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

Authors

  • Shunji Nagai,

    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
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  • Lloyd Brown,

    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
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  • Atsushi Yoshida,

    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
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  • Dean Kim,

    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
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  • Marwan Kazimi,

    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
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  • Marwan S. Abouljoud

    Corresponding author
    1. Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
    • Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, 2799 West Grand Boulevard, CFP-2, Detroit, MI 48202
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    • Telephone: 313-916-2941; FAX: 313-916-4353


  • See Editorial on Page 1134

Abstract

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/m2) similar to that of the hybrid technique patients (25.8 kg/m2, 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. Liver Transpl 18:1188–1197, 2012. © 2012 AASLD.

Living donor liver transplantation (LDLT) is an established treatment option for patients with end-stage liver disease. LDLT accounts for 4% of liver transplants in the United States and for the majority of liver transplants in Asian countries.1 The highest priority in LDLT is donor safety. Every effort should be made to advocate for not only the physical well-being but also the psychosocial well-being of living liver donors.2-4

Minimally invasive approaches to the management of surgical liver disease have been developed and are considered to be safe and effective.5, 6 Nonetheless, minimally invasive approaches to living donor hepatectomy remain controversial and are not widely applied. The first laparoscopic living donor hepatectomy was a left lateral segmentectomy in 2002.7 The first report of hand-assisted laparoscopic living donor right hepatectomy (LDRH) was published in 2006; subsequently, that group reported a comparative study of outcomes for hand-assisted laparoscopic LDRH (33 cases) and open LDRH (33 cases). They concluded that the hand-assisted laparoscopic approach for living liver donors provided physical and psychosocial benefits without added adverse outcomes.8, 9 Although the Louisville statement of 2008 recommended that laparoscopic procedures for living liver donors should proceed only within the confines of a worldwide registry,5 minimally invasive approaches to living donor hepatectomy have been widely reported. Although several centers use a hybrid technique for LDRH with hand-assisted laparoscopic mobilization of the right hepatic lobe and a minilaparotomy for hilar and parenchymal dissection,10-13 a single Korean study described LDRH through an upper midline incision (12-18 cm) without laparoscopic assistance.14

We started to use minimally invasive surgical approaches for LDRH in 2008, and we first used a hand-assisted hybrid technique. In 2010, we began to perform LDRH with a minilaparotomy through a 10-cm upper midline incision without laparoscopic assistance. In this study, we present our experience with a standardized minilaparotomy technique without laparoscopic assistance for LDRH.

Abbreviations:

IVC, inferior vena cava; LDLT, living donor liver transplantation; LDRH, living donor right hepatectomy.

PATIENTS AND METHODS

Donor Selection

Living liver donor candidates were evaluated medically and psychosocially. Principles endorsed by the Vancouver Forum were adopted.15 In addition, protocols were modified in accordance with the final rule of the Centers for Medicare and Medicaid Services and United Network for Organ Sharing policies.16 When hepatic steatosis was suspected, liver biopsy was performed. An acceptable steatosis level was ≤10%. All those considering living liver donation were formally reviewed at a multidisciplinary selection meeting and were considered to be acceptable donors on the basis of consensus. The anatomy and volume of the liver were evaluated with magnetic resonance imaging or computed tomography with 3-dimensional reconstructions and volumetry; the images were enhanced with a MeVis analysis and 3-dimensional renderings (MeVis Distant Services, Bremen, Germany). The biliary and vascular anatomy was examined and was determined to be amenable to reconstruction; the acceptable liver remnant was set at 35% or more of the total liver volume. Living donors were reviewed, and independent donor advocate recommendations were followed and adopted. After approval by the institutional review board of Henry Ford Hospital, the medical records of 58 LDLT procedures performed between 2000 and 2011 were retrospectively reviewed.

Surgical Procedures

Between 2000 and 2007, a right subcostal incision with a midline extension was used for LDRH. Minimally invasive approaches to LDRH were introduced in 2008. Initially, a hybrid technique was developed; this method incorporated hand-assisted laparoscopic mobilization of the right hepatic lobe and a minilaparotomy for the dissection of the hilum and parenchyma of the liver.

