EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Laparoscopic liver donor surgery is a technically difficult and demanding procedure. Our aim was to evaluate its feasibility at an established transplant center. Although our hospital is a small-volume center with <20 liver transplants per year, laparoscopic donor surgery has been performed regularly. In this study, we have reported our experiences with laparoscopic donor right hepa-tectomy and its outcomes.
Materials and Methods: Between May 2014 and March 2021, 26 deceased donor liver transplants and 37 living donor liver transplants, approved by the Korean Network for Organ Sharing, were performed at out center. From these, we reviewed the medical records, including clinical and demographic characteristics and operative outcomes, of 3 living donors who under-went pure laparoscopic donor right hepatectomy and their recipients.
Results: Each of the 3 laparoscopic donor right hepatectomies took over 10 hours with the prolonged Pringle maneuver time and warm ischemic time. However, there were no significant events during surgery or critical postoperative complications. In the recipients, posttransplant complications included middle hepatic vein obstruction, postoperative bleeding, bile leak, septic shock, and primary nonfunction of the graft. We managed and resolved these complications using various approaches, including retransplant, and all 3 recipients recovered and survived.
Conclusions: Laparoscopic donor right hepatectomy had a relatively long operative time at our small-volume center. We believe that successful laparoscopic donor hepatectomy is possible if the donor is selected appropriately according to the center’s experiences and there are constant efforts to overcome the learning curve.

Key words : Laparoscopic donor surgery, Laparoscopic right hepatectomy, Living donor liver transplant

Living donor liver transplant (LDLT) is an effective treatment modality for patients with end-stage liver disease.¹ In liver donor surgery, precise parenchymal transection is required because both blood vessels and hepatic parenchyma must be well preserved in the liver segments to be donated and in the donor’s remnant liver. Vascular and biliary variations pose additional challenges.² Laparoscopic liver donor surgery is a technically more difficult and demanding procedure. Laparoscopic donor major hepatectomy for adult LDLT has been classified as IDEAL 2a (development phase) and was not recommended for wide introduction in the Second International Consensus Conference on Laparoscopic Liver Resection.^3,4 Despite improvements in laparoscopic surgical equipment, instruments, and techniques, laparoscopic donor hepatectomy is presently performed by only a few surgeons at a small number of centers because it requires extensive experience in both open donor hepatectomy and laparoscopic hepatectomy.⁵ Although our hospital is a small-volume liver transplant center, as experience in laparoscopic liver surgery has accumulated (Figure 1), we have attempted laparoscopic donor hepatectomy. In this study, we report our experience with laparoscopic donor right hepatectomy (LDRH) and its outcomes.

Materials and Methods

This retrospective study was conducted at the Kosin University Gospel Hospital (Busan, Korea). The protocol was approved by the Kosin University Gospel Hospital Institutional Review Board (No. KUGH 2021-11-011). This study was performed in accordance with the Declaration on Helsinki and Declaration of Istanbul.

Between May 2015 and March 2021, 26 deceased donor liver transplants and 37 LDLTs were performed at our center. Among these, we reviewed the medical records, including clinical and demographic charac-teristics and operative outcomes, of 3 living donors who underwent pure LRDH and their recipients.

Donor selection
The selection criteria for LRDH are the same as those for open donor hepatectomy at our institution and include the following: donors <65 years of age, macrosteatosis of the liver of <30%, and an expected future remnant liver volume of >30%.6 In addition, for laparoscopic donor surgery, we specifically considered anatomic variations. Initially, donors with normal vascular and biliary anatomy were selected. After successful operations on the first donor without any complications, we expanded the selection criteria to include patients with vascular or biliary anatomic variations.

Operative technique

Position
The donor was placed in the supine position with legs apart and in a reversed Trendelenburg position. The surgeon stood between the legs, with the scopist and scrub nurse standing on the surgeon’s right and left sides, respectively, and 1 assistant standing on the patient’s left side.⁷

Port placement
Five trocar ports were used: one 12-mm port at the supra-umbilicus (flexible scope); one 12-mm port to the operator’s right hand at the upper one-third of the midline; and three 5-mm ports at the right anterior axillary line just below the ribs, at subxiphoid, and at left midclavicular line just below the ribs.⁷

Liver biopsy
Two frozen biopsies from segments 3 and 5 were sent to confirm the degree of steatosis.

