Comparison of perioperative outcomes between pure laparoscopic surgery and open right hepatectomy in living donor hepatectomy: Propensity score matching analysis

Current Status of Laparoscopic Liver Resection

The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

Living liver donor pain management

PURPOSE OF REVIEW

Optimal pain control in living liver donors undergoing hepatectomy is strongly recommended considering their unique status as healthy individuals willingly undergoing surgery for the benefit of the recipient. This review aims to examine and evaluate different strategies aimed at ensuring effective postoperative pain management in living liver donors.

RECENT FINDINGS

Enhanced recovery after surgery (ERAS) protocols have proven effective in optimizing patient outcomes, including in living liver donor hepatectomy. By implementing these protocols, healthcare professionals can enhance postoperative pain control and accelerate recovery. Multimodal analgesia, which combines different techniques and agents, is crucial in pain management for living liver donors. Regional analgesia techniques, such as spinal anesthesia and various peripheral nerve blocks, have shown efficacy in reducing pain and facilitating early recovery. Systemic nonopioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, ketamine, lidocaine, and dexmedetomidine act synergistically to alleviate pain and reduce inflammation. Minimizing the use of opioids is important to avoid adverse effects, and they should be reserved for rescue medication or breakthrough pain.

SUMMARY

Applying the principles of ERAS and multimodal analgesia to living liver donors can effectively control pain while promoting early recovery.

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.

Comparison of two doses of intrathecal morphine in laparoscopic donor hepatectomy: A randomized double-blinded non-inferiority trial

BACKGROUND

Intrathecal morphine (ITM) injection is an effective postoperative analgesic strategy in open or laparoscopic donor hepatectomy; however, the optimal dose has not been determined. In this trial, we compared the post-operative analgesic effects of two doses (300 vs. 400 μg) of ITM injections.

METHODS

In this prospective randomized non-inferiority trial, 56 donors were divided into either the 300 μg or 400 μg ITM group (n = 28, each). The primary outcome was the resting pain score at 24 h postoperatively. Pain scores, cumulative opioid consumption, and side effects (postoperative nausea and vomiting [PONV]) were compared up to 48 h postoperatively.

RESULTS

Fifty-five donors participated in the entire study. The mean resting pain scores at 24 h after surgery were 1.7 ± 1.6 and 1.7 ± 1.1 in the ITM 300 and ITM 400 groups, respectively (mean difference, 0 [95% CI, -.8 to .7], p = .978). The upper limit of the 95% CI was lower than the prespecified non-inferiority margin (δ = 1), indicating that non-inferiority had been established. The incidence of PONV was lower in the ITM 300 group than in the ITM 400 group at 18 (p = .035) and 24 h postoperatively (p = .015). There were no significant differences in the resting and coughing pain scores and cumulative opioid consumption at any time point.

CONCLUSION

For laparoscopic donor hepatectomy, preoperative ITM 300 μg exhibited non-inferior postoperative analgesic effects compared to ITM 400 μg, with a lower incidence of PONV.

Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey

BACKGROUND

We aimed to report a single-center experience in laparoscopic donor left-side and right-side hepatectomy cases regarding preoperative evaluation, perioperative and anesthetic management protocols, and postoperative follow-up.

METHODS

Laparoscopic donor left-side and right-side hepatectomy cases were included in the study because of their excessive transection area and bleeding potential. Medical records of living donors were reviewed in terms of age, sex, body mass index (BMI), presence of consanguinity with the recipient, perioperative and early postoperative biochemical parameters, hemodynamic changes during surgery, duration of surgery, the ratio of liver volume to total liver volume, perioperative complications, and length of hospital stay.

RESULTS

Eighty-one laparoscopic living-donor hepatectomy procedures were performed in our unit between 2018 and 2022. Six laparoscopic donor right-side cases and two left-side cases were retrospectively reviewed. Donors' mean age and BMI were 29.6 ± 8.6 years and 23.1 ± 4.3, respectively. The average weights of the right and left lobe liver grafts were 727 g and 279 g, respectively, constituting 65.8% and 22.7% of the total liver volume, respectively. The mean operation time was 593 ± 94 minutes, and the mean volume of blood loss was 437 ± 294 mL. A major complication, namely portal vein stenosis, developed in 1 donor (1/8), and portal vein patency was achieved postoperatively.

