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Keywords:

  • Adult;
  • laparoscopy;
  • left lobe graft;
  • live donor transplantation;
  • liver transplantation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

In recent years different minimal access strategies have been designed in order to perform living donor liver surgery for adult recipients with less morbidity. Techniques involve shortening the length of the incision with or without previous laparoscopic mobilization of the liver. Herein we present two cases of totally laparoscopic living donor left hepatectomy, with and without removal of the middle hepatic vein, respectively. We describe in detail the anatomical and technical aspects of the procedure focusing on relevant points to enhance safety.


Abbreviations
GRWR

graft to recipient weight ratio

LDLT

means living donor liver transplant

LHV

left hepatic vein

MHV

middle hepatic vein.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

The first successful living donor liver transplant (LDLT) was performed in children in 1989 [1] and subsequently extended to adults with the use of full lobe grafts. Nevertheless, the widespread use of LDLT has been restricted due to concerns about donor morbidity and mortality [2] as several donor deaths have been widely reported in the national media. The major concerns of potential donors are mainly related to pain, morbidity associated with open surgery and a slow return to normal functioning.

In 2002, one of us performed the first laparoscopic living donor hepatectomy for LDLT in children [3]. Safety and reproducibility of the procedure were then established on a larger series [4] and the approach successfully adopted by other groups [5].

In this paper we report two cases of totally laparoscopic left hepatectomy for LDLT recently performed in our center.

Donors and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

A totally laparoscopic living donor left hepatectomy was performed in two donors. We discussed with donors and recipients that the procedure is novel and had not previously been used for full hemilobe grafts. We discussed with donors the mortality and morbidity based on previous published studies as well as our own center data [6, 7]. It was detailed proposed to the donors, who gave written consent. Study of donors and recipients was conducted under protocol approved by the institutional review board of Columbia University. Liver volume was estimated by CT volumetry. Vascular anatomy was assessed by CT and biliary anatomy by MRCP. No preoperative liver biopsy was performed.

Donor 1

A 47 y.o. father volunteered to donate to his 13 y.o. daughter with autoimmune hepatitis (MELD score 18). She had been hospitalized a month prior with ascites, spontaneous bacterial peritonitis and sepsis. Donor and recipient were blood type O+ and their weights were 82.1 and 43.6 kg, respectively. Examination of the donor liver showed no contraindications. Total donor liver volume was 1,925 cm3. Left liver without caudate, including middle hepatic vein (MHV), 610 cm3. Graft to recipient weight ratio (GRWR) was 1.4. Given this high GRWR, we planned a laparoscopic left hepatectomy without MHV. Measured volume without MHV was 534 cm3 and GRWR 1.22.

Donor 2

A 28 y.o female donor, with a weight of 54 kg and blood type O+, offered to donate to her husband's mother, who was 52 y.o. and blood type A+. The recipient suffered cryptogenic cirrhosis (Meld score 10) decompensated with refractory ascites requiring paracentesis, lower extremity edema and encephalopathy. The volume of the donor's left liver, including MHV, was 461 cm3, 35% of the total liver volume. With a recipient weight of 59.5 kg, GRWR was 0.77. A replaced left hepatic artery for segments II, III and IV originated from the left gastric artery. No other anomalies or variants were noted. A laparoscopic left hepatectomy including MHV was planned.

Surgical Technique

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

When designing this procedure under laparoscopic approach, our aim was to reproduce the same steps and in the same way as they are performed in open surgery.

The donor was placed in the supine position with legs abducted and 30° reverse Trendelenburg, the surgeon standing between the patient's legs.

A 12 mm optic trocar was inserted 3 cm above the umbilicus using direct cut down. Four additional ports were inserted (Figure 1a). A 30° high-resolution optic was used. The left lobe was mobilized by dividing the round, falciform and triangular ligaments.

image

Figure 1. Steps of the procedure: (a) trocar position, (b) the transection line is kept along the right side of the middle hepatic vein (left and middle hepatic veins are outlined and veins from segments V and VIII labeled), (c) the left liver remains attached only by its inflow and outflow vascular connections (artery outlined in red, portal vein in light blue and suprahepatic veins in dark blue/white), and (d) implanted graft.