In 2010, LDRH began to be preferentially performed through a single 10-cm upper midline incision without laparoscopic assistance. We start all LDRH cases at our institution with this approach. If it becomes difficult to visualize the retrohepatic area and mobilize the liver off the vena cava, the decision is made to use laparoscopic assistance. The midline incision is used for the hand port. Hence, the 10-cm upper midline incision approach to LDRH has become standard, and laparoscopic assistance is regarded as an optional procedure at our institution.

Mobilization of the Right Hepatic Lobe Through a 10-cm Upper Midline Incision

After general endotracheal anesthesia, patients are placed in a supine position. The legs are spread apart to allow the surgeon to stand between them during possible laparoscopic dissection. Beginning at the xiphoid, a 10-cm midline incision is then made. The operator stands on the left side of the patient; this is favorable for liver mobilization and optimal visualization. The roles of the assistant on the patient's right side involve the manual retraction of the body wall and assistance as indicated with exposure. During the mobilization, manual retraction is preferred (Fig. 1). The falciform ligament is dissected to the suprahepatic inferior vena cava (IVC) with cautery. For mobilization of the right hepatic lobe, the operator places his left hand on the right hepatic lobe and retracts it medially (Fig. 2A). The triangular ligament is dissected both superiorly and inferiorly with cautery or scissors under direct visualization (Fig. 2B). The right adrenal gland is dissected off the liver with LigaSure (Covidien, Mansfield, MA) if necessary. Once the dissection of the triangular ligament is complete, the right lobe can be retracted medially to the left side, and the IVC can be visualized just below the incision (Fig. 2C). The small branches between the liver and the IVC can be divided with LigaSure. Sharp and gentle tease dissection around the IVC with scissors is favored in order to avoid accidental injury to the major branches or the IVC. When a large right inferior hepatic vein is encountered, the vein is preserved, and it is later divided with the Endo GIA stapler (Covidien). The IVC ligament usually is divided with LigaSure; the Endo GIA stapler is used if a larger vein is suspected within the ligament. The space between the right and middle hepatic veins is separated bluntly with a large tipped right angle, and the right hepatic vein is subsequently encircled with umbilical tape. The IVC branches are divided, and the anterior surface of the IVC is cleared more than half of the way medially to the left side of the IVC; this makes it safe to use the hanging maneuver. The umbilical tape is positioned medially to the right hepatic vein and the right posterior inferior hepatic vein (if present) at the junction of the caudate lobe and right lobe of the liver.

Figure 1.

Mobilization of the right hepatic lobe. (A) The operator stands on the left side of the patient. (B) The right-side assistant is involved in manually retracting the body wall and assisting as indicated with exposure. During the mobilization, manual retraction is preferred.

Figure 2.

(A) The right hepatic lobe is mobilized with scissors. (B) The right hepatic lobe is completely mobilized, and the IVC is directly visualized below the incision. (C) The liver is retracted medially by hand and is mobilized with scissors (or cautery).

Mobilization of the Right Hepatic Lobe With Hand-Assisted Laparoscopy

If laparoscopic assistance is deemed necessary for hepatic mobilization, a hand port is placed at the 10-cm upper midline incision. A 12-mm laparoscopic port is placed at the umbilicus, a 10-mm port is placed in the subcostal region at the right midclavicular line (usually approximately 4 fingers below the costal margin), and a 5-mm port is placed at the right anterior axillary line. The pneumoperitoneum is set at 10 to 12 mm Hg. The mobilization of the right hepatic lobe is performed with hand assistance by the assistant positioned on the left side of the table. The surgeon is positioned inferiorly between the patient's legs. Cautery and LigaSure are used for mobilization. Smaller hepatic/cava venous branches are divided with LigaSure. The right posterior inferior hepatic vein, if it is present, is preserved. The IVC ligament is divided with the Endo GIA stapler if it is noted to be large. After the completion of the mobilization of the right hepatic lobe, the hand port and all trocars are removed. The dissection of the hilum and parenchyma is then performed through the 10-cm upper midline incision.

