Standardization of basic skills for laparoscopic liver surgery towards laparoscopic donor hepatectomy

Лапароскопическое изъятие левого латерального сектора печени у прижизненного донора.. [DOI: 10.61726/5567.2024.63.97.001]

В педиатрической практике трансплантация фрагментов печени позволяет достичь высоких результатов [Bowring M.G., 2020] и, при этом, полностью гарантировать безопасность родственных доноров. В то же время, при выполнении трансплантации «взрослый – ребенок», практически отсутствуют этические вопросы, поскольку, чаще всего, донором является один из родителей реципиента. Тем не менее, важной задачей остается создание условий для ускорения реабилитации и минимизации хирургической травмы у донора, в этой связи, внедрение миниинвазивных методов имеет особое значение. В последние два десятилетия миниинвазивные подходы к резекциям печени прочно вошли в арсенал крупных гепатобилиарных центров. Это стало возможным благодаря накопленному опыту открытой хирургии печени, а также технологическому прогрессу [Morise Z., 2017]. Однако, применение лапароскопического подхода у родственных доноров фрагментов печени по-прежнему остается предметом живого интереса в трансплантологических центрах всего мира. Первые сравнительные исследования оказались весьма обнадеживающими и продемонстрировали перспективность этого подхода [Broering D. C., 2018]. Накопление подобного опыта, анализ кривой обучения, стандартизация хирургической техники по-прежнему являются важными вопросами развития данного направления. В России лапароскопическое изъятие фрагмента печени для последующей трансплантации было впервые выполнено в ФГБУ «НМИЦ ТИО им. Академика В. И. Шумакова» в 2016 году. Также, в России впервые в мире произведено полностью лапароскопическое изъятие одновременно фрагмента печени и почки для последующей трансплантации детям [Готье С. В., 2016, Gautier S. V., 2019]. Цель исследования. Оптимизация хирургической техники и результатов лапароскопического изъятия левого латерального сектора у прижизненных доноров фрагмента печени на основании анализа накопленного опыта. Задачи исследования. 1. Сравнить результаты открытого и лапароскопического изъятия левого латерального сектора у прижизненных доноров. 2. Определить критерии селекции прижизненных доноров для лапароскопического изъятия левого латерального сектора печени. 3. Стандартизировать хирургическую технику выполнения лапароскопической латеральной секторэктомии печени. 4. Оценить результаты трансплантации левого латерального сектора, полученного открытым и лапароскопическим путём, у реципиентов. 5. Изучить кривую обучения выполнения лапароскопической латеральной секторэктомии печени у родственного донора. Научная новизна. На сегодняшний день, лапароскопическое изъятие левого латерального сектора печени у прижизненных доноров выполняется лишь в нескольких центрах в мире. Суммарный накопленный опыт по всему миру не превышает 500 операций. В настоящее время, по данным литературы, существует лишь несколько исследований, посвященных данной тематике. Проведение псевдорандомизации позволило объективизировать результаты и увеличить их достоверность. Изучение кривой обучения выполнения лапароскопической латеральной секторэктомии печени позволяет оценить потенциал внедрения данной методики в клинические центры. Новыми являются данные сравнительного анализа клинических результатов проведения открытого и лапароскопического изъятия левого латерального сектора печени у живых доноров, а также сравнительного анализа результатов трансплантаций у реципиентов, получивших соответствующие трансплантаты. Новыми являются разработанные рекомендации по селекции доноров для лапароскопического изъятия левого латерального сектора. Впервые разработаны алгоритмы, протоколы и рекомендации по выполнению хирургического вмешательства лапароскопической резекции левого латерального сектора печени у родственного донора. Практическая значимость исследования. Впервые в России на основании доказательной медицины установлена клиническая эффективность и безопасность лапароскопической левой латеральной секторэктомии у прижизненных доноров фрагмента печени. Разработана и стандартизирована хирургическая техника, позволяющая максимально снизить интра- и послеоперационные осложнения у доноров левого латерального сектора печени, а также получать трансплантаты высокого качества. Внедрение