After reporting the first laparoscopic hepatectomy in a living donor for pediatric liver transplantation, we now report a case of pure laparoscopic right hepatectomy for adult transplantation. A 50-year-old female volunteered for living donation to her sister who suffered from primary biliary cirrhosis. The volume of the planned hepatic graft (segments 5–8) was 620 cm3, representing 56% of her entire liver. Five ports were used in the donor to perform the operative procedure. The right hepatic artery and portal vein were isolated. Parenchymal division was performed using an ultrasonic dissector, bipolar coagulation and clips for hemostasis. Cholangiography was performed and the right bile duct was cut at the level of a marker thread. The right liver graft was placed in a bag and removed through a 10-cm suprapubic incision. The veins of segments 5 and 8 were recanalized and the graft was transplanted in the recipient. The postoperative course was uneventful for both the donor and recipient. This case offers evidence that the right liver can be procured via a total laparoscopic approach. This technique may allow for an early rehabilitation for the living donor.
model of end-stage liver disease
standard liver volume.
In 2002 we described the first laparoscopic hepatectomy in a living donor for pediatric liver transplantation . Since then, we and others have demonstrated the safety and reproducibility of this technique for retrieving the left part of the liver [2, 3]. The development of laparoscopic liver resections, primarily for tumors, has been limited and slow because of technical difficulties, especially for major hepatectomies. However, laparoscopy is associated with various advantages such as decreased morbidity, blood loss, transfusion rate and hospital stay, including for liver resection . In the field of living donor liver transplant, laparoscopy raises concerns about not only donor safety but also graft integrity. This is likely why, until now, the laparoscopic retrieval of the right liver was performed using either hand-assisted  or hybrid techniques [6, 7]. The lack of development of living donor liver transplant is explained by the technical complexity of the procedure, the high donor morbidity rate of 40% [8-10] and slow rehabilitation of donors after open hepatectomy. In contrast, laparoscopic living donor nephrectomy has become the gold standard technique for renal transplantation, allowing for reduced morbidity and faster recovery leading to an increase in the donation rate . We report here a case of pure laparoscopic right hepatectomy in a living donor for adult transplantation.
A 47-year-old female had primary biliary cirrhosis complicated by portal hypertension. Her model for end-stage liver disease (MELD) score was 22. Her morphologic characteristics were as follows: body weight 65 kg, height 160 cm, BMI 25 and standard liver volume (SLV): 1360 cm3 . Her liver anatomy was modal. Because her general condition deteriorated with itching and extreme fatigue, intra-familial transplantation was considered.
Her 50-year-old sister volunteered for living donation. She underwent a comprehensive living donor evaluation including computed tomography (CT) angiography, volumetric analysis and cholangiography with MRI. The volume of her right liver (i.e. segments 5–8), which was calculated with CT, was 620 cm3 representing 56% of her entire liver. This graft volume was estimated to be sufficient for her 65 kg sister recipient, and a liver remnant of 44% of the whole liver mass in the donor was deemed to be sufficient to allow for adequate liver regeneration with a low risk of liver failure related morbidity. Liver vasculature anatomy was modal with the presence of portal vein bifurcation, and a single right branch of a middle hepatic artery (Figure 1). MRI showed normal biliary confluence with a single right bile duct. She was informed about the risks of liver donation, which is characterized by a mortality rate of 0.2%, a morbidity rate of 40% and the innovative nature of the pure laparoscopic technique that could modify this risk. She was aware of the two live donors, deaths that occurred in France in the past. According to French Law, the judge of a civilian court registered the donor's informed consent, and the Expert Council from ‘Agence de la Biomédecine’ gave the authorization for surgery.
Surgery was planned in June 2012. To enhance donor safety with this innovative surgery, we decided that two senior surgeons (OS and OSc) would perform the operation together. Moreover, we decided that any incident occurring during the laparoscopic procedure that might compromise donor safety or graft integrity would prompt conversion to laparotomy. We listed the following risks: bleeding, failure to recognize bile duct anatomy, any vessel injury and failure to progress. Under general anesthesia, the donor was placed in the supine position with her legs apart and five trocars were used as shown in Figure 2. A CO2 pneumoperitoneum was created and maintained at 12 mmHg. The cystic artery and duct were clipped and divided. The hepatic pedicle was opened and the right hepatic artery and right portal vein were dissected free and taped. Cholecystectomy was performed and the round and falciform ligaments were cut. The right part of segment I was mobilized to dissect the anterior aspect of the inferior vena cava with sectioning of small accessory veins arising from segment I. This dissection was performed as high as possible without reaching the right hepatic vein. No hanging maneuver was used and the right liver was not mobilized at that time. The right portal vein and hepatic artery were briefly clamped to visualize the main portal fissure and intra-operative ultrasound was used to identify the middle hepatic vein, which was kept with the left liver. The liver capsule was opened with a harmonic scalpel. Parenchyma division used an ultrasonic dissector and bipolar coagulation and clips for hemostasis. When the right bile duct level was reached, intra-operative cholangiography was performed via the cystic duct and the right bile duct was cut at the level of a marker thread (Figure 3A). On the hilum side, the right bile duct was closed with a secured clip. The liver section was then completed and the right hepatic vein was isolated (Figure 3B). The right liver was mobilized by freezing the right triangular ligament. A 10-cm suprapubic incision was made without opening the peritoneum allowing for the insertion of a large bag through a 15-mm port. The right hepatic artery was closed with a secured clip and the right portal and hepatic veins were closed using a one-sided stapler and then divided. The right liver graft was placed in the bag and removed through the suprapubic incision without muscle section. On the back table, the liver graft was flushed with cold storage solution. After flushing, the graft weighed 590 gm. The veins from segments 5 and 8 were recanalized using an allogeneic iliac conduit obtained from the tissue bank. The right hepatic vein stump was enlarged with a cuff tailored in an iliac conduit from the tissue bank. The normothermic ischemia time was 12 min including 5 min of right portal vein and hepatic artery clamping to delineate the main portal fissure and 7 min for the graft removed just before cold flushing.
