Pure laparoscopic donor hepatectomy: Sharing experiences for the next generation

Laparoscopic liver surgery (LLS) has widely been used in different liver diseases. Recently, the indications for LLS has expanded from minor liver resections to living donors with acceptable outcomes (1,2). LLS has the advantages of faster recovery and better wound satisfaction than conventional surgery (3,4). Since the first successful LDLT of a left lateral section graft by laparoscopy in 2002 (5), the indications for pure laparoscopic donor hepatectomy (PLDH) have been extended to various grafts including the right liver (6). Several transplant centers have tried to proceed with PLDH, but donor safety and learning curve issues of laparoscopic donor hepatectomy would be an obstacle to start a new technique. Nevertheless, attempts to expand donor indication of PLDH have continued, such as reports of successful laparoscopic surgery in donors with anatomical variations at highly specialized centers (7,8). As an expert panel meeting of PLDH announced in 2018, laparoscopic donor surgery has been considered as a challenging procedure and recommended only to the surgeons with both numerous laparoscopic hepatectomy and open donor surgery (9). However, for young surgeons who have used laparoscopy as a training tool early on, these statements may make them feel frustrated. Recently, the trainee can perform laparoscopic appendectomy without the experience of open appendectomy. A laparoscopic approach is no longer a novel innovation, but a tool accessible to all surgeons. We all agree that donor hepatectomy is indeed more difficult and challenging than other surgery. However, we also need to acknowledge that there are a lot of differences between open donor and PLDH. As the experience of PLDH accumulated, standardization of PLDH is being achieved in some centers. Donors, unlike cirrhosis patients, are easier to standardize a surgical procedure because the liver parenchyma is relatively soft and well dissected from surrounding tissues. Therefore, it is time to share the accumulated knowledge and protocols of PLDH with young surgeons without numerous experiences in open donor hepatectomy as well as laparoscopic hepatectomy.

The learning curves of pioneers who tried PLDH for the first time and the learning curves of young surgeons who learned through this standardized procedure must be different. Of course, we need experience in open donor surgery to solve various problems that can occur during laparoscopic surgery. However, this fact alone is not correct to prevent the entry of laparoscopic liver donor surgery.

We have been pioneering and trying to develop pure laparoscopic donor hepatectomy. Now is the time to put together our tips and know-how for the training of laparoscopic liver donor surgery for the next generation. The series “Pure Laparoscopic Donor Hepatectomy” aims to present a comprehensive review of the history to the current status and consensus on the experiences of the current laparoscopic donor surgeons. The history of laparoscopic surgery, various surgical techniques of experts, tips of energy devices and CUSA manipulation during surgery and learning curve issues are all summarized. These issues would be a good guide for young HBP surgeons who will lead pure laparoscopic donor hepatectomy in the future.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office for the series “Pure Laparoscopic Donor Hepatectomy” published in Laparoscopic Surgery. This article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ls-2019-pldh-08). The series “Pure Laparoscopic Donor Hepatectomy” was commissioned by the editorial office without any funding or sponsorship. KWL and JML served as the unpaid Guest Editors of the series. KWL also serves as an unpaid editorial board member of Laparoscopic Surgery from Jan 2019 to Dec 2020.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg 2009;250:831-41. [Crossref] [PubMed]
2. Tranchart H, Di Giuro G, Lainas P, et al. Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study. Surg Endosc 2010;24:1170-6. [Crossref] [PubMed]
3. Kim KH, Jung DH, Park KM, et al. Comparison of open and laparoscopic live donor left lateral sectionectomy. Br J Surg 2011;98:1302-8. [Crossref] [PubMed]
4. Suh SW, Lee KW, Lee JM, et al. Clinical outcomes of and patient satisfaction with different incision methods for donor hepatectomy in living donor liver transplantation. Liver Transpl 2015;21:72-8. [Crossref] [PubMed]
5. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392-6. [Crossref] [PubMed]
6. Hong SK, Lee KW, Choi Y, et al. Initial experience with purely laparoscopic living-donor right hepatectomy. Br J Surg 2018;105:751-9. [Crossref] [PubMed]
7. Hong SK, Suh KS, Kim HS, et al. Pure 3D laparoscopic living donor right hemihepatectomy in a donor with separate right posterior and right anterior hepatic ducts and portal veins. Surg Endosc 2017;31:4834-5. [Crossref] [PubMed]
8. Shehta A, Lee JM, Lee KW, et al. Pure Laparoscopic Living Donor Hepatectomy for Donors With Right Portal Vein Anatomical Variations. Liver Transpl 2019;25:1445-54. [Crossref] [PubMed]
9. Han HS, Cho JY, Kaneko H, et al. Expert Panel Statement on Laparoscopic Living Donor Hepatectomy. Dig Surg 2018;35:284-8. [Crossref] [PubMed]

Kwang-Woong Lee

Jeong-Moo Lee