научных разработок в клиническую практику позволит: • обезопасить хиругическое пособие у доноров путем снижения интраоперационой кровопотери и минимизации хирургической травмы; • ускорить послеоперационную реабилитацию у доноров; • получить хороший косметический эффект после оперативного пособия. Методология и методы исследования. В исследовании проведен статистический анализ клинических данных, результатов оперативного вмешательства, лабораторных и инструментальных исследований до, во время и после резекции левого латерального сектора печени у родственных доноров и трансплантации левого латерального сектора детям. Проведен статистический анализ клинических данных, результатов трансплантаций левого латерального сектора печени у реципиентов, получивших трансплантат от доноров, оперированных открыто и лапароскопически. Основные положения, выносимые на защиту 1. Лапароскопическое изъятие левого латерального сектора является эффективным и безопасным методом, позволяющим уменьшить операционную травму и ускорить реабилитацию, а также получить хороший косметический эффект. 2. Результаты трансплантации левого латерального сектора печени детям от доноров, оперированных лапароскопически, сопоставимы с аналогичными от доноров, оперированных по классической открытой методике. 3. Унификация хирургической методики позволяет уменьшить длительность операции, а также позволяет добиться максимального снижения интра- и послеоперационных осложнений у доноров. 4. Более строгая селекция доноров для лапароскопического изъятия левого латерального сектора позволяет снизить риск интраоперационных осложнений на этапе становления методики и наработки хирургического опыта. Степень достоверности и апробация результатов Достоверность результатов определяется объемом проведенных исследований с использованием современных методов статистической обработки. Апробация работы состоялась 15 июля 2020 года на совместной конференции научных и клинических подразделений федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Министерства здравоохранения Российской Федерации (ФГБУ «НМИЦ ТИО им. ак. В.И. Шумакова» Минздрава России) и кафедры трансплантологии и искусственных органов Института клинической медицины имени Н.В. Склифосовского Федерального государственного автономного образовательного учреждения высшего образования Первый осковский государственный медицинский университет имени И.М. Сеченова Министерства здравоохранения Российской Федерации (Сеченовский Университет). Материалы диссертации доложены и обсуждены на III Российском национальном конгрессе «Трансплантация и донорство органов» (Москва 2017г.), на 15-м международном конгрессе по донорству органов (ISODP, Дубай, ОАЭ), на 10-м Всероссийском съезде трансплантологов (Москва, 2020 г.), и на международном съезде трансплантологического общества (The Transplantation Society, Сеул, Южная Корея, 2020г.). Внедрение результатов исследования в практику Результаты исследования используются в хирургическом отделении № 2 федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Министерства здравоохранения Российской Федерации, в отделении онкологии и детской хирургии федерального государственного бюджетного учреждения «Национальный медицинский исследовательский центр детской гематологии, онкологии и иммунологии имени Дмитрия Рогачёва» Министерства здравоохранения Российской Федерации, а также в образовательной программе кафедры трансплантологии и искусственных органов Института клинической медицины имени Н.В. Склифосовского Федерального государственного автономного образовательного учреждения высшего образования Первый осковский государственный медицинский университет имени И.М. Сеченова Министерства здравоохранения Российской Федерации (Сеченовский Университет). Личный вклад автора. Автор принимал непосредственное участие в разработке концепции и постановке задач исследования; в оперативных вмешательствах у родственных доноров печени и операциях по трансплантации печени; самостоятельно осуществлял сбор материала для исследования. Автором самостоятельно сформирована база данных, проведена статистическая обработка, анализ и интерпретация полученных результатов. Публикации по теме диссертации По теме диссертации опубликовано 15 научных работ, из них 3 статьи в центральных рецензируемых журналах, рекомендованных ВАК, а также 2 статьи в международных журналах.