CONCLUSIONS

Anesthesia management and teamwork between surgeons and anesthesiologists are the most important building blocks for donor safety, which is of the utmost priority. Effective communication and cooperation in the operating room may prevent potential donor complications and improve postoperative recovery time.

Minimally Invasive Donors Right Hepatectomy versus Open Donors Right Hepatectomy: A Meta-Analysis

BACKGROUND

How to obtain a donor liver remains an open issue, especially in the choice of minimally invasive donors right hepatectomy versus open donors right hepatectomy (MIDRH versus ODRH). We conducted a meta-analysis to clarify this question.

METHODS

A meta-analysis was performed in PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases. Baseline characteristics and perioperative outcomes were analyzed.

RESULTS

A total of 24 retrospective studies were identified. For MIDRH vs. ODRH, the operative time was longer in the MIDRH group (mean difference [MD] = 30.77 min; p = 0.006). MIDRH resulted in significantly less intraoperative blood loss (MD = -57.86 mL; p < 0.00001), shorter length of stay (MD = -1.22 days; p < 0.00001), lower pulmonary (OR = 0.55; p = 0.002) and wound complications (OR = 0.45; p = 0.0007), lower overall complications (OR = 0.79; p = 0.02), and less self-infused morphine consumption (MD = -0.06 days; 95% CI, -1.16 to -0.05; p = 0.03). In the subgroup analysis, similar results were observed in pure laparoscopic donor right hepatectomy (PLDRH) and the propensity score matching group. In addition, there were no significant differences in post-operation liver injury, bile duct complications, Clavien-Dindo ≥ 3 III, readmission, reoperation, and postoperative transfusion between the MIDRH and ODRH groups.

DISCUSSION

We concluded that MIDRH is a safe and feasible alternative to ODRH for living donators, especially in the PLDRH group.

Pure Laparoscopic Donor Left Hepatectomy Reduces Postoperative Analgesic Use and Pain Scale

BACKGROUND

Many recent reports have described the efficacy and safety of pure laparoscopic donor hepatectomy (PLDH). Here we investigated the extent to which this technique could reduce patients' experienced pain.

METHODS

Among donor left hepatectomy procedures performed between July 2011 and November 2022, we retrospectively analyzed 20 open donor hepatectomy (ODH), 20 laparoscopy-assisted donor hepatectomy (LADH), and 5 PLDH cases. We compared these 3 procedures regarding the total amount of postoperative analgesic use (narcotics and non-narcotics) and the first date when the donor was completely pain-free, as evaluated by the patients using a pain scale.

RESULTS

Total postoperative fentanyl use did not significantly differ among the 3 procedures: median (range), ODH, 0.5 mg (0-2 mg); LADH 1.2 mg (0-7 mg); PLDH, 0.5 mg (0-3.5; P = .172). The percentage of patients who completely discontinued analgesics on postoperative day (POD) 5 was significantly higher for PLDH (80%) than for ODH (35%) or LADH (20%) (P = .041). The day when 50% of donors were completely pain-free on a pain scale was POD9 for ODH, POD11 for LADH, and POD5 for PLDH, significantly shorter in the PLDH group (P = .004).

CONCLUSION

At our institution, we found that PLDH was a useful technique for postoperative pain management compared with PDH and LADH. Our results suggest that PLDH effectively reduces the duration of postoperative analgesia use. Further studies are warranted as the number of PLDH cases gradually increases.

Influence of surgical technique in donor hepatectomy on immediate and short-term living donor outcomes - A systematic review of the literature, meta-analysis, and expert panel recommendations

BACKGROUND

There are currently no guidelines pertaining to ERAS pathways in living donor hepatectomy.

