Robot-assisted Living-donor Left Lateral Sectionectomy

Abstract

INTRODUCTION In 2002, Cherqui et al. reported the first purely laparoscopic living-donor left lateral sectionectomy (LDLLS).[1] This technique has now become a standardized procedure and has significantly shortened donor hospitalization.[2] The da Vinci robotic surgical system was introduced into the field of liver surgery more than 10 years ago. Its flexible mechanical “wrist” and stable three-dimensional (3D) visual field help minimize risks from complicated procedures. However, robotic LDLLS has not yet been reported. Recently, we performed such a case of robotic LDLLS. CASE REPORT A 7-month-old male patient was admitted to our hospital for congenital biliary atresia. His jaundice did not dissipate after the Kasai procedure and was eligible for liver transplantation. Preoperative computed tomography (CT) did not reveal his common bile duct but did reveal extensive dilation of the intrahepatic biliary tree and severe ascites. His serum total bilirubin was 343.3 μmol/L, direct bilirubin was 284.2 μmol/L, albumin was 29.6 g/L, and prothrombin time was extended by 6 s. His 27-year-old mother (height: 168 cm; weight: 68 kg; blood type: A) volunteered to donate her liver's left lateral lobe to him. Preoperative evaluation, including triphasic contrast-enhanced CT with 3D reconstruction and magnetic resonance cholangiopancreatography, showed normal hepatic structures [Figure 1a]. Several gallstones were identified under ultrasonography. The estimated total liver volume was 1545 ml, while the left lateral lobe's volume was estimated as 285 ml [Figure 1b]. The calculated graft-versus-body weight ratio of the recipient was 3.2% (285 ml/9.0 kg).Figure 1: (a) Preoperative CT scan of donor; (b) Preoperative estimation of liver volumes; (c) CT scan of the recipient on postoperative day 15; (d) Position of the trocars and the incision; (e) Position of the mechanical arms during robotic surgery; (f) (arrow) The stump of the left bile duct; (g) (arrows) The left hepatic arteries; (h) (arrow) The left portal vein; (i) (arrow) The left hepatic vein. CT: Computed tomography.Our center has great experience with purely laparoscopic living-donor hemihepatectomy. The possibility of using minimally invasive robotic LDLLS was discussed during the process of informed consent. All technical aspects and safety issues were explained, emphasizing the fact that robotic LDLLS had never been reported. Later, the Ethics Committee of the West China Hospital, Sichuan University, evaluated the donor in accordance with the previously published standard protocol. The donor agreed to undergo the first robotic LDLLS in our center. The donor lay in a supine position and the reverse Trendelenburg position was applied with a slight left tilt. A laparoscopic trocar was placed above the umbilicus, and the other four trocars were placed on the curve toward the surgical region, with at least 10 cm between each [Figure 1d]; then, the da Vinci robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was installed [Figure 1e]. The gallbladder was removed first, and then, the liver was carefully scanned under laparoscopic ultrasonography. The left lateral branches of the artery, portal vein, and hepatic vein were located; then, the liver hilum was dissected to isolate the respective vessels. Thereafter, the left lateral lobe was split with a robotic harmonic scalpel; vessels >5 mm were closed with Hem-o-lok clips. While transecting the liver parenchyma, the left bile duct, hepatic artery, and proximal branch of the left portal vein were dissected [Figure 1f-1h]. Finally, the left hepatic vein was transected with an Echelon stapler [Figure 1i]. There was no inflow occlusion during the procedure. The left lateral lobe was placed in a bag and harvested from a 7-cm bikini incision on the lower abdomen. The donor's procedure lasted 6.5 h with blood loss of 400 ml. Immediately, histidine-tryptophan-ketoglutarate solution was perfused through the portal vein branch, an