Mini-incision Right Hepatectomy for Living Donor Hepatectomy

BACKGROUND

The application of a minimally invasive technique to graft procurement in living donor liver transplantation has minimized skin incisions and led to early recovery in donor hepatectomy while ensuring donor safety. This study aimed to evaluate the safety and feasibility of mini-incision living donor right hepatectomy compared with conventional open surgery.

METHODS

The study population consisted of 448 consecutive living donors who underwent living donor right hepatectomy performed by a single surgeon between January 2015 and December 2019. According to the incision type, the donors were divided into 2 groups: a right subcostal mini-incision group (M group: n = 187) and a conventional J-shaped incision group (C group: n = 261). A propensity score matching analysis was conducted to overcome bias.

RESULTS

The estimated graft volume and measured graft weight were significantly lower in the M group ( P = 0.000). The total of 17 (3.8%) postoperative complications were identified. The readmission rate and overall postoperative complication rate of donors was not significantly different between the groups. The biliary complication rates in the recipients were 12.6% and 8.6% in the C group and M group, respectively ( P = 0.219). Hepatic artery thrombosis requiring revision developed in 2 patients (0.8%) in the C group and 7 patients (3.7%) in the M group ( P = 0.038). After propensity score matching, these complications were not significantly different between the groups.

CONCLUSIONS

Mini-incision living donor right hepatectomy shows comparable biliary complications to open surgery and is considered a safe and feasible operative technique.

Clinical Experience of Mini-Open Hepatectomy to Aid a Laparoscopic Approach: A Case Series

Introduction

Laparoscopic surgery is recently becoming widespread in the area of liver treatment. However, mobilization of the liver is difficult using laparoscopy alone because of its volume and weight. Ensuring a wider visual field and controlling blood loss are also difficult. We used a hybrid approach involving direct vision and laparoscopy for performing hepatectomy through a small incision to overcome these problems.

Case Presentation

Mini-open hepatectomy was performed on 64 patients between January 2010 and December 2013. Mobilization of the liver was performed using the smallest possible laparotomy incision. Detachment of right or left triangular ligaments was done using laparoscopy because direct vision of the operation field was impossible. Hepatectomy was performed through a small laparotomy incision. Most operations (47%) involved partial resections. Of these, segmentectomies were performed on 20 patients, whereas lobectomy was performed on 7 patients. The median intraoperative bleeding was 565 mL, and the operative time was 247 minutes. The median postoperative hospital stay was 14 days. There was no postoperative mortality.

Conclusion

We present the clinical use of mini-open hepatectomy to aid the laparoscopic approach with satisfactory short-term results.

Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS)

BACKGROUND

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS).

METHODS

A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80.

RESULTS

A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19).

CONCLUSIONS

The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long-term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO-compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow-up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long-term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA)

OBJECTIVE

The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

BACKGROUND

Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

METHODS

A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

RESULTS

Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

CONCLUSIONS

The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Laparoscopy-assisted extended right hepatectomy for giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma: a case report

BACKGROUND

Hemorrhagic hepatic cysts infrequently involve several iconographic changes requiring a differential diagnosis, primarily with a cystic malignancy. We herein report a case of laparoscopy-assisted extended right hepatectomy for a giant hemorrhagic hepatic cyst with an enhancing mural nodule that was clinically suspected of being biliary cystadenocarcinoma.

CASE PRESENTATION

A 73-year-old woman was followed up for giant hepatic cyst occupying the right lobe of the liver. During the follow-up, an enhancing mural nodule was newly noted on computed tomography in 2016. Based on additional clinical examinations, biliary cystadenocarcinoma was undeniable, and laparoscopy-assisted extended right hepatectomy was performed for diagnostic and therapeutic purposes. She had no perioperative complications and was discharged on postoperative day 13. A histological examination of the mural nodule showed neovascularization within an organized hematoma.

CONCLUSION

We herein report a rare case of giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma that was successfully treated with laparoscopy-assisted extended right hepatectomy. Laparoscopic surgery in our case was an effective procedure performed with the utmost care.

Feasibility Study of a Newly Developed Hybrid Energy Device Used During Laparoscopic Liver Resection in a Porcine Model

BACKGROUND

Although various devices have been clinically used for laparoscopic liver resection (LLR), the best device for liver parenchymal transection remains unknown. Olympus Corp (Tokyo, Japan) developed a laparoscopic hybrid pencil (LHP) device, which is the first electric knife to combine ultrasound and electric energy with a monopolar output. We aimed to evaluate the feasibility of using the LHP device and to compare it with the laparoscopic monopolar pencil (LMP) and laparoscopic ultrasonic shears (LUS) devices for LLR in a porcine model.

METHODS

Nine male piglets underwent laparoscopic liver lobe transections using each device. The operative parameters were evaluated in the 3 groups (n = 24 lobes) during the acute study period. The imaging findings from contrast-enhanced computed tomography and histopathological findings of autopsy on postoperative day 7 were compared among groups (n = 6 piglets) during the long-term study.

RESULTS

The transection time was shorter ( P = .001); there was less blood loss ( P = .018); and tip cleaning ( P < .001) and instrument changes were less often required ( P < .001) in the LHP group than in the LMP group. The LHP group had fewer instances of bleeding ( P < .001) and coagulator usage ( P < .001) than did the LUS group. In the long-term study, no postoperative adverse events occurred in the 3 groups. The thermal spread and depth of the LHP device were equivalent to those of the LMP and LUS devices (vs LMP: P = .226 and .159; vs LUS: P = 1.000 and .574).