OBJECTIVES

The aim of this study was to identify whether surgical technique influences immediate and short-term outcomes after living liver donation surgery.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review and meta-analysis following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021260707). Endpoints were mortality, overall complications, serious complications, bile eaks, pulmonary complications, estimated blood loss and length of stay.

RESULTS

Of the 2410 screened articles, 21 articles were included for final analysis; three observational, 13 retrospective cohort, four prospective cohort studies, and one randomized trial. Overall complications were higher with right versus left hepatectomy (26.8% vs. 20.8%; OR 1.4, P = .010). Donors after left hepatectomy had shorter length of stay (MD 1.4 days) compared to right hepatectomy. There was no difference in outcomes after right donor hepatectomy with versus without middle hepatic vein. We had limited data on the influence of incision type and minimally invasive approaches on living donor outcomes, and no data on the effect of operative time on donor outcomes.

CONCLUSIONS

Left donor hepatectomy should be preferred over right hepatectomy, as it is related to improved donor short-term outcomes (QOE; Moderate | Grade of Recommendation; Strong). Right donor hepatectomy with or without MHV has equivalent outcomes (QOE; Moderate | Grade of Recommendation; Strong); no preference is recommended, decision should be based on program's experience and expertise. No difference in outcomes was observed related to incision type, minimally invasive vs. open (QOE; Low | Grade of Recommendation; Weak); no preference can be recommended.

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Background

Posterior quadratus lumborum block (QLB) and intrathecal morphine are accepted analgesic strategies in laparoscopic liver resection, but their effects have not been compared after laparoscopic donor hepatectomy. This study was planned to perform this comparison.

Methods

Fifty-six donors were randomized to receive bilateral posterior (QLB2, 20 mL of 0.375% ropivacaine on each side, 150 mg total) or preoperative injection of 0.4 mg morphine sulfate intrathecally. Primary outcome was resting pain score at 24 hour postsurgery. Secondary outcomes included cumulative opioid consumption and recovery parameters. Serial plasma ropivacaine concentrations were measured in QLB group. Only the outcome assessor was properly blinded.

Results

Mean resting pain score at 24-hour postsurgery was 4.19±1.66 in QLB group (n=27) and 3.07±1.41 in intrathecal morphine group (n=27, p=0.04). Mean difference (QLB group-intrathecal morphine group) was 1.11 (95% CI 0.27 to 1.95), and the upper limit of CI was higher than prespecified non-inferiority margin (δ=1), indicating an inferior effect of QLB. Cumulative opioid consumption was significantly higher in QLB group at 24 hours and 48 hours postsurgery. QLB group exhibited lower incidence of postoperative pruritus at all time points, and there were no differences in other recovery outcomes. All measured ropivacaine concentrations were below the threshold for systemic toxicity (4.3 µg/mL).

Conclusions

Bilateral posterior QLB elicited higher resting pain scores at 24-hour after laparoscopic donor hepatectomy than intrathecal morphine and did not meet the definition of non-inferiority.

Trial registration number

KCT0005360.

Complete transition from open surgery to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomies

This study was designed to review laparoscopic living donor liver transplantations (LDLTs) at a single center that achieved complete transition from open surgery to laparoscopy. LDLTs performed from January 2013 to July 2021 were reviewed. Comparisons between open and laparoscopic surgeries were performed according to periods divided into initial, transition, and complete transition periods. A total of 775 LDLTs, 506 laparoscopic and 269 open cases, were performed. Complete transition was achieved in 2020. Bile duct variations were significantly abundant in the open group both in the initial period (30.2% vs. 8.1%; p < 0.001) and transition period (48.1% vs. 24.3%; p < 0.001). Portal vein variation was more abundant in the open group only in the initial period (13.0% vs. 4.1%; p = 0.03). Although the donor reoperation rate (0.0% vs. 4.1%; p = 0.02) and Grade III or higher complication rate (5.6% vs. 13.5%; p = 0.03) were significantly higher in the laparoscopy group in the initial period, there were no differences during the transition period as well as in overall cases. Median number of opioids required by the donor (three times [interquartile range, IQR, 1-6] vs. 1 time [IQR, 0-3]; p < 0.001) was lower, and the median hospital stay (10 days [IQR, 8-12] vs. 8 days [IQR, 7-9]; p < 0.001) was shorter in the laparoscopy group. Overall recipient bile leakage rate (23.8% vs. 12.8%; p < 0.001) and overall Grade III or higher complication rate (44.6% vs. 37.2%; p = 0.009) were significantly lower in the laparoscopy group. Complete transition to laparoscopic living donor hepatectomy was possible after accumulating a significant amount of experience. Because donor morbidity can be higher in the initial period, donor selection for favorable anatomy is required for both the donor and recipient.