Dissection of the Hilum and Parenchyma of the Liver

A Thompson retractor (Thompson Surgical Instruments, Inc., Traverse City, MI) is used for mechanical exposure. Small retractor blades with narrower profiles are preferred because they limit the impact on visualization (Fig. 3A). The duodenum and the liver are retracted with the small, malleable blades, and the hilum and the hepatoduodenal ligament are exposed. The right hepatic artery is skeletonized but is not encircled because retraction may cause intimal dissection. If the anatomy of the hepatic artery is normal, the right hepatic artery is later divided because it crosses the common hepatic/bile duct. The right portal vein is dissected and encircled with an elastic vessel loop. The confluence of the hepatic ducts is then identified. The dimple between the right and left bile ducts can be detected with gentle, blunt dissection. This is then matched with the anatomy outline on the computed tomography cholangiogram and the MeVis reconstructions. Intraoperative cholangiography is not performed when the anatomy of the hepatic ducts is standard or is identifiable with preoperative imaging. If any questions arise about the biliary anatomy, intraoperative cholangiography with fluoroscopy is then performed.

Figure 3.

Dissection of the parenchyma and graft retrieval. (A) A Thompson retractor is used for mechanical exposure. Small retractor blades with narrower profiles are preferred because they limit the impact on visualization. (B) Liver parenchyma resection is performed with a Gyrus PlasmaKinetic coagulator. (C) The hanging maneuver is shown (umbilical tape is placed with tension, and the dividing surface is withdrawn toward the tape). (D) Graft retrieval is shown (the inferior tip is held with surgical gauze to retrieve the right liver graft).

Ultrasound is used to outline the venous anatomy (specifically the course of segment 5 and 8 veins) and to help to define the best plane of transection. At the hilum, the parenchymal resection line is tailored to align with the right hepatic duct transaction within the hilar plate with preservation of the periduct blood supply and parenchyma. Cephalad, the resection line meets the previously placed suspending umbilical tape, which is medial to the right hepatic vein. The resection of the liver parenchyma is performed with the Gyrus PlasmaKinetic coagulator (Olympus Corp., Tokyo, Japan) and the ERBE Helix Hydro-Jet (ERBE USA, Inc., Marietta, GA; Fig. 3B). The hanging umbilical tape is placed with tension, and the dividing surface is withdrawn toward the tape (Fig. 3C).17 Vessels are controlled with silk ties, surgical clips, and Prolene sutures as appropriate; however, most branches are controllable with LigaSure, the Gyrus PlasmaKinetic coagulator, and argon beam coagulation. Larger veins (eg, the segment 5 and 8 vein branches) are divided and preserved for possible reconstruction, and they are later evaluated on the back table for reconstruction for the recipient surgery.

Dissection of pericholedochal tissue is minimized, and the right hepatic duct is divided sharply with the hilar plate; this preserves the arterial blood supply.18 At this point, the hanging tape is passed superior to the right hepatic artery and the right portal vein. After the completion of the parenchymal dissection, the right hepatic artery is clamped and divided with scissors; the right portal vein is controlled with the Endo TA stapler (Covidien) and is divided distally; and the right hepatic vein is then divided with the Endo GIA stapler or the Endo TA stapler. After it is confirmed that the right lobe graft is completely free of surrounding tissue, the inferior tip is held with surgical gauze to retrieve the graft (Fig. 3D). Every effort is made to prevent injury to the liver capsule and parenchyma. The graft is delivered and flushed with a histidine tryptophan ketoglutarate solution on the back table. The stump of the right hepatic duct is closed with running or interrupted 6-0 polydioxanone sutures (Ethicon, Menlo Park, CA), and the right hepatic artery is closed with running 6-0 Prolene sutures (Ethicon). Bioglue (CryoLife, Kennesaw, GA) is applied to the liver's raw surface. Finally, the remnant left lobe should be fixed to the diaphragm or body wall. The falciform ligament is reconstructed with several silk sutures. This is an important step to prevent the rotation of the left lobe, which may cause twisting or narrowing of the middle and/or left hepatic veins.

Comparison of Perioperative Factors With the Minimally Invasive Techniques and the Standard Surgery Technique for Living Liver Donors

The characteristics of the patients and the perioperative factors for donors and recipients were compared for the following 3 groups: (1) LDRH with a subcostal incision and a midline extension (the standard technique), (2) LDRH through a 10-cm upper midline incision with laparoscopic assistance (the hybrid technique), and (3) LDRH through a 10-cm upper midline incision without laparoscopic assistance (the minilaparotomy technique). The assessed donor characteristics included the age, sex, body weight, height, body mass index, and graft weight. The perioperative characteristics included the operative time, estimated blood loss, liver function test results, and postoperative morbidity. Liver function tests were performed daily during the hospitalization and included total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels. The lengths of stay in the hospital, complications, and readmission rates were compared. Donor complications were graded according to the modified Clavien classification19: (I) a deviation from the normal postoperative course without the need for therapy; (II) a complication requiring pharmacological treatment; (III) a complication requiring surgical, endoscopic, or radiological intervention [(IIIa) without or (IIIB) with general anesthesia]; (IV) a life-threatening complication requiring intensive care; and (V) death.