CONCLUSIONS

The LHP device may be an efficient device for LLR if it can be applied to human surgery.

Laparoscopic left lateral section procurement in living liver donors: A single center propensity score-matched study

BACKGROUND

Laparoscopic living donor liver procurement for transplantation has increased in popularity over the past decade. The purpose of this study was to compare the laparoscopic and open approaches in living donor left lateral sectionectomy (LLS) and to assess the safety and feasibility of this laparoscopic approach.

METHODS

A total of 103 living donor LLSs were performed at our center from May 2016 to December 2017. Of these, 35 were completely laparoscopic procedures, which represented the subject of this study. An additional 68 open living donor LLSs performed during the same period were studied as a comparison group. To overcome selection bias, LLS donors were balanced on a 1:1 ratio (laparoscopic [n = 35]: open [n = 35]) according to covariates with similar values. The PSM was based on the operation date, recipient age, diagnosis, recipient weight, and donor age.

RESULTS

There were significant differences between the laparoscopic and open LLS groups (P < 0.001) in terms of blood loss (96.8 ± 16.5 vs 155.8 ± 17.8 mL) as well as the duration of hospital stay (4 ± 0.4 vs 6.9 ± 0.5 days).

CONCLUSION

Laparoscopic LLS is a feasible and efficacious in the setting of a developed program with advanced laparoscopic expertise.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

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.

The liver hanging maneuver in laparoscopic liver resection: a systematic review

PURPOSE

Laparoscopic surgery has gained the acceptance of the hepatobiliary surgical community and expert teams are now advocating major laparoscopic liver resections (LLRs). In this setting, the liver hanging maneuver (LHM) has been described in numerous series. We conducted a systematic review to investigate the effectiveness of the LHM in LLR.

METHODS

We performed an electronic literature search using PubMed, EMBASE, and COCHRANE databases. The final search was carried out in December, 2015.

RESULTS

We found 11 articles describing a collective total of 104 surgical procedures that were eligible for this study. Laparoscopic LHM was used in LLR for both benign and malignant conditions, and also in living donor liver transplantation (LDLT). The LHM was used mainly in right hepatectomy and only two authors reproduced the original LHM. We investigated the intraoperative parameters, preservation of postoperative liver function, and oncological outcomes. The clear benefit of using the LHM in LLR is for better identification of the parenchymal transection plane with less blood loss. The other benefits of LHM could not be corroborated by solid data on its positive value.

CONCLUSIONS

In view of the data published in the literature, our findings are not strong enough to support the systematic use of LHM in LLR.

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.

Laparoscopic Hepatectomy for Liver Cancer

This chapter covers a range of important topics of laparoscopic hepatectomy as a novel approach toward treatment of liver cancer. Although laparoscopic hepatectomy was performed in a limited number of centers in the 1990s, technological innovations, improvements in surgical techniques and accumulation of experience by surgeons have led to more rapid progress in laparoscopic hepatectomy in the late 2000s for minimally invasive hepatic surgery. Currently, laparoscopic hepatectomy can be performed for all tumor locations and several diseases via several approaches. The laparoscopic approach can be applied to several types of resection, not only for tumors but also for liver transplantation, with equivalent or better results compared with those obtained with open surgery. Therefore, laparoscopic hepatectomy will become a standard procedure for treatment of liver cancer in the near future.

Totally laparoscopic living donor right hepatectomy in a donor with trifurcation of bile duct

Donor operation in adult living donor liver transplantation is associated with significant postoperative morbidity. To avoid laparotomy wound complications and shorten postoperative recovery, laparoscopic liver graft harvest has been developed recently. However, to determine the cut point of bile duct is challenging. Herein, we report the application of totally laparoscopic approach for right liver graft harvest in a donor with trifurcation of the bile duct. A19-year-old man volunteered for living donation to his father who suffered from hepatitis B virus-related cirrhosis of liver and hepatocellular carcinoma. The graft was 880 mL with a single right hepatic artery and portal vein. The graft to recipient weight ratio was 1.06. The middle hepatic vein was preserved for the donor and the liver remnant was 42.3%. Two branches of middle hepatic veins were > 5 mm in diameter and needed reconstruction with cryopreserved allograft. Ductoplasty using laparoscopic intracorporeal suture technique was done to achieve single orifice of the graft bile duct. The postoperative course was uneventful for the donor. This report adds evidence of the feasibility of pure laparoscopic right donor hepatectomy and describes the necessary steps for bile duct division in donors with trifurcation of bile duct.