The recipient operation began shortly after donor's surgery began. A temporary portacaval shunt was performed and total hepatectomy was completed. The liver graft was orthotopically transplanted in the sister recipient. The cuffed right hepatic vein (20 mm diameter) was anastomosed to the recipient's right hepatic vein enlarged on the vena cava. Then, the iliac conduit draining segments 5 and 8 veins was anastomosed to the recipient's middle hepatic vein stump. The portal vein was anastomosed end-to-end between the recipient's right branch to the graft right branch. Arterial reconstruction was performed between the recipient's and graft's right branches of the middle hepatic artery with interrupted 8/0 sutures. The clamps were released with no hemorrhage from the cut surface. At 30 min after reperfusion, when the systemic hemodynamics were stable, the pressure was measured in the portal vein and inferior vena cava. Blood flow was measured in the portal vein using an ultrasonic transit time flowmeter. Because of a graft-to-recipient body weight ratio of 0.91, the liver graft representing 43% of the recipient standard liver volume (SLV), and the presence of hyperdynamic splanchnic circulation, the splenic artery was ligated, allowing for a decrease in portocaval pressure and portal blood flow by an average of 25%. The former, defined as portal pressure–caval pressure, decreased from 17 to 12 mmHg and the latter decreased from 322 to 254 mL/min/100 gm hepatic tissue. Biliary reconstruction used a Roux-en-Y hepaticojejunostomy on the right bile duct stented with an 8F silastic catheter externalized through the abdominal wall.
The blood loss was 100 and 500 cm3 for donor and recipient, respectively, and no transfusion was required in either of them. The donor operation duration was 480 min.
The postoperative course was uneventful in both donor and recipient with hospital stay of 7 and 15 days, respectively, with normal liver function.
Laparoscopic major hepatectomy can be performed using three main techniques: pure laparoscopy, the hand-assisted technique and the hybrid technique [7, 13, 14]. Currently, there are no published data indicating the superiority of one technique over the others. Our hypothesis, which is still to be demonstrated, is that pure laparoscopy might give good results for major liver resections in terms of morbidity and functional recovery to the patient and thus to the living donor as well.
Liver resections performed through pure laparoscopy are more technically challenging than hand-assisted or hybrid techniques. Pure laparoscopy may decrease intra-operative blood loss and the subsequent need for transfusion as well as the postoperative morbidity of liver resections , including in living donors  compared to open surgery. In contrast, hybrid or hand-assisted liver resections do not seem to have those advantages over open resections including in living donors [6, 15]. Several studies have already reported that intra-operative blood loss and transfusions were significant risk factors for overall morbidity in living donors [9, 10, 16].
Laparoscopic right hepatectomy in a living donor was envisaged in our center under three conditions: first, assuming a routine technique of pure laparoscopic right hepatectomy in patients with tumors ; second, taking advantage of our experience of more than 50 laparoscopic left-sided liver retrievals in living donors (OS, OSc, FP, personal data); and third, considering the first cases in living donors with favorable anatomy, especially for bile ducts .
Living donor liver transplantation was considered with great enthusiasm in the 1990s, and reached a peak in 2001 in the United States accounting for 10% of the total number of liver transplants . Then, reports of fatal complications published in both scientific journals and the public press led to a marked decrease in the number of procedures, which now represents 4% of the total number of liver transplants in the United States . This proportion contrasts with those of living kidney transplant, which averages almost 40% in the last 10 years in the United States [19, 20]. This large difference is likely due to the superior risks of complications and death.
The risk of death in live liver donation is difficult to evaluate in the absence of an international registry. It is most likely lower for left lateral section procurement, ranging from 0.05% to 0.1% but as high as 0.2 for right liver donation , thus 5–10 times higher than the lethal risk of nephrectomy, which ranges from 0.02% to 0.04% . In their worldwide survey on death in live liver donors, Cheah et al.  have reported 23 deaths out of 11 553 donors. Several deaths had already been reported in Western countries: for example, two deaths occurred in France and four in the United States, including one intra-operative death from hemorrhage in 2010 .
The aim of laparoscopic liver procurement in living donors should provide at least equal donor safety on one hand and faster rehabilitation on the other hand. The risk of the mortality and morbidity of liver resection in a living donor depends on three main parameters: the physiological status (including the presence of co-morbidity), the proportion of liver mass removed associated with a proportional risk of postoperative liver cell failure, and last, the amount of intraoperative blood loss and subsequent need for allogeneic transfusion. These last two parameters have direct immuno-suppressive consequences and carry the risk of bacterial sepsis. Thus, to reduce morbidity in living liver donors, transplant teams must focus their efforts on the best technique of surgery in the donor and, leaving an adequate liver remnant with the lowest blood loss. We do not yet know whether the laparoscopic technique is able to achieve this goal.
In summary, this case offers evidence that the right liver can be procured through pure laparoscopy in a living donor in a center with extensive experience in laparoscopic major hepatic resection. The question of donor safety is, more than ever, the major concern of live donor liver transplantation and the laparoscopic technique must be carefully evaluated in larger series before it can be recommended.
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.