Statistical Analysis

The values presented in the tables are means and standard deviations. The results were tested with nonparametric methods; the Mann-Whitney test and the chi-square test were used for continuous and categorical variables, respectively. Differences were considered statistically significant when the P value was <0.05. All analyses were performed with SPSS 19.0 (IBM, Chicago, IL).

RESULTS

Between December 2000 and September 2011, 58 living liver donors underwent right hepatectomy. Standard right hepatectomy (a subcostal incision with a midline extension) was performed in 30 patients. The hybrid technique, which was introduced for LDRH in June 2008, was performed in 15 patients through July 2010. Since the 10-cm upper midline incision technique began to be used in August 2010, 13 patients underwent LDRH, the 10-cm upper midline incision technique (without laparoscopic assistance) was used for 9 patients, and the hybrid technique (with laparoscopic assistance) was used for 4 patients. There were no instances of a conversion to a full subcostal incision from laparoscopy or a midline mini-incision.

Table 1 compares donor characteristics and perioperative factors with standard LDRH and minimally invasive LDRH. As for perioperative factors, the operative times were similar for the patients undergoing a minimally invasive procedure and the patients undergoing the standard procedure (371 versus 363 minutes, P = 0.76), whereas the estimated blood loss was significantly lower for the minimally invasive technique group (212 versus 316 mL, P = 0.001). The length of stay was also significantly shorter for patients who underwent minimally invasive LDRH versus those undergoing the standard procedure (5.9 versus 7.8 days, P < 0.001). In the minimally invasive technique group, 7 of 28 patients (25%) experienced a complication: 4 were grade II, 2 were grade IIIa, and 1 was grade IIIb. The grade II cases involved anticoagulation for postoperative deep vein thrombosis (n = 1), treatment with antibiotics for phlebitis (n = 1), and readmission for ileus without an intervention (n = 2). The grade IIIa cases required endoscopic retrograde cholangiopancreatography for a bile leak from the cutting surface (n = 1) and computed tomography–guided drainage for an infected abdominal fluid collection (not a biloma; n = 1). The grade IIIb case involved relaparotomy for postoperative hemorrhaging (n = 1). In the standard technique group, 7 of the 30 patients (23%) experienced a complication: 3 were grade II, 2 were grade IIIa (endoscopic retrograde cholangiopancreatography for a biloma and computed tomography–guided drainage of an intra-abdominal fluid collection), and 2 were grade IIIb (an incisional hernia repair and re-exploration for postoperative bleeding). The difference in the complication rates did not reach statistical significance (P = 0.88). Changes in liver function tests were also comparable between these 2 groups (Table 2).

Table 1. Comparison of Donor Characteristics and Perioperative Factors With the Standard Technique and the Minimally Invasive Techniques
Characteristic/FactorStandard Technique (n = 30)Minimally Invasive Techniques (n = 28)P Value
  • NOTE: The data are presented as means and standard deviations unless otherwise indicated.

  • *

    Clavien's classification. No patient showed grade I, IV, or V complications.

Age (years)38.6 ± 9.434.3 ± 10.10.1
Sex: male/female (n/n)9/2115/130.07
Height (cm)168 ± 10172 ± 100.12
Body weight (kg)86 ± 1971 ± 150.001
Body mass index (kg/m2)30.1 ± 5.124.0 ± 3.3<0.001
Graft weight (mL)800 ± 184915 ± 3610.55
Remnant liver weight ratio (%)36.2 ± 4.936.1 ± 11.80.31
Operative time (minutes)363 ± 53371 ± 520.76
Estimated blood loss (mL)316 ± 121212 ± 1140.001
Postoperative liver function   
 Peak aspartate aminotransferase (IU)319 ± 131345 ± 1730.82
 Peak alanine aminotransferase (IU)311 ± 150361 ± 1590.17
 Peak total bilirubin (mg/dL)2.8 ± 1.32.8 ± 1.90.61
Hospital stay (days)7.8 ± 2.35.9 ± 1.2<0.001
Perioperative complication [n (%)]*7 (23)7 (25)0.88
 Grade II34
 Grade IIIa22
 Grade IIIb21
Table 2. Comparison of Living Liver Donor Characteristics and Perioperative Factors With the Hybrid Technique and the Minilaparotomy Technique
Characteristic/FactorHybrid Technique (n = 4)Minilaparotomy Technique (n = 9)P Value
  1. NOTE: The data are presented as means and standard deviations unless otherwise indicated.