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Comparative outcomes of pure laparoscopic and open donor right hepatectomy: the first report from a Southeast Asian transplant center

Background

Pure laparoscopic donor right hepatectomy (PLDRH) can provide better operative outcomes for the donor than conventional open donor right hepatectomy (CODRH). However, the complexity of the procedure typically makes transplant teams reluctant to perform it, especially in low-volume transplant centers. We compared the outcomes of PLDRH and CODRH to demonstrate the feasibility of PLDRH in a low-volume transplant program.

Methods

We carried out a retrospective study of adult living donor liver transplantation in Chiang Mai University Hospital from January 2015 to March 2021. The patients were divided into a PLDRH group and a CODRH group. Baseline characteristics, operative parameters, and postoperative complications of donors and recipients were compared between the two groups.

Results

Thirty patients underwent donor hepatectomy between the dates selected (9 PLDRH patients and 21 CODRH patients). The baseline characteristics of the 2 groups were not significantly different. The median graft volume of the PLDRH group was 693.8 mL, which was not significantly different from that of the CODRH group (726.5 mL) The PLDRH group had a longer operative time than the CODRH group, but the difference was not statistically significant (487.5 min vs 425.0 min, p = 0.197). The overall complication rate was not significantly different between the two groups (33.3% vs 22.2%, p = 0.555). Additionally, for the recipients, the incidence of major complications was not significantly different between the groups (71.3 vs 55.6%, p = 0.792).

Conclusion

Even in the context of this low-volume transplant program, whose staff have a high level of experience in minimally invasive hepatobiliary surgery, PLDRH showed similar results to CODRH in terms of perioperative outcomes for donors and recipients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01507-0.

Pure laparoscopic versus open donor hepatectomy for adult living donor liver transplantation - A systematic review and meta-analysis

Background

Pure laparoscopic donor hepatectomy (PLDH) for adult living donor liver transplantation (LDLT) remains controversial. The aim of this study was to undertake a systematic review and meta-analysis of donor outcomes following PLDH for adult LDLT.

Materials and Methods

Systematic review in line with the meta-analysis of observational studies in epidemiology guidelines.

Results

Eight studies were included in the systematic review and six in the meta-analysis. A total of 575 donors underwent PLDH for adult LDLT. The mean donor age was 32.8 years with a BMI of 23.4 kg/m² and graft weight of 675 g. The mean operative time was 353 min and the conversion rate was 2.8% (n = 16). Overall morbidity was 10.8% with 1.6% major complications (Clavien-Dindo grade 3b), zero mortality and 9.0 days length of stay (LOS). The meta-analysis demonstrated that the operative time was significantly shorter for the open donor hepatectomy group (mean difference 29.15 min; P = 0.006) and the LOS was shorter for the PLDH group (mean difference -0.73 days; P = 0.02), with a trend towards lesser estimated blood loss in PLDH group. However, no difference between the two groups was noted in terms of overall morbidity or major complications.

Conclusions

Perioperative outcomes of PLDH are similar to the standard open approach in highly specialised centers with trend towards lesser blood loss and overall shorter hospital stay. Careful donor selection and standardisation of the technique are imperative for the successful implementation and adoption of the procedure worldwide.