Anatomical laparoscopic hepatectomy for hepatocellular carcinoma using indocyanine green fluorescence imaging

PURPOSE

It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC), and consequently laparoscopic hepatic resection is widely performed. However, most anatomical resections, except left lateral sectionectomy, remain difficult technically, and laparoscopy-assisted procedures have been introduced as an alternative approach because of the safety and curative success of the operation. We reported previously pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites. Herein, we describe pure anatomical laparoscopic segmentectomy using the puncture method with indocyanine green (ICG) injection under laparoscopic US.

PATIENTS AND METHODS

Pure laparoscopic segmentectomy was planned for 2 patients with HCC of the liver. Identification of the segment was performed by ICG injection for optical imaging using near-infrared fluorescence under laparoscopic US guidance.

RESULTS

The procedures were completed successfully, and the postoperative courses were uneventful.

CONCLUSIONS

Pure laparoscopic segmentectomy for HCC with a conventional puncture technique by ICG injection under laparoscopic US is considered to be a useful procedure featuring both low invasiveness and curative success.

Development and clinical usefulness of the liver hanging maneuver in various anatomical hepatectomy procedures

PURPOSE

To assess the clinical application and usefulness of the liver hanging maneuver (LHM), proposed by Belghiti, for major hepatectomy, including its (1) historical development, (2) usefulness and application and (3) advantages and disadvantages, by reviewing the English literature published during the period 2001-2014.

RESULTS

In major hepatic transection via the anterior approach, the deep area of transection around the vena cava is critical with regard to bleeding during right hemi-hepatectomy. Belghiti and other investigators identified avascular spaces that are devoid of short hepatic veins at the front of the vena cava and behind the liver. Forceps can be inserted into this space easily and then maneuvered to lift the liver using hanging tape. This procedure, termed LHM significantly reduces intraoperative blood loss and the transection time during right hemi-hepatectomy. LHM has been used in various anatomical hepatectomy procedures worldwide, including laparoscopic hepatectomy. The use of LHM markedly improves the amount of intraoperative blood loss, operative time and postoperative outcome.

CONCLUSIONS

We conclude that the application of LHM is an important development in the field of liver surgery, although a further evaluation of its true impact on clinical outcomes is necessary.

What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection

The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Approaches to laparoscopic liver resection: a meta-analysis of the role of hand-assisted laparoscopic surgery and the hybrid technique

Laparoscopic liver resection has been established as a safe and feasible treatment option. Surgical approaches include pure laparoscopy, hand-assisted laparoscopy (HALS), and the hybrid technique. The role of these three approaches, and their superiority over open laparotomy, is not yet known. A literature review was performed using specific search phrases, relating to hand-assisted or hybrid approaches to laparoscopic liver resection. Surgical results from 18 case series (HALS, nine series; hybrid technique, nine series), each with ≥ 10 patients, were analyzed. Results indicated that HALS was associated with a mean operative time of 82-264.5 min, an estimated blood loss of 82-300 mL, and a complication rate of 3.8-27.1%. Analysis of series involving the hybrid technique indicated a mean operative time of 111-366.5 min, an estimated blood loss of 93-936 mL, and a complication rate of 3.4-23.5%. In conclusion, there is insufficient evidence to conclude that any single approach is superior to the others, although HALS and the hybrid technique are useful when dealing with difficulties associated with pure laparoscopy. Conversely, the need for these two methods, which can function as a bridge to pure laparoscopic liver resection, may be overcome with appropriate training.

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.

Laparoscopic liver resection: Wedge resections to living donor hepatectomy, are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.

Laparoscopic left lateral sectionectomy as a training procedure for surgeons learning laparoscopic hepatectomy

BACKGROUND

Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.

METHODS

Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).

RESULTS

The median operative time was significantly shorter for Group B (103 min; range, 99-109 min) and C (107 min; range, 85-135 min) patients than for Group A (153 min; range, 95-210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.

CONCLUSION

The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.

A hybrid method of laparoscopic-assisted open liver resection through a short upper midline laparotomy can be applied for all types of hepatectomies

BACKGROUND

Although hepatectomy procedures should be designed to provide both curability and safety, minimal invasiveness also should be pursued.

