Pure laparoscopic living donor liver transplantation: Prowess or progress?

Abstract

This editorial balances both concerns and prospects of pure laparoscopic living donor liver transplantation, a daring undertaking by Suh and colleagues (page 260). This editorial balances both concerns and prospects of pure laparoscopic living donor liver transplantation, a daring undertaking by Suh and colleagues (page 260). In the current issue of AJT, Suh et al. report the first case of pure laparoscopic living donor liver transplantation, including native liver explantation and graft implantation.1Suh KS, Hong SK, Lee S, et al. Pure laparoscopic living donor liver transplantation: dreams come true [published online ahead of print 2021]. Am J Transplant. doi: 10.1111/ajt.16782.Google Scholar The procedure was successful with both donor (graft also procured by a pure laparoscopic approach of course) and recipient discharged without early complications. Liver transplantation, considered the ultimate limit to minimally invasive surgery, has now been overcome and the authors should be congratulated for this amazing technical feat. Laparoscopic/robotic kidney transplantation has been reported2Tzvetanov IG Spaggiari M Tulla KA et al.Robotic kidney transplantation in the obese patient: 10-year experience from a single center.Am J Transplant. 2020; 20: 430-440Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar but liver transplantation is a much more complex operation with several steps including explantation, large vessels clamping, and numerous anastomoses. Previous case reports of laparoscopic recipient hepatectomy followed by open graft implantation using a midline incision were recently published,3Dokmak S Cauchy F Sepulveda A et al.Laparoscopic liver transplantation: dream or reality? The first step with laparoscopic explant hepatectomy.Ann Surg. 2020; 272: 889-893Crossref PubMed Scopus (11) Google Scholar,4Suh KS, Hong SK, Hong K, et al. Minimally invasive living donor liver transplantation: pure laparoscopic explant hepatectomy and graft implantation using upper midline incision [published online ahead of print 2021]. Liver Transpl. doi: 10.1002/lt.26066.Google Scholar but this is the first report that also included pure laparoscopic liver graft implantation, resulting in all stages of the living donor liver transplantation performed by pure laparoscopy. This was not achieved overnight. The senior author is currently the surgeon with the largest worldwide experience on pure laparoscopic donor right hepatectomy and the reader should realize the immense dedication and body of work that allowed this achievement. However, this fascinating report invites to reflection and will definitely generate mixed reactions. Many, probably a majority, will question the rationale of this undertaking and consider it futile and probably undesirable or misleading. Some will consider it a significant breakthrough. Others, like myself, will be ambivalent but interested. There are serious concerns about this procedure. Safety and operative time are the first that come to mind. Major bleeding may occur at all stages during liver transplantation and is usually handled swiftly during open surgery. It may occasionally turn into catastrophic events and it is not certain that a suprapubic handport and available open liver tray will always be sufficient. Therefore, increased attention to all steps is required participating in a striking 16-h operative time. Although global duration is likely to improve with experience, increased times are, at least in part, inherent to the laparoscopic approach. The presented case started with a 6-h native liver explantation. But there are more critical time-related issues, in particular increased graft warm ischemic time and prolonged venous clamping times. Warm ischemic time was 84 min, 2.5 times longer than the mean 33 min in the author’s unit. Although it did not affect graft function in this specific case, this parameter requires attention. Longer IVC clamping time with its potential hemodynamic and r