Living donor right hepatectomy (LDRH) is nowadays performed widely as a part of adult-to-adult living donor liver transplantation. The abdominal incision is inevitable in the living donor as in other patients. It is a great pity that many young unmarried female donors thoughtful about their father or mother sick in bed are no exception to this rule, which is common in Korea and other Asian countries in which brain-dead donors are scarce.
The usual incision has been a bilateral rooftop incision with a vertical extension, a J-shaped incision with or without a left extension, as for the majority of liver resections for tumors. The incision depends on circumstances. Large tumors of the right liver, especially those lying posteriorly and possibly involving the inferior vena cava (IVC), may require extension as a right thoracoabdominal approach. It goes without saying that there should never be any hesitation about extending or enlarging the wound in order to gain adequate access. However, as long as safety and efficiency are secured, in view of the wound, the shorter it is, the better it is.
Living donors can be considered a homogeneous group because nearly all of them are healthy, are not too obese, and have a normal liver, although some have a slightly fatty liver. Therefore, a standardized operation is more likely to be established and performed in them than in patients with a pathologic liver.
Innovations and refinements in the techniques of LDRH have been made in the past decades, but the type and size of abdominal incision have been at a standstill since its inception. Moreover, few efforts to reduce the incision have been made until now. Recently, a few laparoscopic-assisted approaches have been reported,1–3 which have shown good results, but they may be complex and expensive because of the required conversance in both living donor hepatectomy and laparoscopic liver surgery and the additional expenditure for laparoscopic instruments.
On the basis of our acquired expertise in LDRH, we introduce herein the upper midline incision in LDRH using the standard open technique.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; GRWR, graft versus recipient body weight ratio; HCC, hepatocellular carcinoma; IVC, inferior vena cava; LDRH, living donor right hepatectomy; MELD, Model for End-Stage Liver Disease; MHV, middle hepatic vein; NS, not significant; POD, postoperative day; RHA, right hepatic artery; RHV, right hepatic vein; RPV, right portal vein; SD, standard deviation.
PATIENTS AND METHODS
We prospectively designed a study to assess the potential benefits of an upper midline incision for LDRH. A single experienced surgeon was involved and was fully trained with LDRH before this study was initiated. During the median follow-up of 6.0 months (range, 4-7 months), any event that deviated from the normal course of recovery was recorded as a complication. Each donor who underwent the operation under the upper midline incision was retrospectively matched one by one with donors who underwent a J-shaped incision. Matching criteria were age, gender, and body mass index.
In January 2005, we started LDRH under the conventional J-shaped incision and performed 54 consecutive cases before February 2008. The first 17 donors were excluded from the selection process for the control group to avoid a learning curve bias. From February to May 2008, the 23 consecutive living donors underwent LDRH under the upper midline incision (I group). The surgical and clinical factors of the I group were retrospectively compared with those of 23 donors with the J-shaped incision (J group).
The surgical features and postoperative course were studied from in-hospital and out-clinic medical records. The assessment of perioperative parameters included the operative time, blood loss, period of postoperative analgesic use, hospital stay, postoperative serum levels of aspartate aminotransferase, alanine aminotransferase, and total bilirubin in donors and recipients, and complaint of wound pain after discharge. Categorical and continuous variables were compared with Fisher's exact test and the Mann-Whitney U test, respectively. P values were considered significant at levels less than 0.05.
The donor is placed in an approximately 15° reverse Trendelenberg position under general endotracheal anesthesia. A nasogastric tube is inserted to facilitate gastric decompression. The upper abdomen is opened through an upper midline incision from the xiphoid to 5 cm above the umbilicus. Under temporary retraction by an assistant, the ligamentum teres is divided, and the falciform ligament is incised and separated from the anterior abdominal wall. A firm ligature is taken on the ligamentum teres, which acts as a useful retractor during subsequent dissection. The open incisional wound is made to spread wide open by a self-retaining retractor that also plays a role in elevating the rib cage cephalad for better exposure. The falciform ligament is divided along the anterior surface of the liver as far back as the suprahepatic IVC. The space between the right hepatic vein (RHV) and middle hepatic vein (MHV) is dissected 2 or 3 cm in the caudal direction.
The retractor blade applied to the left edge of the wound is fixed a little higher than the right one so that the right liver, being mobilized, can be easily retracted to the left under the abdominal wall. Only a dominant hand of the first assistant is inserted into the abdominal cavity and used to carefully retract and rotate the liver to the left and anteriorly. Because the normal liver surface is usually slippery, we make it a rule to apply gauze on the liver surface to prevent slippage that may be bothersome and make exposure difficult.