Liver mobilization
The round, coronary, falciform ligaments and the right triangular ligament were dissected and cut. After the inferior vena cava was exposed, the small, short hepatic veins were ligated and cut.

Hilum dissection
After the cystic artery and duct were dissected and cut, the right hepatic artery and portal vein were isolated and looped (Figure 2). We clamped the vessels to identify the demarcation line of the ischemic area and verified with ultraso-nography that the middle hepatic vein was retained within the remaining left liver.⁸

Parenchymal transection
After the liver was tagged using a rubber band, we resected the liver parenchyma with a Cavitron ultrasonic surgical aspirator (CUSA EXcel, Integra) or an ultrasonic energy device (Sonicision from Medtronic or Harmonic Ace from Ethicon) and bipolar coagulation. We used a totally intracorporeal Pringle maneuver with a Penrose drain tube intermittently.^9,10 The hepatic vein branches from segments 5 and 8 (V5 and V8) were divided and used for reconstruction on the bench table.

Bile duct resection
After transection of two-thirds of the parenchymal width and isolation of the right Glissonian pedicle, except for the right hepatic artery and portal vein, a 3F polyvinyl chloride nasogastric tube was passed through the cystic duct for injection of the contrast medium (Figure 2). We placed a radiopaque marker on the expected division line of the right bile duct and performed cholangiography.¹¹

Vessel ligation
The right hepatic artery and portal vein were clamped and cut after double polymer clipping. A white 30-mm endo-gastrointestinal anastomosis stapler was used for transection of the right hepatic vein (Figure 2).

Graft extraction
The right liver graft was placed in a plastic bag and removed through a Pfannenstiel incision. The graft and vein openings were immediately flushed with cold histidine-tryptophan-ketoglutarate solution, for recanalization of V5 and V8.

Finishing process
After the Pfannenstiel incision was closed, the pneumoperitoneum was reinsufflated. The remnant bile duct opening was closed using a 6-0 polydioxanone suture. Cholangiography was performed to check the patency and leakage of the superior biliary confluence. The remaining left hemi-liver was fixed in the orthotopic position by suturing the falciform ligament. Finally, we placed 2 closed-suction drains through both lateral 5-mm ports.

Outcomes of living donors
The first donor (donor A) was a 32-year-old woman, the recipient’s daughter (recipient A), with normal vascular and biliary anatomy. Her body mass index (BMI; in kilograms divided by height in meters squared) was 17.2, and the graft liver was relatively small at 568 cm³. After the successful operation of donor A, we carefully expanded the criteria of BMI, as well as criteria for vascular and biliary variations.

Donor B was a 34-year-old woman, the recipient’s daughter (recipient B), with a BMI of 25.9 (overweight) and type IIIb bile duct. The graft had 2 bile duct openings (4 mm and 2 mm) of the right anterior and posterior bile ducts. On the bench, we performed ductoplasty to create 1 opening.

Donor C was a 47-year-old man, the recipient’s brother (recipient C), with a BMI of 21.4 and 2 promi-nent right inferior hepatic veins. Moreover, the graft weighed >650 g. After resection of the right hepatic vein, we divided and cut the 2 right inferior hepatic veins and the residual internal part of the triangular ligament beyond the inferior hepatic veins. The pro-cedure required a long operative time of 750 minutes with a relatively longer warm ischemic time (WIT).

All 3 donors recovered well and were discharged without major complications. The perioperative out-comes of the 3 living donors are presented in Table 1.

Outcomes of recipients
The aspartate aminotransferase and alanine aminotransferase levels of recipient A increased up to 2000 U/L and 699 U/L, respectively, with a prolonged international normalized ratio (>2.5), acidosis, and increased serum lactate level. Recipient A was diagnosed with primary nonfunction of the graft liver and listed as a candidate for retransplant. She underwent salvage deceased donor liver transplant 11 days after LDLT.

In recipient B, the vein graft for reconstruction of V5 and V8 was obstructed by a thrombus. On postoperative day 1, we removed the thrombus and reanastomosed the vein graft to the inferior vena cava. Transient bile leakage was observed during the recovery phase, but there has been no biliary tract stricture to date.

