Adult to adult living related liver transplantation: Where do we currently stand?

Adult to adult living donor liver transplantation (AALDLT) was first preformed in the United States in 1997. The procedure was rapidly integrated into clinical practice, but in 2002, possibly due to the first widely publicized donor death, the number of living liver donors plummeted. The number of donors has since reached a steady plateau far below its initial peak. In this review we evaluate the current climate of AALDLT. Specifically, we focus on several issues key to the success of AALDLT: determining the optimal indications for AALDLT, balancing graft size and donor safety, assuring adequate outflow, minimizing biliary complications, and maintaining ethical practices. We conclude by offering suggestions for the future of AALDLT in United States transplantation centers.

A narrative review of the current and future role of robotic surgery in liver surgery and transplantation

Background:Minimally invasive surgery(MIS)is the technique of choice in selected patients for the treatment of liver tumors.The robotic approach is considered today the natural evolution of MIS.The application of the robotic technique in liver transplantation(LT)has been recently evaluated,especially in the living donation.The aim of this paper is to review the current role of the MIS and robotic donor hepatectomy in the literature and to evaluate the possible future implication in the transplant field.Methods:We conducted a narrative review using PubMed and Google Scholar for reports published so far,using the following keywords:minimally invasive liver surgery,laparoscopic liver surgery,robotic liver surgery,robotic living donation,laparoscopic donor hepatectomy and robotic donor hepatectomy.Results:Several advantages have been claimed in favor of robotic surgery:three-dimensional(3-D)imaging with stable and high-definition view;a more rapid learning curve than the laparoscopic one;the lack of hand tremors and the freedom of movements.Compared to open surgery,the benefits showed in the studies evaluating the robotic approach in the living donation are:less postoperative pain,the shorter period before returning to normal activity despite sustaining longer operation time.Furthermore,the 3-D and magnification view makes the technique excellent in distinguishing the right plane of transection,vascular and biliary anatomy,associated with high precision of the movements and a better bleeding control(essential for donor safety)and lower rate of vascular injury.Conclusions:The current literature does not fully support the superiority of the robotic approach versus laparoscopic or open method in living donor hepatectomy.Robotic donor hepatectomy performed by teams with high expertise and in properly selected living donors is safe and feasible.However,further data are necessary to evaluate properly the role of robotic surgery in the field of living donation.

Optimizing future remnant Iiver prior to major hepatectomies:increasing volume while decreasing morbidity and mortality

Post hepatectomy liver failure(PHLF)remains the most dreaded complication in major hepatectomies.Adequate future remnant liver(FRL)plays a pivotal role in prevention of PHLF.Pre-operative portal vein embolization(PVE)has become standard of care for increasing the FRL in preparation for major hepatectomies.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has also been used,though has demonstrated a substantial risk of morbidity and mortality.However,there are many situations in which PVE achieves an inadequate extent of hypertrophy,potential increasing the risk of PHLF.Panaro and colleagues explore their data with a prospective review of preoperative PVE versus liver venous deprivation(LVD)regarding intra and post-operative complications,as well as,histologic findings(1).This study adds to a growing body of literature assessing the benefit of LVD over PVE and ALPPS both,in regards to increased rate of hypertrophy,improvement in FRL,in the face of similar morbidity/mortality rates compared to PVE.

Use of robotics in liver donor right hepatectomy

Thank you for inviting us to comment the review article entitled"Use of robotics in liver donor right hepatectomy"by Chen PD et al.(1),published on HBSN journal.In their interesting paper,the authors stated that despite the fact that minimally invasive surgery(MIS)has been documented with safety and feasibility in complex liver surgery the progress has been slow in regard to the application of MIS in donor graft hepatectomy.Pioneer surgeons have devoted themselves to develop pure MIS approach for donor hepatectomy,but the steep learning curve remains barrier for its wide adoption.The authors suggest that the introduction or robotic assisted surgery may contribute to a wider acceptance of MIS as the technique of choice for live donor hepatectomy.Despite a great attention to donor selection and continuous improvement in donor care the risks of donor hepatectomy remain real and the complication rate not insignificant(2).Traditional open liver resection results in post-operative pain and in at least 30%of the cases these pains were attributed to abdominal wall trauma(1,2).For these reasons and with the aim of facilitating donor recovery,transplant surgeons have been exploring the possibility of routinely applying MIS to live donor hepatectomy.To bridge the gap between open and pure MIS donor procurement,hand-assisted laparoscopic surgery was initially introduced in the 90'.It was not until 2002 that Soubrane O presented the first two cases of pure laparoscopic left lateral living donor hepatectomy,followed in the years to come by several successful attempts to extend the procedure to the procurements of full left and right hepatic lobes(1-6).