Perihepatic attachments are divided. The right liver is rotated gradually to the left by division of its ligamentous attachments; this begins from the right lateral side by retraction of the liver to the left and then continues to the inferior side by anterior retraction. Multiple short hepatic veins between the IVC and posterior surface of the liver are ligated as the liver is retracted anteriorly and to the left. The inferior RHV (more than 5 mm) is dissected and preserved. After the right liver is fully mobilized, a right-angled clamp is passed cranially with great care along the anteromedian surface of the retrohepatic IVC toward the space between the RHV and MHV previously dissected. A tape is seized with the clamp, passed down between the anterior surface of the IVC and liver on the left side of the inferior RHV if present, and laid under the caudate lobe on the middle of IVC (Fig. 1). Laparotomy pads are placed posteriorly between the liver and diaphragm after mobilization of the liver to enhance exposure by anterior displacement.
After cholecystectomy, the right lateral aspect of the hepatoduodenal ligament is incised longitudinally just posterior to the bile duct; hilar dissection is performed to free the right hepatic artery (RHA) and right portal vein (RPV), and each is encircled with a vascular sling (Fig. 2). Temporary occlusion of RHA and RPV with a bulldog clamp reveals the demarcation line on the liver surface that corresponds to a transection plane. With central venous pressure maintained at less than 5 mm Hg, the parenchymal transection is performed along the line from an anteroinferior direction to a posterosuperior direction with the ultrasonic dissection device without any occlusion of vascular inflow or outflow until the liver hilum is approached, when a large curved clamp is introduced between the liver parenchyma and the upper edge of the hilar plate and passed caudally toward the posterior surface of the hilar plate, up to which the inferior parenchyma of the caudate lobe is transected along the tape along the middle of the IVC. The lower end of the tape, which is exposed under the transected caudal edge of the caudate lobe, is seized with the clamp and pulled up behind the hepatic hilum. Then, the lower end of the tape is positioned between the bifurcated hilar plates, and the upper end is positioned between the RHV and MHV. Consequently, the hanging tape comes to surround the transection plane of the right liver. With both ends of the tape oriented and pulled up for the transection plane, the remaining parenchymal transection continues cephalad and posteriorly, aimed at the tape until the tape is exposed (Fig. 3).4, 5 Any MHV branch over 5 mm in diameter is clipped and cut for reconstruction. After the parenchymal transection up to exposure of the anteromedian surface of the IVC and the request from the recipient surgeon to take the graft, the dissected RHA and RPV are put aside by slight traction on a sling. The remaining hilar plate is carefully dissected to expose the right hepatic duct, which is divided near the confluence of the bile ducts. The stump is oversewn with a 6-0 monofilament, nonabsorbable suture. The RHA is ligated proximally, bulldog-clamped distally, and transected. A vascular clamp is applied to the RPV. The RHV and inferior RHV, if present, are stapled and divided with an endovascular stapler. Then, the RPV is cut distally to the clamp. The graft is extracted through the incision; this allows backbleeding from the RPV of the graft. The stump of the RPV is sutured with a 6-0 monofilament, nonabsorbable suture (Fig. 4). The falciform ligament is reconstructed. A closed suction drain is placed near the cut surface. The abdominal incision is closed layer by layer (Fig. 5).
On the back table, the vascular staple lines on the RHV and inferior RHV, if present, are excised. The clips and bulldog clamp applied to the branches of the MHV and RHA, respectively, are removed, and then the right liver graft is flushed with histidine-tryptophan-ketoglutarate solution at 4°C through the RPV cannula. The graft is implanted after additional bench work for hepatic venous reconstruction.
Under the upper midline incision, the standard open technique was successfully performed to extract a right liver graft in all 23 donors. The mean length of the incision was 13.5 cm (range, 12-17 cm). The right liver was mobilized, and a hanging tape was positioned successfully in all cases along the anteromedian surface of the retrohepatic IVC with its upper end between the RHV and MHV and with its lower end between the bifurcated hilar plates. In our initial experience, 2 donors had minor bleeding during the dissection of the triangular ligament and IVC ligament, respectively, but the bleeding was controlled under the same field without an extension of the incision for a broader operative field. The Pringle maneuver was not used in any donors during the parenchymal transection.