Age (years)43.2 ± 3.731.5 ± 10.70.045
Sex: male/female (n/n)3/16/30.76
Height (cm)175 ± 15 (157-193)173 ± 13 (152-195)0.88
Body weight (kg)80 ± 19 (52-95)73 ± 20 (53-121)0.44
Body mass index (kg/m2)25.8 ± 3.5 (21.0-29.2)24.0 ± 4.2 (18.5-31.7)0.36
Graft weight (mL)948 ± 247780 ± 1800.22
Operative time (minutes)389 ± 69359 ± 540.44
Estimated blood loss (mL)350 ± 174177 ± 890.09
Postoperative liver function   
 Peak aspartate aminotransferase (IU)298 ± 122356 ± 1970.76
 Peak alanine aminotransferase (IU)347 ± 63357 ± 1550.76
 Peak total bilirubin (mg/dL)4.9 ± 4.02.8 ± 0.80.64
Hospital stay (days)6.3 ± 1.36.0 ± 1.50.72

Perioperative characteristics were compared for the hybrid technique and minilaparotomy groups. The minilaparotomy donors and the hybrid technique donors had similar body weights (73 versus 80 kg, P = 0.44), body mass indices (24.0 versus 25.8 kg/m2, P = 0.36), and graft sizes (780 versus 948 mL, P = 0.22; Table 2). The maximum body size in the minilaparotomy group was 121 kg by weight and 31.7 kg/m2 by body mass index. There were no significant differences between these 2 techniques in terms of postoperative liver function tests and length of hospital stay, but the estimated blood loss tended to be lower in the minilaparotomy group versus the hybrid technique group (177 versus 350 mL, P = 0.09).

Table 3 shows recipient characteristics and complications possibly related to donor surgery (eg, biliary complications, hepatic vessel complications, and subhepatic infected fluid collections). The standard and minimally invasive technique groups were similar with respect to the recipient age and sex, the Model for End-Stage Liver Disease score, and the length of the hospital stay. The complication rates for the recipients were 36.7% and 35.7% in the standard and minimally invasive technique groups, respectively (P = 0.94). In the minimally invasive technique group, 2 patients with hepatic artery complications showed strictures (but not thrombosis) that did not require surgical intervention. One patient with a hepatic vein stricture required stenting. Two patients with biliary strictures underwent endoscopic retrograde cholangiopancreatography and stenting. One patient with a biliary leak underwent a revision of the bile duct anastomosis. The overall survival rates of these 2 groups were similar. The 3-year survival rates were 93.3% and 89.5% in the standard and minimally invasive technique groups, respectively (P = 0.22).

Table 3. Comparison of Recipient Characteristics and Perioperative Complications With the Standard Technique and the Minimally Invasive Techniques
Characteristic/ComplicationStandard Technique (n = 30)Minimally Invasive Techniques (n = 28)P Value
  • *

    The data are presented as means and standard deviations.

Age (years)*55.8 ± 10.954.2 ± 12.40.61
Sex: male/female (n/n)16/1411/170.28
Primary diagnosis (n)  0.31
 Hepatitis C1311
 Hepatitis B10
 Alcoholic cirrhosis22
 Autoimmune hepatitis12
 Primary biliary cirrhosis23
 Primary sclerosing cholangitis25
 Other95
Model for End-Stage Liver Disease score*10.5 ± 5.111.1 ± 5.50.61
Hospital stay (days)*18.7 ± 11.113.9 ± 8.30.07
Perioperative complication [n (%)]11 (36.7)10 (35.7)0.94
 Biliary stricture/leak64
 Hepatic artery thrombosis/stricture22
 Portal vein stricture10
 Hepatic vein stricture12
 Intra-abdominal abscess12

