Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy(MIDH)is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors.After an initial period in which donor safety was not effectively validated,MIDH currently seems to provide improved results,provided that it is conducted by experienced surgeons.Appropriate selection criteria are crucial to achieve better outcomes in terms of complications,blood loss,operative time,and hospital stay.Beyond a pure laparoscopic technique,various approaches have been recommended such as hand-assisted,laparoscopic-assisted,and robotic donation.The latter has shown equal outcomes compared to open and laparoscopic approaches.A steep learning curve seems to exist in MIDH,mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding.This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination.Surgeons need expertise in liver transplantation,hepatobiliary surgery,and minimally invasive techniques to perform MIDH.Barriers can be categorized into surgeon-related,institutionalrelated,and accessibility.More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

Robotic donor hepatectomy:Are we there yet?

In living donor liver transplantation(LDLT)the safety of the live donor(LD)is of paramount importance.Despite all efforts,the morbidity rates approach 25%-40%with conventional open donor hepatectomy(DH)operations.However,most of these complications are related to the operative wound and despite increased selfesteem and satisfaction in various quality of life analyses on LD,the most common grievance is that of the scar.Performing safe and precise DH through a conventional laparoscopic approach is a formidable task with a precipitous learning curve for the whole team.Due to the ramifications the donor operation carries for the donor,the recipient,the transplant team and for the LDLT program in general,the development and acceptance of minimally invasive DH(MIDH)has been slow.The robotic surgical system overcomes the reduced visualization,restricted range of motion and physiological tremor associated with laparoscopic surgery and allows for a comparatively easier transition from technical feasibility to reproducibility.However,many questions especially with regards to standardization of surgical technique,comparison of outcomes,understanding of the learning curve,etc.remain unanswered.The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH,appreciating the existing challenges and its future role.

Right or left hepatectomy: a continuing question in the era of pure laparoscopic donor hepatectomy

We read with great interest the article by Fujiki et al.published in the Annals of Surgery(1),which advocates for the use of a left liver graft with a pure laparoscopic donor hepatectomy(PLDH)approach to reduce the burden on living donors.Minimally invasive techniques,including laparoscopic surgery,have been increasingly adopted in donor hepatectomy for liver transplantation.This reflects a broader trend in various surgical fields to enhance patient outcomes both cosmetically and functionally.Since the first report of a PLDH in the form of a left lateral sectionectomy in 2002(2),this approach has expanded to include full left and full right hepatectomies(3,4).With advancements in laparoscopic instruments and growing experience,PLDH has become a standard practice for left lateral section grafts,as recognized by the most recent international consensus guideline(5).However,PLDH for full left and full right grafts has not yet reached the same level of acceptance.Predominantly performed in Asian countries,PLDH for these grafts highlights differences in donor and recipient characteristics compared to Western countries.Further studies and evidence are required to confirm the safety and feasibility of PLDH for full left and full right grafts on a broader scale.

Robotic donor hepatectomy:a niche advancement or the way forward?A perspective from the world’s largest center

The application of minimally invasive liver surgery(MILS)in the field of living donor hepatectomy has been exceedingly slow,and its impact is limited to a handful of centers worldwide.Widespread adoption has been primarily hampered by the technical limitations of laparoscopy,namely rigid instrumentation,suboptimal optics,and a seemingly steep learning curve.These deficiencies are magnified in the donor hepatectomy operation wherein the parenchyma and vasculature must be handled atraumatically to produce a pristine allograft fit for implantation.Donor safety concerns and medicolegal ramifications are also cited as impediments to MILS in donor surgery.In 2013,our institution embraced a purely laparoscopic approach to living donor left lateral sectionectomy,and it quickly became our default technique.However,with donor hemi-hepatectomy,we gravitated to the robotic surgical system as our preferred modality.Herein,we describe our experience with minimally invasive donor hepatectomy,which we now universally offer to all living donors.Our extensive familiarity with robotic donor hepatectomy will provide the reader with an instructive perspective on the attributes and merits of the robotic approach.With appropriate collaboration and proctorship,we believe that the robotic platform will actualize a more rapid and widespread adoption than that experienced with the purely laparoscopic technique.