World Survey on Minimally Invasive Donor Hepatectomy: A Global Snapshot of Current Practices in 2370 Cases

BACKGROUND

Having little evidence on the real extent of the minimally invasive donor hepatectomy (MIDH), a world survey was conducted aiming to picture the spread of MIDH and to identify geographical, institutional, and individual differences.

METHODS

A web-based survey was created with 5 sections (general, institutional, surgeon's experience, technical, and spread and dissemination), comprising up to a total of 47 questions. A thorough search was carried out to identify all possible centers and surgeons performing MIDH.

RESULTS

A global MIDH experience of 2370 cases was collected: 1587 right hepatectomies (RHs; 48.9% pure laparoscopic), 471 left lateral sectionectomies (LLS; 81.1% pure laparoscopic), and 366 left hepatectomies (LHs; 77.6% laparoscopic-assisted). LLS and adult MIDH conversion rates were 5.4% and 3.9%, respectively. Median blood loss was 250 mL (100-600), 100 mL (50-250), and 150 mL (50-500) for RH, LLS, and LH, respectively. Intra- and postoperative transfusion rates were 0.5%, 0%, and 0.3%; and 1.3%, 1.6%, and 0% for RH, LLS, and LH, respectively. Geographically, Asia accounts up to 1730 cases (73% of the global experience, 49.6% pure lap), of which 1374 cases are RH; Europe and Middle East-395 cases-stands out for its experience in left lateral sectionectomy: 289 cases (93% pure lap). Finally, America accounts for 245 cases, using a laparoscopic-assisted technique in 72.6% of the cases (178).

CONCLUSIONS

This world survey provides evidence and data on the global spread of MIDH and anticipates how in a near future a large-scale adoption of these techniques may be observed.

Comparison of Analgesic Efficacy of Erector Spinae Plane Block and Posterior Quadratus Lumborum Block in Laparoscopic Liver Resection: A Randomized Controlled Trial

Purpose

Ultrasound-guided fascial plane blocks, including the erector spinae plane (ESP) and quadratus lumborum (QL) blocks, provide effective postoperative abdominal analgesia. However, there is limited evidence on the analgesic efficacy of ESP and QL blocks after liver surgery. Therefore, we aimed to compare the cumulative opioid consumption between the ESP and QL blocks in patients with hepatocellular carcinoma undergoing laparoscopic liver resection.

Patients and Methods

Eighty-eight patients scheduled to undergo laparoscopic liver resection were randomized to receive bilateral single injection of ESP block at T8 (ESP group) or bilateral single injection of posterior QL block (QL group; 20 mL of 0.375% ropivacaine for each side, ie, total 150 mg of ropivacaine), in addition to intravenous (IV) fentanyl patient-controlled analgesia and multimodal analgesia. The primary outcome was cumulative opioid consumption over the first 24 h, expressed as IV morphine equivalents. Secondary outcomes included serial plasma ropivacaine concentrations, pain scores, time to first flatus, and Quality of Recovery-15 scores.

Results

Eighty-five patients were analyzed (ESP group, n = 42; QL group, n = 43). Cumulative 24-h opioid consumption was similar between the ESP and QL groups (41.4 ± 22.6 mg vs 44.2 ± 20.0 mg, mean difference (QL-ESP), 2.8 mg, 95% confidence interval, −6.4 to 12 mg, p > 0.99). There were no significant differences in resting pain scores at 24, 48 and 72 h postoperatively or recovery outcomes. The peak plasma ropivacaine concentration 30 min after injection was significantly higher in the ESP group (1.5 ± 0.3 µg/mL) than in the QL group (1.3 ± 0.5 µg/mL, p = 0.035); however, both were lower than the arterial threshold value of systemic toxicity (4.3 µg/mL).

Conclusion

ESP and QL blocks provided similar postoperative analgesia in patients undergoing laparoscopic liver resection.