DISCUSSION

Since the introduction of minimally invasive LDRH at our institution in 2008, 28 consecutive living liver donors have undergone minimally invasive right hepatectomy by the hybrid or minilaparotomy technique. Minimally invasive liver surgery for living liver donors remains controversial, chiefly because of concerns about donor safety. Our experience mirrors previous reports of comparable complication rates for laparoscopic living donor hepatectomy and open living donor hepatectomy.5, 9 In our series, the estimated blood loss was significantly lower for the minimally invasive technique group; the complication rates were similar to those of the standard technique group. Because of the limited visualization of minimally invasive surgery, every procedure must be performed with increased vigilance to minimize bleeding; it is possible that this accounts for the lower estimated blood loss with these procedures. The length of the hospital stay was significantly shorter in the minimally invasive technique group, although there may be a historical bias or a learning curve effect. Furthermore, we continue to be conservative with the discharge date because of the remoteness of the donors from the transplant center. Taken together, our findings demonstrate that minimally invasive LDRH can be performed by experienced surgeons without compromises to donor safety. In addition, the complication rates and overall survival rates of the recipients in the standard technique and minimally invasive technique groups were comparable, although it was not clear that the complications were related to the donor surgeries. These results suggest that minimally invasive donor surgery does not jeopardize the outcomes of the recipients. Furthermore, the biggest effects that we have seen are a rapid drop in the need for pain medications, a great sense of well-being, and increased activity at the first postoperative visit. Also, all the patients seemed to like the small incision. It has been reported that living liver donors experience long-term incisional pain, general malaise, and psychosocial disability.20, 21 In this study, we did not investigate these aspects. Our mini-incision technique may reduce long-term discomfort, but further evaluation is warranted.

The operative mortality rates of living liver donors have been reported to be 0.15% to 0.3% and as high as 0.5% with LDRH.22-24 Ringe and Strong22 reported mortality in their study: 14 of 19 deaths were related to surgical procedures, whereas no intraoperative deaths were identified. However, it is uncertain that all donor deaths were reported. LDRH bears a certain risk of major bleeding even through the standard subcostal incision with a midline extension. The mini-incision technique may cause apprehension because of the limited visualization and possible unexpected and uncontrolled bleeding. In our experience, this mini-incision technique does not reduce the visualization as much as one would imagine. As long as good retraction of the body wall and mobilization of the liver are accomplished, the entire procedure can be done under good direct visualization. We think that the most critical step in our mini-incision technique is the encirclement of the right hepatic vein and/or the inferior right hepatic veins when they need to be preserved. When we are dissecting out the IVC and encircling the right hepatic vein, these structures are in our direct line of sight, and visualization is secured by the rotation of the liver to the left side. Every effort should be made to identify vein branches very carefully and not to be aggressive with retraction. If bleeding is encountered, we can control the source immediately with pressure manually and/or with surgical gauze (which may be an advantage of the minilaparotomy technique over the laparoscipic procedure) and then fix it under direct visualization. We have encountered 1 event with bleeding from a small branch on the anterior aspect of the right hepatic vein; it was unrelated to the approach. We successfully controlled the bleeding (as described previously) and repaired the vein in a standard fashion. If it is difficult to control bleeding through the mini-incision, we can extend the incision rapidly for better exposure as needed, although this was not required in our series.

Our approach for minimally invasive LDRH consists of the following 4 steps: (1) initially starting with a 10-cm upper midline incision, (2) selecting hand-assisted laparoscopy for the mobilization if there is difficulty in proceeding with the mobilization through this incision, (3) performing hilar and parenchymal dissection through the 10-cm incision, and (4) retrieving the right liver graft. Although the hybrid technique has been adopted as a minimally invasive approach for LDRH in many centers, our experience suggests that LDRH can be completed in most patients without laparoscopy, and laparoscopic assistance can be reserved as an adjunct technique for larger donors in whom the mobilization of the liver through a 10-cm incision tends to be difficult.