Different techniques for harvesting grafts for living donor liver transplantation: A systematic review and meta-analysis

AIM To perform a systematic review and meta-analysis on minimally vs conventional invasive techniques for harvesting grafts for living donor liver transplantation. METHODS PubMed, Web of Science, EMBASE, and the Cochrane Library were searched comprehensively for studies comparing MILDH with conventional living donor hepatectomy (CLDH). Intraoperative and postoperative outcomes (operative time, estimated blood loss, postoperative liver function, length of hospital stay, analgesia use, complications, and survival rate) were analyzed in donors and recipients. Articles were included if they: (1) compared the outcomes of MILDH and CLDH; and (2) reported at least some of the above outcomes. RESULTS Of 937 articles identified, 13, containing 1592 patients, met our inclusion criteria and were included in the meta-analysis. For donors, operative time [weighted mean difference (WMD) = 20.68, 95% CI: -6.25-47.60, p = 0.13] and blood loss (WMD = -32.61, 95% CI: -80.44-5.21, p = 0.18) were comparable in the two groups. In contrast, analgesia use (WMD = -7.79, 95% CI: -14.06-1.87, p = 0.01), postoperative complications [odds ratio (OR) = 0.62, 95% CI: 0.44-0.89, p = 0.009], and length of hospital stay (WMD): -1.25, 95% CI: -2.35-0.14, p = 0.03) significantly favored MILDH. No differences were observed in recipient outcomes, including postoperative complications (OR = 0.93, 95% CI: 0.66-1.31, p = 0.68) and survival rate (hr = 0.96, 95% CI: 0.27-3.47, p = 0.95). Funnel plot and statistical methods showed a low probability of publication bias. CONCLUSION MILDH is safe, effective, and feasible for living donor liver resection with fewer donor postoperative complications, reduced length of hospital stay and analgesia requirement than CLDH.

The application of real-time indocyanine green fluorescence cholangiography in laparoscopic living donor left lateral sectionectomy

Background:The judgment of the division point of the bile duct has always been one of the difficulties of laparoscopic left lateral sectionectomy(LLLS).The purpose of this study was to assess the effects of indocyanine green(ICG)fluorescence cholangiography during LLLS on the occurrence of biliary complications in both donors and recipients.The optimal dose and injection time of ICG were also investigated.Methods:This is a retrospective cohort study.From October 2016 to December 2022,the clinical data of 103 donors who underwent LLLS and relevant recipients were retrospectively analyzed.According to whether ICG fluorescence cholangiography was used,they were divided into a non-ICG group(n=46)and an ICG group(n=57).Biliary complications were observed and the optimal dose and injection time of ICG were explored.Results:Three donors in the non-ICG group suffered from bile leakage.Four grafts had multiple bile duct openings and biliary complications were observed in the relevant recipients who received these grafts in the non-ICG group.Two recipients had bile leakage,and the other two had biliary stenosis.There was no biliary complications both in donors and recipients in the ICG group.The fluorescence intensity of the liver was 108.1±17.6 at a dose of 0.004 mg/kg 90 minutes after injection,significantly weaker than that at 0.05 mg/kg 30 minutes(200.3±17.6,P=0.001)and 90 minutes after injection(140.2±15.4,P=0.001).The fluorescence intensity contrast value at a dose of 0.004 mg/kg was stronger than that at 0.05 mg/kg,both measured 90 minutes after injection(0.098±0.032 vs.0.078±0.022,P=0.021).Conclusions:ICG fluorescence cholangiography is safe and feasible in LLLS.It reduces biliary complications in both donors and recipients.The optimal ICG dose was 0.004 mg/kg,and 90 minutes after injection was the best observation time.ICG fluorescence cholangiography is recommended for routine use in LLLS.

General-motors diet: A quick fix for steatotic live liver donors

Background and aims:GM(General-Motors)diet is a low-calorie 7-day diet plan using complex carbohydrates used for quick weight loss.Dietary optimisation is known to decrease steatosis and improve outcomes in liver donors.We evaluated the efficacy and feasibility of using GM diet in steatotic live liver donors(LLD).Methods:LLDs who either had BMI>30 kg/m^(2),Computerised tomography liver attenuation index(CT-LAI)<0 HU,Magnetic resonance(MR)fat-fraction of>10%were started on GM diet for 1 week.Records of these LLDs and their recipients were retrieved retrospectively and analysed.Weight,liver function tests(LFT),MR fat-frac-tion,CT-LAI,hospital-stay and complications were analysed in LLDs while early graft dysfunction(EGD)and complications were assessed in recipients.Results:A total of 51 LLDs with mean age of 34.6?9.5 years with baseline mean weight of 80.6±10.8 kg and BMI of 29.1±2.78 kg/m^(2) were started on GM diet.After a week of following the GM diet,there was an average weight loss of 3.46±2.1 kg,a decrease in fat-fraction by 3.8%±2.7,and an improvement in CT-LAI by 6.7?3.7 HU.All patients could successfully undergo donor hepatectomy with an average postoperative ICU stay of 2.86±0.8 days and hospital stay of 6.82?0.81 days.No donor had steatosis>10% on intraoperative Tru-cut biopsy and their post-operative outcomes were similar to normal liver donors.There were intra-abdominal collections in 2 donors requiring drainage and one required re-exploration for intestinal obstruction.There was EGD in 8 recipients(15.6%)and mortality in 1(1.9%)recipients.Conclusion:GM diet is safe and effective regimen to reduce steatosis and increase healthy LLD pool without compromising donor or recipient safety.

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.