Download figure to PowerPoint

Calot's triangle elements were dissected and transected, but cholecystectomy was not completed, as the gallbladder was later utilized to mobilize the liver.

The left hepatic artery was dissected and encircled with a piece of umbilical tape, whether originated from the common hepatic artery or from the left gastric artery (Case 2). Left portal vein was identified, and after dividing the branch for segment I, encircled with umbilical tape. Finally, left bile duct was sharply divided at its horizontal trajectory behind the quadrate lobe. Small bleedings from biliary arterial branches were controlled with low power bipolar cautery.

The common trunk of the left hepatic vein (LHV) and MHV was encircled. For this purpose, we bluntly dissected a tunnel between this trunk and the inferior caval vein, above the caudate lobe.

By transient clamping inflow vessels, left liver demarcation defined the transection line, marked on the liver surface with monopolar cautery.

No Pringle maneuver was used during parenchymal division. Gallbladder and round ligament were handled along the transection to mobilize both hemilivers and get an adequate exposure. The transection of the liver was performed using an alternating combination of laparoscopic ultrasonic aspirator (CUSA™ Excel, Valleylab Corp, Boulder, CO) and Ligasure V™ (Valleylab, Boulder, CO).

In Case 1 (left hepatectomy without MHV), the transection line was kept along the left side of the vein. Small tributary veins from segment IV to the MHV were safely sealed and transected with Ligasure. In Case 2 (MHV included in the graft), the MHV was identified and transection was performed following its right side (Figure 1b). Several small tributaries as well as drainage veins from segments V and VIII were identified and divided with Ligasure. When bleeding occurred, it was effectively controlled with bipolar cautery and there was no need to place any stitch.

To help in the transection of the last and deepest third of the parenchyma, a cotton tape was passed behind the LHV and MHV and above the left portal vein. Pulling from both ends of the tape a hanging maneuver was performed. After dividing the parenchymal bridge defined by this maneuver, the left liver remained attached only by its inflow and outflow vascular connections (Figure 1c).

In order to minimize the cold ischemia time, we waited for the recipient preparation to be finalized before removing the graft. During this time, hemostasis was carefully revised, the biliary stump on the remnant was clipped and an 8 cm Pfannestiel incision was prepared. A pursestring stitch was placed around the peritoneum at the Pfannestiel, and through it, a large endocatch bag was placed into the abdomen.

A unilateral linear stapler (30 mm Endo TA; Covidien, Mansfield, MA) was used to seal the proximal left artery and a second firing for the left portal vein. The hepatic artery and portal vein were then divided with scissors. The common LHV/MHV trunk was transected using a vascular endostapler (endoGIA 45-2.5, Covidien). Heparin was not given to the donors prior to stapling of the vessels. The allograft was placed into a bag and gently removed through the suprapubic incision. After removal of the graft the surgical field was checked again for hemostasis and biliostasis. No drain was left.

After removing the staple line of the suprahepatic veins stump, graft was immediately flushed in the back table with 2,000 cm3 of Custodiol® HTK SolutionGrafts (Odyssey Pharmaceuticals, East Hanover, NJ).

In Case 2, left and MHV were sutured in a wide common cuff. Standard vascular and biliary anastomosis techniques were used for implantation of the grafts (Figure 1d).

See Video for a detailed presentation of the technique.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

The procedures were completed totally laparoscopically with no intraoperative complications. Total operative time was 358 and 379 min, respectively, although, as previously said, in both cases there was a waiting time for the recipient to be ready, which artificially increased operative duration. Approximate blood loss was 125 cm3 in both cases and neither donor required transfusion. Graft weights were 407 and 396 g.

Oral intake was resumed on the first POD. After an uneventful postoperative they were discharged on the fifth and third POD, respectively. No intraoperative or early (<30 days) procedure-related complications were registered for the two donors.