Lee et al.25 published the only report of an upper midline incision technique for LDRH without laparoscopic assistance. However, at 12 to 18 cm, their incision was significantly larger than the incision used at our institution. In a minimally invasive donor hepatectomy, the size of the incision needs to match the size of the right lobe liver graft. A 10-cm incision appears to be safe for retrieval of the right liver graft in most instances. Some centers select pure laparoscopic procedures for hepatectomy.26-29 Pure laparoscopic techniques already have been used in living donor nephrectomy.30, 31 However, the isolation of the hepatic vessels is more challenging than the isolation of the renal vessels. In addition, the potential risk of significant bleeding during the dissection of the liver parenchyma cannot be ignored. Therefore, minilaparotomy placed at the upper midline 10 cm down from the xiphoid allows for meticulous hilar dissection under direct visualization and full control. Nowadays, we prefer the mini-incision technique to the hybrid technique. In fact, the mini-incision technique was successfully performed even for donors with a large body mass. There are some advantages to the mini-incision technique versus the hybrid technique: (1) there is no need for laparoscopic techniques, so the need for more equipment and laparoscopic expertise (which would further complicate the learning phase) is avoided; (2) there is direct visualization (ie, no 2-dimensional view); and (3) the response to unexpected bleeding is quick (major bleeding is controlled manually, and the incision can be extended rapidly if necessary). Thus, laparoscopic assistance is considered to be an alternative and an option, especially when the mobilization of the posterior triangular ligament is difficult through the mini-incision.

There are several technical limitations to LDRH through a 10-cm upper midline incision. First, according to our results, we could perform this procedure even for donors who have a larger body mass index. However, the possibility of laparoscopic mobilization should be considered for larger donors. The decision to use laparoscopic assistance can be made after surgery is initiated with the minilaparotomy with a 10-cm incision. In our experience, mobilization through a 10-cm incision without laparoscopic assistance is much quicker and is technically less complicated because the dissection can be performed under direct visualization, and it is probably superior to mobilization with the hybrid technique (with laparoscopic assistance). Second, in order to keep the incision wide open, retraction techniques are critically important. Because the incision is only 10 cm, wide retractors will not work adequately. We suggest small retractor blades, which can open the incision and minimize interference. Third, the dissection of the parenchyma through a 10-cm incision can be technically challenging, especially when the deep part of the liver is being divided. The dividing plane should be just below the incision, and the hanging maneuver is necessary to keep the plane fixed and up.17 Special devices such as the Gyrus PlasmaKinetic coagulator, ERBE Helix Hydro-Jet, LigaSure, and Endo GIA stapler are beneficial for achieving satisfactory hemostasis during the dissection. Therefore, surgeons may need to be familiar with these devices as part of their armamentarium.32 In addition, surgeons have to exercise extreme vigilance and patience to avoid any potential vascular accidents leading to significant bleeding. Some cava branches can be encountered deep in the resection plane, and surgeons should avoid aggressive approaches to dividing the final layer of tissue because of the risk of bleeding deep into the field. Fourth, because the right hepatic vein is divided with the Endo GIA stapler, the vein may be shorter than the ideal length for the anastomosis. We have not, however, experienced problems with the anastomosis between the right hepatic vein and the IVC in the recipient surgery. More recently, we have used the Endo TA stapler, which adds length to the stump of the hepatic vein and can provide approximately 5 mm more. Stapler malfunction may lead to massive bleeding and significant morbidity33-35; fortunately, this has not been encountered in our experience. Lastly, there is a theoretical risk of injury, including capsular tears, hematoma, and parenchyma laceration, to the right liver graft due to retrieval through the 10-cm incision. The previously described technique of retrieval appears to mitigate these risks. It is important to confirm that the graft is completely free before retrieval.

In this longitudinal case series, we have used a novel technique for living donor hepatectomy, and we have demonstrated the safety and efficacy of minimally invasive LDRH when it is performed by an experienced hepatobiliary surgery team. LDRH through a 10-cm upper midline incision without laparoscopic assistance can be performed even for donors with a large body mass. For donors with a larger body mass index, laparoscopic assistance can be used as an adjunct technique. Our mini-incision technique was initiated just a few years ago, and it is still too early to popularize it. Thus, further experience and study are necessary. Although technically challenging, this surgical approach can be safely used by surgeons experienced in advanced laparoscopic procedures and open hepatic surgery. We have performed minimally invasive liver surgery for more than 10 years in nondonors. Through this experience, we have learned to use a careful technique and a meticulous and deliberate approach while we are performing these procedures. We have not seen increased risk as long as basic surgical techniques are adopted without shortcuts, rules of safety are maintained, and the team continues to learn and improve from its experience and the reported experience of others. Because of the technical challenges of this approach, it is likely that it should be performed only in experienced centers with large numbers of minimally invasive liver procedures as well as sufficient experience with LDLT.

Ancillary