled toward the upper left using a Thompson retraction system so that the wound came over the lateral segment (Fig 2A). The chief surgeon directly watched the left-lateral working area and dissected the ligament around the left lobe and the Arantius duct, while the other surgeons assisted with the procedures while watching the video view in a monitor (Fig 2D). Next, the chief surgeon performed midline procedures (ie, cholecystectomy, inserting a tube into the cystic duct, cholangiography, and dividing the hepatic artery and portal vein) under direct view, while the other surgeons watched mainly the direct view and partially the video view. Finally, procedures from liver parenchymal transection to removing the graft were performed through the reduced incision under direct view without fiberscope assistance, in the same way as with the standard method. Procedures for Left Hepatectomy With and Without the Caudate Lobe. First, after mobilizing the left lobe as described above, the right lobe was also mobilized to an extent by which the Cantlie line came to the midline. The wound was pulled toward the right, and the chief surgeon directly watched the right lateral working area and
1403 dissected the ligament around the right lobe, while the other surgeons watched the video view in the monitor (Fig 2B, E). The common trunk of the middle and left hepatic veins was encircled using a Penrose drain tube under the combination view. The tube was used for the hanging maneuver during liver parenchymal transaction (Fig 3A). For left hepatectomy with the caudate lobe, the caudate lobe was mobilized while pushing to the cranial side with a spatula and dissecting the short hepatic veins with energy devices under the combination view (Fig 2C, F). Next, midline procedures (ie, cholecystectomy, inserting a biliary tube, cholangiography, and dividing hilar vessels) and finally procedures from liver parenchymal transection to removal of the graft were performed in the same way as the lateral segmentectomy and extended lateral segmentectomy through the reduced incision.
Statistical Analysis Results are expressed as means standard deviations (SDs). For parametric data, differences between groups were evaluated using Student t test for unpaired data, based on the assumption that the data were derived from populations with equal SDs. Differences were considered significant at P values less than .05.
RESULTS Comparison Between Operations With Standard and Reduced Incisions
The numbers of living donors who underwent left side hepatectomies between October 2006 and June 2012 are shown in Table 1. Clinical parameters of the operations with standard and reduced incisions are shown in Table 2. Incision length and duration of operation were significantly lower for the operations performed with reduced incision length compared to those with standard incision in the lateral segmentectomy and extended lateral segmentectomy patients. Incision length, duration of operation, aspartate aminotransferase level, alkaline phosphatase level, gamma-glutamyl transferase level, and length of hospital stay were significantly lower in the reduced-incision operations compared with standard incision in patients who underwent left hepatectomy with and without the caudate lobe. With respect to postoperative complications, bile leakage, corresponding to grade
Fig 3. Direct view of dissection of the liver parenchyma and left hepatic vein. Midline procedures in a case of left hepatectomy with the caudate lobe are shown. (A) Liver parenchymal dissection with hanging maneuver. The cut line shown is the right side of the middle hepatic vain. A Penrose drain (PD) was used. Lt, left lobe of the liver; Rt, right lobe of the liver. (B) Clamp of the left hepatic vein (HV). The Satinsky vena cava clamp (CL) is used in the deep area.
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Table 1. Patient Number for Standard and Reduced Incision Operations
Lateral segmentectomy Extended lateral segmentectomy Left hepatectomy Left hepatectomy with caudate lobe Total
Standard Incision
Reduced Incision
9 2 8 15 34
10 2 5 2 19
The liver parenchymal transection line was on the right side of the umbilical portion for lateral segmentectomy, the right side of one of the hepatic veins in the medial segment for extended lateral segmentectomy, and the right side of the middle hepatic vein for left lobectomy with and without the caudate lobe.