Pure Laparoscopic Versus Open Approach for Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis

Background: Pure laparoscopic liver donor right hepatectomy (LLDRH) remains challenging, and its value is still unclear compared with open liver donor right hepatectomy (OLDRH). Objective: To provide comprehensive evidence about the safety and efficacy of LLDRH. Methods: The MEDLINE, Embase, Web of Science, and Cochrane Library electronic databases were searched from the date of inception to July 2021. A fixed-effects or random-effects model was used to analyze the pooled data by using Review Manager Version 5.3. Results: A total of 1940 patients from 6 studies were enrolled in this meta-analysis. For perioperative outcomes of donors, LLDRH had a longer operative time than OLDRH (weighted mean difference [WMD] = 29.75 [4.23-55.26] minutes, P = .02), but it had lower overall morbidity (odds ratio [OR] = 0.67 [0.45-0.99], P = .04), fewer pulmonary complications (OR = 0.47 [0.29-0.76], P = .002), and shorter hospital stays (WMD = -1, P < .001) than OLDRH. However, major complications, biliary complications, portal vein problems, and intra-abdominal bleeding were comparable between the 2 groups. With regard to the postoperative data of recipients, the risks of biliary problems, hepatic artery problems, portal vein problems, hepatic vein problems, and postoperative liver failure were similar between the 2 groups. Conclusions: LLDRH for living donors is safe and effective, and it offers superior perioperative outcomes to OLDRH.

Minimally invasive versus open living donors right hepatectomy: A systematic review and meta-analysis

BACKGROUND

Although minimally invasive technology has been widely used in hepatectomy, it remains controversial with regards to liver transplantation, especially in donors right hepatectomy. Herein, we compared the short-term safety and efficacy of minimally invasive donors right hepatectomy (MIDRH) with open donors right hepatectomy (ODRH).

METHODS

A systematic literature search was carried out using PubMed, Embase, Web of Science and the Cochrane Library database in order to identify comparison studies of MIDRH and ODRH. Next, we obtained the relevant data, and carried out the meta-analysis.

RESULTS

This meta-analysis included 12 studies, which included 1755 cases that underwent donors right hepatectomy. Compared to ODRH, patients that underwent MIDRH had less bleeding (SWD = -0.52, p<0.001), shorter hospital stays (SWD = -0.58, p < 0.001) and lower overall postoperative complications of donors (RR = 0.74, p = 0.008). However, MIDRH was found to be associated with prolonged operative times (SWD = 0.74, p < 0.001), as well as a higher rate of biliary complications in donors (RR = 2.26, p = 0.007) and recipients (RR = 1.69, p < 0.001). There were no statistically significant differences between MIDRH and ODRH in postoperative liver function, rate of major complications and vascular complications of both donors and recipients and overall postoperative complications.

DISCUSSION

MIDRH is superior to ODRH with regards to intraoperative bleeding, postoperative hospital stay and overall donor complications. Although biliary-related complications are higher, it is feasible to develop MIDRH in experienced liver transplant centers. However, higher-quality research is still needed for corroboration.

The impact of liver steatosis on the postoperative evolution after right lobe living-donor hepatectomy

Background

Living donor liver transplantation has become a feasible treatment modality for end-stage liver disease. The obesity epidemic worldwide has made it increasingly common to encounter liver steatosis in living donor candidates. The aim of study was to analyze the impact of moderate hepatic steatosis on the postoperative evolutions after right lobe living-donor hepatectomy.

Methods

Living donors who underwent donor hepatectomy during the period 2000 to 2020 in two medical centers were included in this study. We distinguished 3 groups based on the degree of steatosis: Group O - 0%, Group I - 1-10% and Group II >10%.

Results

A total number of 157 living donors underwent surgery, of whom 112 (71.34%) were right lobe liver donors. There were 62 without steatosis, 31 - with steatosis 1-10% and 19 with steatosis >10%. No difference has been found in proportion of men, median of age, body mass index and left lobe/total liver volume ration in compared groups. Total liver volume was significantly higher in the Group I than in the Group O (p=0.028). The moderate hepatic steatosis (HS) group presented significant higher volume of intraoperative hemorrhage than no-HS group (p=0.041). No differences were observed in the postoperative liver function between the groups. The minimal HS group comprised a significantly higher proportion of postoperative complications than no-HS group (67.7% vs 40.3%, p=0.043). The longer postoperative length of hospital stay in ICU was observed in Group I than in Group O (p=0.024).

