Approach to minimally invasive donor hepatectomy: Laparoscopic, robotic, or bit of both!

摘要

The advent of living donor surgery has been an important milestone in the evolution of liver transplantation over the past two decades. This accomplishment has been built on the twin pillars of utmost donor safety and exemplary recipient outcomes. Currently, mortality to the donor is <0.5%. However, morbidity that is predominantly wound related, which occurs in approximately 30%–38% of cases, remains a pressing concern. It is against this backdrop that minimally invasive donor hepatectomy (MIDH) garnered interest. There is still debate as to what constitutes MIDH. In this article we restrict the term MIDH to totally laparoscopic or robotic resection and use of a remote incision, usually Pfannenstiel for graft retrieval. The first laparoscopic live donor hepatectomy (LLDH) for left lateral segmentectomy was performed in 2002. It was not until a decade later that laparoscopic right donor hepatectomy as well as the first robotic live donor hepatectomy (RLDH) were completed. To date about 1000 LLDHs and a similar number of RLDHs have been reported. Donor and recipient outcomes following MIDH were comparable with open donor hepatectomy, notably with no increase in postoperative complications. Additionally, lesser blood loss, reduced pain scores, and earlier hospital discharge leading to faster return to work were observed as plausible benefits of MIDH. This has led to multiple consensus conferences on MIDH and they have recommended minimally invasive left lateral segmentectomy as an acceptable alternative to its open counterpart.1 Liver mobilization without trauma, control of bleeding during transection, and handling of hepatic duct are a few of the hurdles that need to be overcome while advancing from open to MIDH. The majority of centres well-versed in living donor liver transplantation (LDLT) usually have negligible experience in minimally invasive surgery and vice versa. Furthermore, units with experience in LDLT as opposed to those with expertise in minimally invasive surgery were able to successfully establish MIDH programmes, affirms the importance of having a successful LDLT programme as a basic tenet to performing MIDH. In this context, the evident question is whether the robotic platform or laparoscopy will be the superior option. Although laparoscopy with its lower establishment costs, widespread availability, and conventional accessories (cavitron ultrasonic surgical aspirator [CUSA]/water jet, fluorescent radiography) appears to be the natural choice, a closer scrutiny of published data suggests otherwise. Despite its early start, LLDH has had a slower assimilation among transplant surgeons when compared to RLDH. Reasons are manifold. Firstly, versatility of the robotic arm with seven degrees of motion “mimicking open surgery,” tremor filtering with motion scaling, ability to perform precise suturing, abolition of fulcrum effect, and superior ergonomics has resulted in a shorter learning curve for RLDH when compared to LLDH.2 Secondly, most of the reports of MIDH have revealed outcomes in carefully selected donors with uncomplicated anatomy while data on donors with complex anatomy (large grafts, inferior hepatic veins requiring reconstruction/portal/biliary, and arterial variations) is lacking. Such extended-criteria donors do constitute a substantial portion of live donors, where robotic platform, with its capability to control bleeding in deeper planes and tackle biliary variations with accuracy, may possibly offer several advantages over laparoscopy. Indeed, centres with the robotic platform have expanded their selection criteria early on to include all donors suitable for open donor hepatectomy.3 Thirdly, laparoscopy is labour intensive with the need to train multiple members to initiate and successfully perform MIDH. Availability of a dual console for training and the reduced dependence on other team members except for a bedside surgeon makes proctoring easier on the robotic platform. Conversely, drawbacks of the