In recipient C, the increases in aspartate amino-transferase and alanine aminotransferase after liver transplant were probably due to frequent Pringle maneuvers, the relatively long WIT, and total operation time in the donor. In particular, the serum immunoglobulin G titer was elevated to 1:64 after an ABO-incompatible LDLT. The recipient was treated with salvage plasmapheresis and high-dose intra-venous immunoglobulin due to suspicion of antibody-mediated rejection. Thereafter, the serum immunoglobulin G titer and liver enzyme levels decreased and stabilized.

The perioperative outcomes of the 3 recipients are presented in Table 2.

In LDLT, donor safety is the most important factor. Donor hepatectomy has a mortality rate of 0.1% to 0.2% and a morbidity rate of 25% to 35%.¹² Therefore, safety has been a major obstacle in extending the application of a minimally invasive approach in living liver donors. Compared with other surgeries, laparoscopic liver surgery has developed much more slowly. Laparoscopic hepatectomy is technically challenging due to complex vascular and biliary tract variations and the possibility of significant intra-operative bleeding.² According to a previous report, the number of cases required to overcome the learning curve and to optimize operating time and blood loss during laparoscopic hepatectomy is reported to range from 30 to 60 cases.¹³ Meanwhile, precise parenchymal transection is required in donor surgery to optimize graft anatomy and to avoid remnant bile leak. The indications for laparoscopic living donor hepatectomy have been steadily expanded, but it is still used in only a handful LDLT centers worldwide.¹⁴ Lee and colleagues suggested that approximately 73 cases of laparoscopic major liver resection are required to overcome the learning curve in terms of operative outcomes for LDRH.¹⁵

Lee and colleagues reported that the total operation time (319.6 vs 391.4 min; P = .004) and WIT from the stapling of the right portal vein to the perfusion of histidine-tryptophan-ketoglutarate solution (1.4 vs 7.4 min; P < .01), the early postoperative period, and peak alanine aminotransferase level were significantly longer in the LDRH group than in the open donor right hepatectomy group.^4,14 The presence of anatomic variations in the biliary or portal systems can increase rates of major complications, with rate of 9.3% in patients with normal anatomy compared with rate of 45.5% in patients with variations.⁶ In the LDRH group, the rate of multiple bile duct openings was reported to be significantly higher than in the open donor right hepatectomy group (53.3% vs 26.2%; P = .01).¹⁶ In addition, it has been reported that the rate of donor complications is higher when the donor’s right liver is used.¹⁷ In this regard, LDRH is a technically more difficult and demanding procedure. Another important factor related to the success of laparoscopic donor hepatectomy is the experience of the center. The incidence of near-miss events was significantly lower at high-volume centers than at low- and moderate-volume centers.¹²

Early reports of pure laparoscopic donor hepa-tectomy have suggested strict selection criteria for donation of the right liver: donors with a single long right hepatic artery, right portal vein, and right hepatic duct; fewer branches of the hepatic vein in V5 and V8; and no large inferior hepatic veins.⁴

Because the minimally invasive surgery approach for hepatectomy is known to reduce pain, be more cosmetically appropriate, and allow faster recovery to normal life, it is highly popular and is expected to be more in demand in the future. Donors can have substantial medical, social, and psychological burdens after donor hepatectomy.¹⁸ The purpose of minimally invasive surgery in living donors is to provide at least equivalent donor safety on one hand and faster rehabilitation on the other hand.¹⁹ If these conditions are met, it would be ideal to perform minimally invasive surgery in healthy donors.⁶

In this study, we reported our experience with 3 purely laparoscopic donor hepatectomies among 37 LDLTs performed between May 2015 and March 2021 at a small-volume center (Table 3 ). As reported here, LDRH required a long time (approximately 10 hours) and required a relatively longer WIT. Vascular anastomosis was slightly difficult in the recipient because the length of the blood vessels of the graft was relatively shorter. Nevertheless, if the donor is selected appropriately according to the center’s experience and there are constant efforts to overcome the learning curve, we believe that successful laparoscopic donor surgeries can be possible.

Volume: 20 Issue: 4 April 2022

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