Conclusion

Moderate HS does not importantly impair living liver donors' safety.

The impact of mini-invasive right hepatectomy in the setting of living donation: a meta-analysis

Adult-to-adult living-donor liver transplantation (A2ALDLT) represents a challenging procedure, mainly when the right hepatic lobe is donated. Therefore, especially in Western countries, the medical community still considers it a “risky procedure”. The present meta-analysis investigated the postoperative results reported in donors undergoing right hepatectomy for A2ALDLT through a minimally invasive liver resection (MILR) vs. open liver resection (OLR) approach, with the intent to clarify the hypothesis that the MILR approach should minimize the risks for the donor. A systematic literature search was performed using MEDLINE-PubMed, Cochrane Library, and EMBASE electronic databases. The primary outcome investigated was the complication rate after transplant. Fifteen studies were included (n = 2094; MILR = 553 vs. OLR = 1541). The MILR group only merged the statistical relevance in terms of advantage in terms of a lower number of complications (OR = 0.771, 95% CI 0.578–1.028; P value = 0.077). Investigating the complications ≥ IIIa according to the Dindo-Clavien classification, the estimated blood loss, and the length of hospital stay, no statistical difference was reported between the two groups. MILR represents a novel and promising approach for improving the results in A2ALDLT. However, no benefits have been reported regarding blood loss, length of stay, and postoperative complications. More extensive experiences are needed to re-evaluate the impact of MILR in right lobe live donation.

Laparoscopic living-donor hepatectomy: Review of its current status

The laparoscopic living-donor hepatectomy procedure has been developing rapidly. Although its use has increased worldwide, it is still only performed by experienced surgeons at a limited number of institutions. However, technical innovations have improved the feasibility of more widespread use of laparoscopic living-donor hepatectomy. The advantages of laparoscopic living-donor hepatectomy should not be overemphasized, and the fundamental principle of "living-donor safety first" cannot be neglected. This review aims to summarize the current status of laparoscopic living-donor hepatectomy and to emphasize that, while this procedure may soon be used as a reliable, donor-friendly substitute for traditional open donor hepatectomy, its safety and efficacy require further substantiation first.

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose

To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery.

Methods

Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included. Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed.

Results

Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30.

Conclusion

This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Safety and feasibility of laparoscopic living donor right hepatectomy for adult liver transplantation: a meta-analysis

BACKGROUND

Laparoscopic living donor right hepatectomy (LDRH) was a controversial topic due to its unknown safety and feasibility.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched for studies comparing LDRH with open living donor right hepatectomy (ODRH), which were published between the date of database establishment and June 2020. Revman5.3 was used for statistical analysis.

RESULTS

Fourteen studies were included. For the donors, there was no significant difference in warm ischemic time, hospital stay, graft weight, hepatic arterial anomalies (HAA), hepatic vein anomalies (HVA), portal vein anomalies (PVA), biliary anomalies, bleeding, wound infection, severe complication rate and readmission rate. The estimated blood loss, incidence of complication, intra-abdominal fluid rate in the LDRH group were significantly lower than those in the ODRH group, while the operation time, time to remove liver in the LDRH group were significantly higher than those in the ODRH group. For the recipients, there was no significant difference in complication rate, bleeding, HAA, PVA, biliary anomalies, graft failure and mortality. The HVA rate in the LDRH group was significantly higher than that in the ODRH group.

CONCLUSION

LDRH is safe and feasible for adult living donor liver transplantation compared with ODRH and it can reduce intraoperative bleeding and postoperative complication in donors, which requires further verification by more multi-center comparative studies with large sample and high quality.

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (P_group*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (P_group*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

Laparoscopic liver resection: indications, limitations, and economic aspects

Background

Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery.

Purpose

This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion.

Conclusions

While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.