IIIa according to the Clavien-Dindo classification [10], was observed in 2 cases of left hepatectomy (1 from the standard incision group and 1 from the reduced incision group), and both were treated uneventfully by conservative methods. In the case with reduced incision, the bile leakage was associated with technical issues pertaining to the bile duct transection but not with the incision length. There were no complications of grade IIIb or higher. With respect to outcomes in recipient, a statistically significant difference was detected only in the comparison of total bilirubin levels in recipients who received the left lobe with or without the caudate lobe. Analyses of Incision Length and BMI
In the group of patients who underwent lateral segmentectomy and extended lateral segmentectomy, BMI was less than 22 in 7 cases and greater than 22 in 5 cases (Fig 4). The incision length was 10 cm or less in all 7 cases in which BMI less than 22 and was greater than 10 cm in all 5 cases in which BMI was greater than 22. In the group of patients who underwent left hepatectomy with and without the caudate lobe, BMI was less than 22 in 4 cases and greater than 22 in 3 cases. The incision length was 12 cm or less in all of the 4 cases in which BMI was less than 22, and was 12 cm or more in all of the 3 cases in which BMI was greater than 22. DISCUSSION
Laparoscopic and laparoscopy-assisted approaches are beneficial for magnifying the intraoperative view, improving cosmetic appearance, and reducing postoperative pain and wound complications, as reported previously [2e6]. However, these procedures are sometimes complex and require considerable expertise with the technique. Consequently, there have been attempts to reduce incision length without employing laparoscopic procedures for donor operations. Lee and coworkers successfully performed 143 consecutive living donor hepatectomies, including both right- and left-side hepatectomies, through an 18-cm upper midline incision and found that a reduced upper-midline incision without laparoscopic assistance can be safely used for living donor hepatectomy [11]. Kasahara and associates performed 70 living donor hepatectomies via lateral segmentectomy through a 7-cm upper midline incision and reported that the duration of operation and hospital stay were significantly shorter for
donors who underwent the procedure with reduced incision versus standard incision [12]. We recognized that the attempts by Lee and Kasahara presented a third option, using neither a full open nor a pure laparoscopic approach, for donor operations. In February 2009, we began using a similar nonlaparoscopic procedure for left hepatectomy and lateral segmentectomy, in which the chief surgeon performed the entire procedure through an upper-midline minilaparotomy without abdominal wall lifting or pneumoperitoneum, but we introduced some modifications. Left hepatectomy and lateral segmentectomy are essentially performed as a 2-step procedure (ie, the lateral procedure and the midline procedure). The lateral portion is performed in the early part of the operation and includes mobilization of the left lobe and right lobe, while the midline portion includes all the other procedures (eg, cholecystectomy, dividing the hepatic artery and portal vein, and dissecting the liver parenchyma). The lateral procedures are usually difficult to perform through a minilaparotomy and are instead done under laparoscopic observation for laparoscopy-assisted lateral segmentectomy and left hepatectomy [5,8]. In this study, we effectively applied traction to the wound toward the lateral working area using the traction system and pushed the liver toward the midline using a spatula. It was feasible to place the minilaparotomy nearly above the working area in the lateral region, enabling the chief surgeon to obtain a good direct view of the area. We also placed a fiberscope above the wound to obtain an additional video view for the assistant surgeons. Although the direct view of the lateral region through the minilaparotomy was fully available to only the chief surgeon, the additional video view was useful for assistant surgeons to create the working area without a direct view. We inserted no