METHODS

We analyzed the data related to our method for laparoscopy-assisted open resections (hybrid method) through a short upper midline incision for various types of hepatectomies. Of 215 hepatectomies performed at Nagasaki University Hospital between November 2009 and June 2012, 102 hepatectomies were performed using hybrid methods.

RESULTS

A hybrid method was applicable for right trisectionectomy in 1, right hemihepatectomy in 32, left hemihepatectomy in 29, right posterior sectionectomy in 7, right anterior sectionectomy in 1, left lateral sectionectomy in 2, and segmentectomy in 7 patients, and for a minor liver resection in 35 patients (12 combined resections). The median duration of surgery was 366.5 min (range 149-709) min, and the median duration of the laparoscopic procedure was 32 min (range 18-77) min. The median blood loss was 645 g (range 50-5,370) g. Twelve patients (12 %) developed postoperative complications, including bile leakage in three patients, wound infections in two patients, ileus in two patients, and portal venous thrombus, persistent hyperbilirubinemia, incisional hernia, local liver infarction each in one patient. There were no perioperative deaths.

CONCLUSIONS

Our method of hybrid hepatectomy through a short upper midline incision is considered to be applicable for all types of hepatectomy and is a reasonable approach with no abdominal muscle disruption, which provides safe management of the hepatic vein and parenchymal resection even for patients with bilobular disease.

The learning curve in laparoscopic major liver resection

Laparoscopic major hepatectomy remains a relatively rare operation because it is a difficult and technically demanding procedure, and a standard, safe, reproducible technique has not been widely adopted. This is compounded by "major hepatectomy" encompassing multiple different operations each with their own anatomic and procedural considerations. In 2010, we investigated our learning curve for laparoscopic liver resection. We found a significant increase in the number of major hepatectomies performed over a 12-year period, with concurrent reductions in the use of hand-assistance, pedicle clamping, median clamping time, median operative time, blood loss and morbidity. This learning curve was confirmed by a subsequent multinational study. Both hospital and surgeon volume have been shown to affect outcomes, and defining a sufficient number of repetitions before the learning curve plateaus is not easy for laparoscopic major hepatectomy. We recommend that laparoscopic competencies be developed upon a foundation of open liver surgery and that laparoscopic major hepatectomy should only be attempted after competency with less technically complex laparoscopic resections. A center advanced along its institutional learning curve provides the collective expertise necessary for safe patient selection and management. An environment with colleagues willing to share their acquired proficiency allows the surgeon to observe and critique his or her performance against colleagues. Also, the guidance of like-minded surgeons supports technical development and improved outcomes. In conclusion, steady progress can be made along the learning curve through committed practice of increasingly complex tasks and with proper coaching in a high-volume environment.

[Laparoscopic liver resection: lessons learned after 132 resections]

INTRODUCTION

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

AIM

To report our experience in laparoscopic liver resections (LLRs).

PATIENTS AND METHOD

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS.

SURGICAL TECHNIQUE

6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

RESULTS

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

CONCLUSION

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.

Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques

OBJECTIVE

This review assesses the current status of laparoscopic liver resection.

BACKGROUND

The trend in laparoscopic liver resection has been moving from limited resections toward major hepatectomy. The surgical techniques for laparoscopic major hepatectomy include pure laparoscopic, hand-assisted laparoscopic, and laparoscopy-assisted methods. We performed a literature search and systematic review to assess the current status of laparoscopic major hepatectomy.

METHODS

Our literature review was conducted in Medline using the keywords "laparoscopy" or "laparoscopic" combined with "liver resection" or "hepatectomy." Articles written in English containing more than 10 cases of laparoscopic major hepatectomy were selected.

RESULTS AND CONCLUSIONS

Twenty-nine articles were selected for this review. The laparoscopic major hepatectomies achieved similar patient and economic outcomes compared with open liver resections in selected (noncirrhotic) patients. Surgeon experience with the techniques affected the results; thus, a learning period is mandatory. Of these 3 techniques, the pure laparoscopic method is suitable for experienced surgeons to achieve better cosmetic outcomes, whereas the hand-assisted laparoscopic method was associated with better perioperative outcomes; the laparoscopy-assisted method is used by surgeons for unique resections such as resection of cirrhotic livers, laparoscopic resection of tumors in unfavorable locations, and living donor hepatectomies. In addition, the laparoscopic major hepatectomy-specific, long-term oncologic outcomes remain to be addressed in future publications.

