Laparoscopy-assisted hybrid left-side donor hepatectomy: is it truly less invasive for living donors?

Pure laparoscopic versus open left lateral hepatectomy in pediatric living donor liver transplantation: a review and meta-analysis

PURPOSE

The meta-analysis was conducted to evaluate the safety and feasibility of pure laparoscopic left lateral hepatectomy in comparison with open approach for pediatric living donor liver transplantation (LDLT).

METHODS

A systemic literature survey was performed by searching the PubMed, EMBASE and Cochrane Library databases for articles that compared pure laparoscopic left lateral living donor hepatectomy (LLDH) and open left lateral living donor hepatectomy (OLDH) by November 2021. Meta-analysis was performed to assess donors' and recipients' perioperative outcomes using RevMan 5.3 software.

RESULTS

A total of five studies involving 432 patients were included in the analysis. The results demonstrated that LLDH group had significantly less blood loss (WMD = -99.28 ml, 95%CI -152.68 to -45.88, p = 0.0003) and shorter length of hospital stay (WMD = -2.71d, 95%CI -3.78 to -1.64, p < 0.00001) compared with OLDH group. A reduced donor overall postoperative complication rate was observed in the LLDH group (OR = 0.29, 95%CI 0.13-0.64, p = 0.002). In the subgroup analysis, donor bile leakage, wound infection and pulmonary complications were similar between two groups (bile leakage: OR = 1.31, 95%CI 0.43-4.02, p = 0.63; wound infection: OR = 0.38, 95%CI 0.10-1.41, p = 0.15; pulmonary complications: OR = 0.24, 95%CI 0.04-1.41, p = 0.11). For recipients, there were no significant difference in perioperative outcomes between the LLDH and OLDH group, including mortality, overall complications, hepatic artery thrombosis, portal vein and biliary complications.

CONCLUSION

LLDH is a safe and effective alternative to OLDH for pediatric LDLT, reducing invasiveness and benefiting postoperative recovery. Future large-scale multi-center studies are expected to confirm the advantages of LLDH in pediatric LDLT.

Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis

Laparoscopic donor hepatectomy (LDH), accepted as a minimally invasive approach, has become increasingly popular for living donor liver transplant. However, the outcomes of LDH remain to be fully clarified when compared with open living donor hepatectomy. Thus, our meta-analysis was designed to assess the efficacy of laparoscopic in comparison with conventional open donor hepatectomy.The PubMed, Cochrane, and Embase electronic databases were searched to identify the articles concerning the comparison of the efficacy of laparoscopic versus open surgery in treatment of living donor liver transplantation updated to March, 2020. The main search terms and medical Subject Heading terms were: "living donor," "liver donor," "minimally invasive," "laparoscopic surgery," and "open surgery." After rigorous evaluation on quality, the data was extracted from eligible publications. The outcomes of interest included intraoperative and postoperative results.The inclusion criteria were met by a total of 20 studies. In all, 2001 subjects involving 633 patients who received laparoscopic surgery and 1368 patients who received open surgery were included. According to the pooled result of surgery duration, the laparoscopic surgery was associated with shorter duration of hospital stay (MD = -1.07, 95% CI -1.85 to -0.29; P = .007), less blood loss (MD = -57.57, 95% CI -65.07 to -50.07; P < .00001), and less postoperative complications (OR = 0.61, 95% CI 0.44-0.85; P = .003). And the open donor hepatectomy achieved a trend of shorter operation time (MD = 30.31, 95% CI 13.93-46.69; P = .0003) than laparoscopic group. Similar results were found in terms of ALT (P = .52) as well as the AST (P = .47) peak level between the 2 groups.LDH showed the better perioperative outcomes as compared with open donor hepatectomy. The findings revealed that LDH may be a feasible and safe procedure for the living donor liver transplantation.

The First Comparative Study of the Perioperative Outcomes Between Pure Laparoscopic Donor Hepatectomy and Laparoscopy-Assisted Donor Hepatectomy in a Single Institution

BACKGROUND

In a statement from the second International Consensus Conference for Laparoscopic Liver Resection, adult-to-adult laparoscopic donor surgery was the earliest phase of development. It was recommended that the procedure be performed under institutional ethical approval and a reporting registry.

METHOD

At our institute, we started laparoscopy-assisted donor hepatectomy (LADH) in 2007 and changed to pure laparoscopic donor hepatectomy (PLDH) in 2012. This study included 40 living donors who underwent LADH and 14 live donors who underwent PLDH. We describe the technical aspects and outcomes of our donor hepatectomy from assist to pure and examine the liver allograft outcomes of the recipients after LADH and PLDH.

RESULTS

There was significantly less blood loss in the PLDH group (81.07 ± 52.78 g) than that in the LADH group (238.50 ± 177.05 g), although the operative time was significantly longer in the PLDH group (454.93 ± 85.60 minutes) than in the LADH group (380.40 ± 44.08 minutes). And there were no significant differences in postoperative complication rate in the 2 groups. The liver allograft outcomes were acceptable and comparable with open living donor hepatectomy.

CONCLUSIONS

By changing our routine approach from assist to pure, PLDH can be performed safely, with better exposure due to magnification, and with less blood loss under pneumoperitoneal pressure. PLDH, which has become our promising donor procedure, results in less blood loss, better cosmesis, and the donor's complete rehabilitation without deterioration in donor safety.