ports and employed neither abdominal wall lifting nor CO2 pneumoperitoneum; nonetheless, the lateral procedures for the left hepatectomy and lateral segmentectomy were performed uneventfully through the minilaparotomy. As for the midline portion, we uneventfully performed procedures through the minilaparotomy without fiberscope assistance. It has already been shown that the midline procedure can be performed through a minilaparotomy using an open approach in laparoscopy-assisted lateral segmentectomy and left hepatectomy, in which laparoscopic procedures are employed only for the lateral portion, by some laparoscopic expert surgeons [5,8]. Nitta, one of the pioneer surgeons of laparoscopic hepatectomy, and associates also showed that it is useful to employ the hanging maneuver for transection of the liver through the minilaparotomy [8], because the maneuver lifts the working area toward the ventral side. We introduced some of these reported techniques to our procedures for the midline portion through the minilaparotomy. An important difference between our techniques and those used by Nitta et al is that we dissected the hepatic vein leaving a margin for anastomosis, because Nitta’s involved hepatectomy for neoplasms for which endolinear stapling devices can be used on the hepatic vein. We needed to use an appropriate clamp and leave a margin
Standard Incision (n ¼ 11)
Left Hepatectomy and Left Hepatectomy þ S1
Mean SD
Age Sex (Male/Female) Body mass index (kg/m2) Incision length (cm) Graft weight (g) Duration of operation (min) Blood loss (mL) Postoperative blood parametes AST (IU/L) ALT (IU/L) ALP (IU/L) gGTP (IU/L) TB (mg/dL) PT-INR Alb (g/dL) Hospital stay (d) Hospital charge (x1000 yen) Recipient’s outcomes AST (IU/L) ALT (IU/L) ALP (IU/L) gGTP (IU/L) TB (mg/dL) PT-INR Alb (g/dL) 3-month survival rate (%) 2-year survival rate (%)
32.5 4.6 4/7 21.8 2.9 19.0 2.8 251 64 486 51 144 127
(MinimumMaximum)
Reduced Incision (n ¼ 12) Mean SD
(MinimumMaximum)
MeanSD
(18.0e26.2) (17.0e21.0) (140e358) (412e558) (50e400)
37.8 7.7 4/8 21.3 2.7 11.4 3.1 251 58 413 76 98 100
(16.9e25.4) (7.5e17.0) (180e375) (310e543) (50e400)
NS NS NS P < .05 NS P < .05 NS
(168e642) (175e821) (230e716) (26e228) (0.9e3.8) (1.1e1.4) (2.4e3.4) (8e21) (138e228)
NS NS NS NS NS NS NS NS NS
(281e9652) (277e6634) (675e1978) (36e353) (2.2e15.6) (1.8e3.2) (2.0e3.5)
NS NS NS NS NS NS NS NS NS
(25e39)
168 191 298 99 1.0 0.1 0.3 2.3 9
(179e688) (162e763) (63e1049) (41e356) (1.0e3.8) (1.1e1.5) (2.4e3.3) (10e17) (143e173)
365 436 401 84 1.8 1.3 2.9 11.8 173
845 612 1281 300 9.7 2.7 2.7 91 91
976 618 775 315 5.6 1.0 0.3
(137e3514) (121e2255) (375e3135) (67e916) (2.6e23.4) (1.8e5.2) (2.2e3.1)
1389 2615 1084 1767 1286 385 162 114 7.0 4.7 2.3 0.4 2.8 0.4 100 100
348 361 456 141 1.9 1.3 2.8 12.6 158
Standard Incision (n ¼ 23)
151 222 128 57 0.9 0.1 0.3 3.7 26
(29e56)
(MinimumMaximum)
Reduced Incision (n ¼ 7) MeanSD
37.1 11.2 8/15 22.9 2.6 27.5 5.1 425 85 560 93 223 196
(16.2e27.4) (23e33) (311e616) (409e812) (30e650)
33.69.3 4/3 21.3 2.4 12.3 2.1 385 96 391 78 229 204
436 450 438 147 2.4 1.2 2.9 14.5 164
194 164 294 134 1.4 0.1 0.2 4.4 12
(176e948) (279e923) (132e1358) (24e500) (1.1e6.3) (1.0e1.5) (2.5e3.1) (8e30) (138e184)
303 377 244 69 1.9 1.4 2.8 10 171
498 548 891 302 15.8 2.3 2.5
669 827 436 284 8.3 0.6 0.4 87 78
(119e3121) (106e3216) (336e1873) (37e1187) (5.5e38.1) (1.5e3.6) (1.8e3.4)
413 631 317 401 695 322 314 300 8.4 6.8 2.3 0.9 2.5 0.4 100 100
(20e57)
82 107 54 57 0.9 0.2 0.3 2.1 10
(MinimumMaximum)
(21e49) (18.2e24.5) (10.0e16.0) (256e534) (248e485) (50e600)
NS NS NS P < .05 NS P < .05 NS
(222e436) (230e507) (162e322) (26e190) (1.1e3.7) (1.2e1.6) (2.5e3.3) (7e13) (160e183)
P < .05 NS P < .05 P < .05 NS P < .05 NS P < .05 NS
(127e1833) (97e1213) (322e1214) (57e924) (3.1e23.1) (1.5e4.1) (2.0e3.1)
NS NS NS NS P < .05 NS NS NS NS
LEFT-SIDE HEPATECTOMY IN LIVING DONORS
Table 2. Comparison of Operations Performed With Standard and Reduced Incisions Lateral Segmentectomy and Extended Lateral Segmentectomy
Abbreviations: AST, aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; gGTP, gamma-glutamyl transferase; TB, total bilirubin; PT-INR, prothrombin time-international normalized ratio; NS, not significant.