No donors required a blood transfusion during surgery. The donor liver functions showed transient liver enzyme elevation and hyperbilirubinemia in the immediate postoperative period, but in all cases, these indices declined smoothly over a week. There were 2 cases of postoperative bleeding immediately controlled under the same incision and a case of pleural effusion. Otherwise, we did not encounter any minor complications such as wound infection. All donors fully recovered and returned to their previous activities. Compared with the J group, the I group had a shorter operative time, a shorter period of analgesic use, and, after discharge, infrequent complaints of wound pain (Table 1).
Table 1. Comparison of Upper Midline and J-Shaped Incisions: Donors' Perioperative Characteristics
Upper Midline (n = 23)
J-Shaped (n = 23)
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; NS, not significant; POD, postoperative day; SD, standard deviation.
Preoperative and intraoperative variables
Age (years, mean ± SD)
36.4 ± 14.3
33.4 ± 11.0
Body mass index (kg/m2, mean ± SD)
23.6 ± 3.79
23.1 ± 3.01
Operative time (min, mean ± SD)
232.3 ± 29.2
268.8 ± 37.1
Blood loss (mL, mean ± SD)
185.6 ± 59.2
218.8 ± 67.1
Graft weight (mean ± SD)
668.9 ± 44.5
688.2 ± 44.5
Total bilirubin (mg/dL, mean ± SD)
2.4 ± 0.9
2.6 ± 1.1
0.9 ± 0.5
0.9 ± 0.3
2.9 ± 1.5
3.2 ± 1.2
AST (IU/L, mean ± SD)
166.4 ± 117.4
186.6 ± 138.2
54.9 ± 18.3
54.1 ± 14.6
166.6 ± 117.3
189.1 ± 137.8
ALT (IU/L, mean ± SD)
177.9 ± 87.6
149.6 ± 71.6
78.6 ± 47.1
68.0 ± 26.5
188.4 ± 47.1
153.9 ± 26.5
Length of hospital stay (days, mean ± SD)
10.0 ± 2.9
11.9 ± 4.1
Period of analgesic use (days, mean ± SD)
3.8 ± 2.4
5.6 ± 3.2
Complaint of pain after discharge
All 23 right liver grafts were successfully transplanted. There was no significant difference in the peak serum levels of aspartate aminotransferase, alanine aminotransferase, and total bilirubin between the I group and J group (Table 2). One recipient had a biliary leak at the cut surface of the graft, which was controlled under relaparotomy 7 days after the operation. Otherwise, all recipients were still alive with good graft function.
Table 2. Comparison of Upper Midline and J-Shaped Incisions: Recipients' Perioperative Characteristics
Upper Midline (n = 23)
J-Shaped (n = 23)
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; GRWR, graft versus recipient body weight ratio; HCC, hepatocellular carcinoma; MELD, Model for End-Stage Liver Disease; NS, not significant; SD, standard deviation.
Preoperative and intraoperative variables
Age (years, mean ± SD)
53.1 ± 10
49.2 ± 12
Viral liver cirrhosis (with HCC)
MELD score (mean ± SD)
17.6 ± 8.3
14.9 ± 7.2
GRWR (mean ± SD)
1.01 ± 0.43
1.05 ± 0.25
Cold ischemic time (min, mean ± SD)
59.3 ± 30.1
68.3 ± 26.5
Warm ischemic time (min, mean ± SD)
38.4 ± 17.2
40.3 ± 19.0
Total bilirubin: peak (mg/dL, mean ± SD)
8.8 ± 3.1
10.2 ± 4.7
AST: peak (IU/L, mean ± SD)
379.6 ± 81.1
410.4 ± 125.2
ALT: peak (IU/L, mean ± SD)
437.2 ± 120.9
466.6 ± 80.7
The present study describes LDRH using the standard open technique with the smallest incision ever reported. The results show that this new approach is feasible and safe, and the operative time is significantly reduced. Furthermore, our approach limits the abdominal incision to the supraumbilical upper midline, avoiding the morbidity associated with the long right subcostal incision with muscular division, often extended to the left, that the usual open procedure has required. Therefore, the days of analgesic use were shortened and complaints of wound pain during follow-up were infrequent in comparison with those of the J-group. Nevertheless, this procedure failed to significantly reduce the length of hospital stay; this reflects the situation in our country, in which the national health insurance system does not force patients to leave the hospital even after they are fully recovered.
