Laparoscopic Live Donor Hepatectomy: Random Mutation or Stepwise Evolution?

Abstract

Totally laparoscopic living donor hepatectomy is a complex procedure with a steep learning curve requiring experienced teams with a commitment to technical excellence; it is not a random act but rather a gradual evolutionary process, decades in the making. See case reports by Samstein et al (page 2462), Soubrane et al (page 2467) and Troisi et al (page 2472). Totally laparoscopic living donor hepatectomy is a complex procedure with a steep learning curve requiring experienced teams with a commitment to technical excellence; it is not a random act but rather a gradual evolutionary process, decades in the making. See case reports by Samstein et al (page 2462), Soubrane et al (page 2467) and Troisi et al (page 2472). Surgical innovation (whether a new procedure or improvement to an existing one) has been the cornerstone of advancing the science and art of surgery and improving the outcomes of patients with surgical diseases. A major advancement in surgery over the past three decades has been the introduction of laparoscopic procedures, which have rapidly gained acceptance and have replaced the open approach in many surgical disciplines. The observed advantages of minimally invasive procedures have been less postoperative pain, reduced morbidity and faster recovery. These observations have led to a wider acceptance of laparoscopic applications with a transition to systematic surgical training and continuous improvement in the instrumentation and technology. Indeed, commercially available robotic platforms are gaining traction and are gradually replacing some traditional laparoscopic applications. In the field of transplantation, laparoscopic live donor nephrectomy has replaced the open approach for renal transplantation in many centers around the world. Broad acceptance of the procedure has contributed to the increased number of live donor kidney transplants performed since its inception. Potential living donors find this to be an attractive option associated with a reduction in morbidity, improved cosmesis and quicker return to normal activities. Living donor liver transplantation is a relatively new surgical innovation that was developed to address the problem of organ shortage. Significant postoperative morbidity, reports of donor mortality and realization of the complexity of the procedure coupled with changes in organ allocation have resulted in a significant decrease in the number of centers performing this procedure after an initial burst of enthusiasm. Despite this, live donor liver transplantation remains an essential option in countries with limited availability of deceased donor organs or cultural impediments to deceased donation. Even in countries with adequate access to deceased donor organs, live donor liver transplantation offers a viable option for regions in the United States with long wait list time and higher wait list mortality. Since starting our live donor liver transplant program in 1998, the donor operation has continued to evolve in an attempt to reduce donor morbidity while not compromising donor safety. Initially, a bilateral subcostal (Chevron) incision with an upper midline extension was eventually replaced by a smaller right subcostal incision and a midline extension. Improved instrumentation has been used to reduce blood loss and increase donor safety during resection whenever available. Over the past few years we have adopted a hybrid approach, well-described by others, utilizing laparoscopic mobilization of the right lobe and then completing the procedure through an upper midline incision (1Baker TB Jay CL Ladner DP et al.Laparoscopy-assisted and open living donor right hepatectomy: A comparative study of outcomes.Surgery. 2009; 146: 817-823Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar). This has reduced postoperative pain for the donor without compromising exposure. More recently a 10 cm mini-incision living donor right hepatic lobectomy with or without laparoscopic assistance