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Fig 4. Relationship between body mass index (BMI) and incision length. The relationships between BMI and final incision length in (A) patients with lateral segmentectomy and extended lateral segmentectomy and (B) patients with left hepatectomy with and without the caudate lobe are shown.
at the hepatic vein for anastomosis to the recipient side of the hepatic vein. We used a Cooley coarctation clamp in the operation with standard incision, but the clamp’s grip interfered with the wound. Therefore, we used a Satinsky vena cava clamp to securely grasp the hepatic vein from the minilaparotomy. Donor safety is an absolute requirement for living donor liver transplantation. When we introduced the new operation in February 2009, we recognized that surgeons should lengthen the incision when the initial incision length appeared insufficient to ensure safety. In fact, an incision greater than 10 cm was used in 8 of the 19 cases. We retrospectively assessed the relationship between BMI and incision length in lateral segmentectomy and extended lateral segmentectomy and found that the boundary between an incision length greater than 10 cm and 10 cm or less was a BMI of 22, which is the average BMI in the Japanese population according to Japan Society for the Study of Obesity [13]. The BMI of 22 was also the boundary between an incision length greater than 12 cm and 12 cm or less in left hepatectomy with and without the caudate lobe. It is therefore reasonable that surgeons lengthened the incision in cases with above average BMI. It is also noteworthy that the average incision length was still much shorter in the reduced incision group than in the standard incision group even after the incision was lengthened in some of the cases. The duration of operation, blood parameters, length of hospital stay, and adverse events may vary depending on the skill of the surgeon. It is difficult to estimate the actual duration of the operation, because the living donor operation sometimes includes waiting time to coordinate the operation with the recipient. However, it is very likely that reducing incision length has a beneficial impact on some clinical outcomes especially for left hepatectomy with and without the caudate lobe. We confirmed that introduction of this procedure produced no unfavorable outcomes in recipients. Since the number of cases was relatively small in this study, a greater number of patients should be evaluated in the future to more precisely determine the benefits of this operation. Great attention should also be paid to the prevention of postoperative complications, such as bile leakage, irrespective of the incision length.
In conclusion, it appears to be feasible to reduce the incision length for living donor left-side hepatectomy by applying wound retraction and obtaining an additional video view. The devices used for the modified procedure were all commercially available. We believe that the procedures presented herein can be performed uneventfully if the surgeon is a hepatobiliary expert and that the procedures are a suitable option for living donor operations. REFERENCES [1] Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392. [2] Baker TB, Jay CL, Ladner DP, et al. Laparoscopy-assisted and open living donor right hepatectomy: a comparative study of outcomes. Surgery 2009;146:817. [3] Choi HJ, You YK, Na GH, et al. Single-port laparoscopy-assisted donor right hepatectomy in living donor liver transplantation: sensible approach or unnecessary hindrance? Transplant Proc 2012;44: 347. [4] Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522. [5] Kurosaki I, Yamamoto S, Kitami C, et al. Video-assisted living donor hemihepatectomy through a 12-cm incision for adultto-adult liver transplantation. Surgery 2006;139:695. [6] Soyama A, Takatsuki M, Hidaka M, et al. Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision. Transplant Proc 2012;44:353. [7] Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009;250:825. [8] Nitta H, Sasaki A, Fujita T, et al. Laparoscopy-assisted major liver resections employing a hanging technique: the original procedure. Ann Surg 2010;251:450. [9] Wakabayashi G, Nitta H, Takahara T, et al. Standardization of basic skills for laparoscopic liver surgery towards laparoscopic donor hepatectomy. J Hepatobiliary Pancreat Surg 2009;16:439. [10] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205. [11] Lee KW, Kim SH, Han SS, et al. Use of an upper midline incision for living donor partial hepatectomy: a series of 143 consecutive cases. Liver Transpl 2011;17:969. [12] Kasahara M, Sakamoto S, Shigeta T, et al. A 7-cm upper midline incision for living donor left lateral hepatectomy: singe-center consecutive 70 donor experience. Transplantation 2012;93:e33. [13] JASSO - Japan Society for the Study of Obesity, http://www. jasso.or.jp/contents/english/index.html; 2014. Accessed on May 18, 2014.