Although not associated directly with the upper midline incision, 2 cases of postoperative minor bleeding occurred, but they could be controlled without extension of the incision. Otherwise, all 23 donors fully recovered without any complications. Above all else, all recipients and donors were satisfied with the upper midline incision, which was much smaller than the conventional incision that they expected.
The upper midline incision has 2 advantages for LDRH. First, it takes the shortest cut to open the abdomen along the linea alba, and this facilitates the placement of the surgical incision in the midline without entry into either the right or left rectus sheath. Second, its course is longitudinal and runs parallel with the transection plane of LDRH, which a hanging tape guides, so the parenchymal transection can be easily and safely performed even through a smaller than usual upper midline incision with the hanging maneuver, which can also be applied to various liver resections.5
The minimum size of the abdominal incision can depend on the graft size. Although there is some difference in the size of a right liver graft, an incision of at least 12 to 17 cm may be required for safe retrieval of the graft even under entirely laparoscopic conditions because the liver has a hard parenchyma and is not as flexible as other intra-abdominal tubular organs such as the stomach or intestines. In this series, under the upper midline 12- to 17-cm incision, the standard open technique, which includes liver mobilization, hilar dissection, and parenchymal transection, was successfully employed to extract a right liver graft. The length of this incision may be somewhat larger than that of the incision reported in a few cases of laparoscopic-assisted LDRH.2, 3 However, if we consider the additional incisions for 3 to 5 ports required in laparoscopic-assisted LDRH, the total length of the incisions, in fact, makes little difference between the 2 techniques. In addition, most liver surgeons become more accustomed to the usual open technique than the laparoscopic technique. Therefore, if the abdomen must be opened to deliver the resected graft and the incision lengths are comparable in the 2 techniques, it would be better to use the standard open technique rather than the laparoscopic-assisted approach from the viewpoint of feasibility, simplicity, expenditure, and universality.
The key and difficult point of this technique is mobilization of the liver, which can be achieved both through harmonious coordination between an operator and a first assistant and by the adjustment of the strength and direction of the retracting force on bilateral edges of the wound. We used an approximately 15° reverse Trendelenberg position and a standard adult Kent retractor frame (Takasago, Tokyo, Japan) to maximize the operative exposure. Not until the lateral and upper ligamentous attachments are dissected does it become possible to dissect the liver from the inferior side because the liver can be easily retracted anteriorly. Once the right liver is mobilized to be rotated to the left near the midline, subsequent procedures, including further dissection to expose the retrohepatic IVC, dissection within the porta hepatis, and the liver parenchymal transection, can be performed in a fashion similar to the usual open technique. To dissect the right hepatic duct from the hilar plate after liver parenchymal transection is another tip for securing a little wider operative field.
The recent interest in a minimally invasive approach in living liver donors and our experience in LDRH have challenged us to try this technique. For a year before applying this technique to living donors, we attempted in 15 cases of major hepatectomy under the upper midline 12- to 16-cm incision in selected patients whose livers were not cirrhotic and whose body mass indices were less than 25 kg/m2. From this preliminary trial, we came to the conclusion that the upper midline incision can be an ideal one because most living donors are not obese and have a normal liver. A normal liver, especially in slim living donors whose perihepatic ligaments are relatively flexible and thin, can be easily retracted and mobilized through the upper midline incision used in the present study. Currently, the upper midline incision is the routine incision for LDRH in our center.
This technique looks simple at first glance, in that the usual open technique is performed under the upper midline incision without any laparoscopic devices. The learning curve is not expected to be long considering our experience. If liver surgeons try the upper midline incision, they will soon find that this seemingly implausible incision can be applied to living donor hepatectomy. However, the one thing to remember is that this incision can be warranted only with the prerequisites of conversance with LDRH, meticulous surgical technique, and a high level of collaboration in the surgical team.
Although we have not yet attempted living donor left hepatectomy, the right hepatectomy performed in 23 cases will not exclude the possibility. Therefore, by mobilization of the left side instead of the right side of the liver, the left hepatectomy could be done with the otherwise same technique. We strongly believe that the upper midline incision used in this new procedure results in less pain, leading to enhanced postoperative recovery.
In conclusion, the upper midline incision, even without laparoscopic assistance, can be used for LDRH with less pain and without impairing safety, reproducibility, or effectivity. Therefore, the seemingly insufficient but technically feasible incision can be recommended as a minimally invasive approach to the transplant centers that are practicing living donor liver transplantation.
The authors express their gratitude to all the anesthesiologists and all the surgery nurses of the Center for Liver Cancer for their help and patience in performing this operation.