Pure laparoscopic living donor hepatectomy: learning curve, technical pearls and pitfalls

Living donor liver transplant (LDLT) has markedly reduced waiting list mortality and expanded access to life-saving therapy for thousands across the globe. Application of minimally invasive surgery to donor hepatectomy has been markedly slower than in many other aspects of surgery. For donors undergoing hepatectomy, many long-lasting issues related to donation appears to involve the large incision typically used for donor hepatectomy. This has provided significant motivation for a minimally invasive approach to donor hepatectomy. Pure laparoscopic donor hepatectomy was initially reported in 2002 but adoption has been slowed by concerns about hemostasis, donor safety and recipient outcomes. Highly select centers have successfully developed minimally invasive living donor programs and have been reporting outcomes and techniques utilized. We review the technical approaches have been learned by early adopters. We discuss some of the pitfalls and challenges associated with laparoscopic donor hepatectomy. We discuss the reported experiences with the learning curve for this complex operation. We discuss the future of minimally invasive surgery for donor hepatectomy.