[Latest indications for hanging manoeuvre in liver surgery]

By definition the liver hanging manoeuvre (LHM) means that a slip is passed between the liver parenchyma and the inferior vena cava. It was first published by Belghiti in 200l, and several changes in the indication as well as in the method have been published since then. In parallel, the anatomical and histological basis has been clarified for LHM, too. According to general consensus LHM increases safety and radicality of liver surgery. Initially LHM was applied for removal of huge tumours infiltrating the diaphragm. Authors worked out two modifications for LHM. Tumours / primary or secondary / in segment IVA are sometimes located in close proximity to the median hepatic vein and inferior vena cava , and the resectability of these tumors can determined by the hanging manoeuvre. Tumors in segment VII can be removed by partial resection of vena cava facilitated by LHM. Four patients with LHM are discussed, and based on this limited experience as well as the latest observations from relevant literature the authors claim that LHM increases the safety of resections from segment IVA and VII. Vascular infiltration of the vena cava is always a technical challenge, which can be suspected on preoperative imaging modalities, but in borderline cases only the intraoperative ultrasound and surgical judgment together with LHM would lead to the exact diagnosis and makes the resection possible.

Mini-incision right hepatic lobectomy with or without laparoscopic assistance for living donor hepatectomy

Minimally invasive procedures are considered to be safe and effective approaches to the management of surgical liver disease. However, this indication remains controversial for living donor hepatectomy. Between 2000 and 2011, living donor right hepatectomy (LDRH) was performed 58 times. Standard right hepatectomy was performed in 30 patients via a subcostal incision with a midline extension. Minimally invasive procedures began to be used for LDRH in 2008. A hybrid technique (hand-assisted laparoscopic liver mobilization and minilaparotomy for parenchymal dissection) was developed and used in 19 patients. In 2010, an upper midline incision (10 cm) without laparoscopic assistance for LDRH was innovated, and this technique was used in 9 patients. The perioperative factors were compared, and the indications for minimally invasive LDRH were investigated. The operative blood loss was significantly less for the patients undergoing a minimally invasive procedure versus the patients undergoing the standard procedure (212 versus 316 mL, P = 0.001), and the operative times were comparable. The length of the hospital stay was significantly shorter for the minimally invasive technique group (5.9 versus 7.8 days, P < 0.001). The complication rates were 23% and 25% for the standard technique and minimally invasive technique groups, respectively (P = 0.88). Patients undergoing minilaparotomy LDRH had a body mass index (24.0 kg/m(2)) similar to that of the hybrid technique patients (25.8 kg/m(2), P = 0.36), but the graft size was smaller (780 versus 948 mL, P = 0.22). In conclusion, minimally invasive LDRH can be performed without safety being impaired. LDRH with a 10-cm upper midline incision and without laparoscopic assistance may be appropriate for donors with a smaller body mass. Laparoscopic assistance can be added as needed for larger donors. This type of LDRH with a 10-cm incision is innovative and is recommended for experienced centers.

Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision

BACKGROUND

Recently, applications of less invasive liver surgery in living donor hepatectomy (LDH) have been reported. The objective of this study was to evaluate the safety and efficacy of a hybrid method with a midline incision for LDH.

METHODS

Hemihepatectomy using the hybrid method was performed in the fifteen most recent among 150 living donors who underwent surgery between 1997 and August 2011. Six donors underwent right hemihepatectomy and 9 underwent left hemihepatectomy. An 8-cm subxiphoid midline incision was created for hand assistance during liver mobilization and graft extraction. After sufficient mobilization of the liver, the hand-assist/extraction incision was extended to 12 cm for the right hemihepatectomy and 10 cm for a left hemihepatectomy. Encircling the hepatic veins and hilar dissection were performed under direct vision. Parenchymal transection was performed with the liver hanging maneuver. Bile duct division was performed after visualizing the planned transection point by encircling the bile duct using a radiopaque marker filament under real-time C-arm cholangiography.

RESULTS

All procedures were completed without any extra subcostal incision. All grafts were safely extracted through the 10-12-cm upper midline incision without mechanical injury. No donors required an allogeneic transfusion; all of them have returned to their preoperative activity levels.

CONCLUSION

LDH by the hybrid method with a short upper midline incision is a safe procedure.