The first recipient returned to the operating room one week after transplantation because of bile leak. She was discharged on the 17th POD. The second recipient underwent a normal postoperative course and was discharged on the eighth POD.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

Although open living donor hepatectomy is still the standard procedure for adult LDLT [6, 8], different strategies have been designed in order to do donor surgery less invasively. Basically, they involve a short midline or subcostal incision with or without previous laparoscopic mobilization of the lobe [8-14]. The latter, known as laparoscopic-assisted or hybrid technique, consists of laparoscopic mobilization of the right lobe of the liver, followed by a 10–13-cm midline incision to complete the procedure. This technique was first described by Koffron et al. in 2006 [9] and we adopted it in June 2009. Since then, we have performed 53 full lobe procurements. Two, early in our experience, were done with open approach due to BMI > 30. With increased experience, we extended approach to all donors. Another two were performed totally laparoscopic, subject of this paper. The other 49 cases [20 left and 29 right lobes] were completed through this hybrid method and none of them were converted to open surgery. Another aspect that deserves a particular comment is referred to the use of left lobes for adult LDLT. Experience has shown that left lobe allografts can be safely transplanted in selected adult recipients [15-17], and unsurprisingly their use is increasing in the United States [18]. The first left lobe transplant for adult recipient in our center was performed in June 1998, but since October 2008 its use has become more frequent. During the period October 2008–December 2012, left livers have accounted for 45% of all full lobe LDLT in our center (28 out of a total of 62). The left lobe is primary choice at our center when GRWR > 0.8 or recipient with MELD < 15 and GRWR < 0.8 and > 0.6. During that same period we have also performed one open and 11 totally laparoscopic left lateral graft procurements for pediatric recipients, with one conversion to a small midline incision.

A regular activity with the hybrid method, our previous and ongoing experience with laparoscopic liver surgery as well as with laparoscopic living donation for children, and the confidence with the use of left liver grafts encouraged us to attempt the totally laparoscopic approach in adult LDLT. With regard to the surgery itself, we would like to emphasize some technical aspects of interest. The bile duct was identified and sectioned prior to the beginning of the transection; a space was developed between the cava and LHV/MHV, which allowed us to perform later a really useful hanging maneuver, and finally, the plane of transection was defined by parenchymal discoloration, rather than with ultrasound, a technique potentially subject to error as a slight angulation of the probe can misguide the surgeon. We feel that these tips, and a favorable anatomy, (a long horizontal left bile duct with safe distance between segment IV and main confluences, as well as a single portal and arterial branch) warranted the safety and success of the procedures. The referred favorable anatomy was confirmed at initial laparoscopic exploration. We also perform routine intraoperative cholangiograms. However, due to quality of the MRCP and clear visualization of the segment four duct joining the left bile duct, we have felt safe without the intraoperative cholangiogram in our left lateral grafts and the two selected cases reported here.

We recognize that this technique is controversial and that donor safety is the primary concern in LDLT. The benefit of laparoscopy has already been observed in kidney donation in which a recent meta-analysis has shown a significantly higher rate of overall donor complications in the open group [19]. A major matter of debate lies in the fact that donor risk is inherently higher in live liver donation by comparison with live kidney donation, and some would argue that the use of laparoscopic techniques in liver donors might increase the risk further. Our experience and that of the few other teams with experience with these innovative techniques does not support this concern [4, 5, 11]. However, only teams with combined mastering of open and laparoscopic liver resection and LDLT should consider using these techniques as they definitely require specific training and a learning curve has been clearly demonstrated with the use of laparoscopic liver resection [20].

In conclusion, we describe our experience of full lobe laparoscopic live donor technique. We caution that this procedure should only be performed in selected cases with a favorable anatomy, as those herein described. We also consider that it should only be performed by teams with significant experience in both living donor activity and laparoscopic liver surgery.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Donors and Methods
  5. Surgical Technique
  6. Results
  7. Discussion
  8. Disclosure
  9. References
  10. Supporting Information

Additional Supporting Information may be found in the online version of this article at the publisher's web-site.

FilenameFormatSizeDescription
ajt12360-sm-0001-SuppVideo.mpeg91546KVideo: This video shows a detailed presentation of the procedure as described in Technique section. It belongs to Case 2.

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