Meta-Analysis of Laparoscopic versus Open Hepatectomy for Live Liver Donors

Objective

To document the safety and efficacy of laparoscopic living donor hepatectomy in comparison with open liver resection for living donor liver transplantation.

Methods

Medline database, EMASE and Cochrane library were searched for original studies comparing laparoscopic living donor hepatectomy (LLDH) and open living donor hepatectomy (OLDH) by January 2015. Meta-analysis was performed to evaluate donors’ perioperative outcomes.

Results

Nine studies met selection criteria, involving 1346 donors of whom 318 underwent LLDH and 1028 underwent OLDH. The Meta analysis demonstrated that LLDH group had less operative blood loss [patients 1346; WMD: -56.09 mL; 95%CI: -100.28-(-11.90) mL; P = 0.01], shorter hospital stay [patients 737; WMD: -1.75 d; 95%CI: -3.01-(-0.48) d; P = 0.007] but longer operative time (patients 1346; WMD: 41.05 min; 95%CI: 1.91–80.19 min; P = 0.04), compared with OLDH group. There were no significant difference in other outcomes between LLDH and OLDH groups, including overall complication, bile leakage, postoperative bleeding, pulmonary complication, wound complication, time to dietary intake and period of analgesic use.

Conclusions

LLDH appears to be a safe and effective option for LDLT. It improves donors’ perioperative outcomes as compared with OLDH.

Comprehensive guide to laparoscope-assisted graft harvesting in live donors for living-donor liver transplantation: perspective of laparoscopic vision

Background

A living donor (LD) for liver transplantation (LT) is the best target for minimally invasive surgery. Laparoscope-assisted surgery (LAS) for LDs has gradually evolved. A donor safety rate of 100% should be guaranteed.

Methods

We began performing LAS for LDs in June 2012. The aim of this report is to describe the surgical procedures of LAS in detail, discuss various tips and pitfalls, and address the potential for a smooth transition to more advanced LAS.

Results

Preoperative planning based on three-dimensional image analysis is a powerful tool for successful surgery. The combination of liver retraction/countertraction and the pressure produced by pneumoperitoneum widens the dissectible/cuttable layer, increasing the safety of LAS. A flexible laparoscope provides excellent magnified vision in both the horizontal view along the inferior vena cava, under adequate liver retraction, and in the lateral view, to harvest left-sided grafts in critical procedures. Intentional omission of painful incisions is beneficial for LDs. Hepatectomy using a smaller midline incision is safe if a hanging maneuver is used. Safe transition from LAS to a hybrid technique involving a combination of pure laparoscopic surgery and subsequent open surgery seems possible.

Conclusion

LDLT surgeons have a very broad intellectual and technical frontier.

Laparoscopic living donor hepatectomy: a review of current status

Over the last two decades, laparoscopic surgery has been adopted in various surgical fields. Its advantages of reduced blood loss, reduced postoperative morbidity, shorter hospital stay, and excellent cosmetic outcome compared with conventional open surgery are well validated. In comparison with other abdominal organs, laparoscopic hepatectomy has developed relatively slowly due to the potential for massive bleeding, technical difficulties and a protracted learning curve. Furthermore, applications to liver graft procurement in living donor liver transplantation (LDLT) have been delayed significantly due to concerns about donor safety, graft outcome and the need for expertise in both laparoscopic liver surgery and LDLT. Now, laparoscopic left lateral sectionectomy in adult-to-pediatric LDLT is considered the standard of care in some experienced centers. Currently, the shift in application has been towards left lobe and right lobe graft procurement in adult LDLT from left lateral section in pediatric LDLT. However, the number of cases is too small to validate the safety and reproducibility. The most important concern in LDLT is donor safety. Even though a few studies reported the technical feasibility and comparable outcomes to conventional open surgery, careful validating through larger sample sized studies is needed to achieve standardization and wide application.

Donor safety in live donor laparoscopic liver procurement: systematic review and meta-analysis

BACKGROUND

Donor safety is a major concern in live organ donation. Live donor laparoscopic liver procurement is an advanced surgical procedure that is performed in highly specialized centers. Since its first report, not much progress has been endeavored for that procedure.

METHODS

We planned to include all the randomized and comparative nonrandomized studies. Patients' population: live donors who are submitted to organ procurement via laparoscopy.

RESULTS

Out of 5,636 records retrieved from the literature, only seven nonrandomized studies were included in this review, which encompassed 418 patients, 151 patients of whom underwent laparoscopic procurement. The quality scores for the included studies ranged from 66 to 76 %. The operative time was significantly shorter in the conventional open group (SD = 0.863, 95 % CI 0.107-1.819). Blood loss in the laparoscopic group was comparable with the conventional open approach (SD = -0.307, 95 % CI -0.807 to 0.192). In subgroup analysis, laparoscopy was protective against blood loss in laparoscopic parenchymal dissection (SD = -1.168, 95 % CI -1.758 to -0.577). The hospital stay was equal in both groups. Patients in laparoscopic group consumed fewer analgesics compared with conventional open group (SD = -0.33, 95 % CI -0.63 to -0.03). Analgesics use was lower in the laparoscopic group compared with the conventional approach. The rate of Clavien complications was equal in both groups (OR 0.721, 95 % CI 0.303-1.716). No difference was found between subgroup analysis based on the harvested liver lobe. Funnel plot and statistical methods used revealed low probability of publication BIAS.

CONCLUSIONS

Live donor laparoscopic liver procurement could be as safe as the conventional open approach. Lower blood loss and lower consumtion of analgesics might be offered in the laparoscopic approach.