Laparoscopic living donor hepatectomy

Shortage of deceased donor organs led to establishment of living donor liver transplantation. Recent reports have strongly suggested that laparoscopic approach should be the gold standard for lesions in the left lateral section. Laparoscopic living donor left lateral sectionectomy was first described in 2002. Subsequently, laparoscopic procurement of left lateral sections was shown to be safe and reproducible, resulting in grafts similar to those obtained with open surgery. In 2006, laparoscopy-assisted right lobe donor hepatectomy was reported. To date, however, only a small number of liver transplant centers have performed laparoscopic donor hepatectomy because the procedure can be performed only by surgical teams with extensive expertise in performing both minimally invasive surgery on the liver and liver transplantation with partial and living donor liver grafts. Herein, we describe the details of laparoscopic living donor hepatectomy including total laparoscopic surgery and laparoscopy-assisted surgery.

Our initial experience with robotic hepato-biliary-pancreatic surgery

BACKGROUND

The authors performed Asia's first robotic surgery in March 2000 and a clinical trial was launched in the following year in order to obtain governmental approval for the da Vinci(®) Surgical System.

METHODS

Fifty-two robotic surgeries were performed at Keio University Hospital, of which the authors performed 28 hepato-biliary-pancreatic surgeries.

RESULTS

In robotic laparoscopic cholecystectomy, articulated monopolar electrocautery scalpels are flexible, enabling precise dissection around the gall bladder and clipless ligation of the cystic artery and cystic ducts. For laparoscopic hepatectomy, hepatic parenchyma was safely resected without hemorrhage by Glisson's pedicles ligation and bipolar hemostatic forceps.

CONCLUSIONS

We review robotic laparoscopic cholecystectomy and hepatectomy and discuss the potential and future outlook for robotic hepato-biliary-pancreatic surgery.

Initial experience with laparoscopic hepatic resection at a comprehensive cancer center

BACKGROUND

Over the past few years, surgeons have been able to obtain training in advanced minimally invasive surgery (MIS) for hepatic, pancreatic, and biliary (HPB) cases instead of having to teach themselves these complex techniques. As a result, the initial experience of a surgeon with advanced MIS HPB training at a national cancer center was reviewed.

METHODS

The experience of a surgeon with the first 50 laparoscopic hepatectomies for cancer was reviewed retrospectively. All cases begun with the intention to complete the hepatectomy laparoscopically were included in the laparoscopic group.

RESULTS

From November 2008 to October 2010, a total of 57 hepatectomies were performed, with 53 attempted laparoscopically. Of these 57 hepatectomies, 46 (87%) were completed laparoscopically, 4 (7%) required hand assistance, and 3 (6%) were converted to an open approach. Laparoscopic minor hepatectomies were performed for 28 patients and laparoscopic major hepatectomies for 25 patients. The mean operative time was 265 min, and the mean estimated blood loss was 300 ml. The mean hospital stay was 7 days. Complications occurred for six patients (11%) (2 bile leaks, 2 hemorrhages requiring conversion, 1 hernia requiring a hernia repair on postoperative day 7, and 1 ileus managed nonoperatively).

CONCLUSIONS

Surgeons with advanced MIS HPB training may be able to perform a higher percentage of their hepatectomies laparoscopically. Training in both open and laparoscopic HPB surgery is advisable before these techniques are performed.

Elective living donor liver transplantation by hybrid hand-assisted laparoscopic surgery and short upper midline laparotomy

BACKGROUND

Although the technique of liver transplantation is well developed, the invasiveness of the operation can be decreased with laparoscopic procedures.

METHODS

We performed elective living donor liver transplantation (LDLT) through a short midline incision combined with hand-assisted laparoscopic surgery (HALS). Nine selected patients with end stage liver disease underwent the procedure between July, 2010 and February, 2011 (median age 60, median Child-Pugh 9, median MELD score 14). Splenectomy was performed simultaneously in 7 cases. The liver (and spleen) were mobilized by a sealing device under a HALS procedure with an 8-cm upper midline incision, followed by explantation of the diseased liver (and spleen) through the upper midline incision which was extended to 12 to 15 cm. Partial liver grafts were implanted through the upper midline incision.

RESULTS

The median duration of the operation was 741 minutes, the median time needed for anastomosis was 48 minutes, the median blood loss was 3,940 g, and the median liver weight was 866 g. Eight recipients are alive and have good graft function. A difficult implantation for one patient required an additional right transverse incision. When compared with 13 recent liver recipients who underwent LDLT with a regular Mercedes-Benz-type incision, no clinically relevant drawbacks of the HALS hybrid procedure were observed.

CONCLUSION

We have shown the feasibility and safety of LDLT performed through a short midline incision without abdominal muscle disruption with the aid of HALS.