Pure Laparoscopic Full-Left Living Donor Hepatectomy for Calculated Small-for-Size LDLT in Adults: Proof of Concept



Adult-to-adult living donor liver transplantation (A2ALDLT) is an accepted mode of treatment for end-stage liver disease. Right-lobe grafts have usually been preferred in view of the higher graft volume, which lowers the risk of a small-for-size syndrome. However, donor left hepatectomy is associated with less morbidity than when it is compared to right hepatectomy. Laparoscopic donor hepatectomy (LDH) has been considered almost exclusively in pediatric transplantation. The results of laparoscopic left-liver graft procurement for calculated small-for-size A2ALDLT in four donors are presented. The graft-to-recipient body weight ratio was <0.8 in all recipients. The mean portal vein flow and the pressure and hepatic artery flows were measured at 190 ± 56 mL/min/100 g, 13 ± 1.4 mm/Hg and 109 ± 19 mL/min, respectively. No early postoperative donor complications were recorded. One graft was lost due to intrahepatic abscesses. Asymptomatic stenosis of a right posterior duct was treated with a Roux-en-Y loop 4 months later in one donor. We show that LDH of the full-left lobe is feasible. LDH is a very demanding operation, potentially decreasing donor morbidity. Standardization of this procedure, making it accessible to the growing number of experienced laparoscopic liver surgeons, could help renewing the interest for A2ALDLT in the Western world.


adult-to-adult living donor liver transplantation


graft-to-recipient body weight ratio


hepatocellular carcinoma


laparoscopic donor hepatectomy


living donor liver transplantation


laparoscopic liver surgery.


Living donor liver transplantation in adult patients (A2ALDLT) carries an inherent risk of complications and death for the healthy donors. Therefore, the reduction to an absolute minimum of the above risk should be a priority, especially in the Western world where deceased donor organ procurement is currently the standard [1]. Living donor left hepatectomy is known to be associated with a significant decreased risk of morbidity compared to the right hepatectomy [2-4]. The limitation of A2LDLT to the left lobe appears preferable if a satisfactory ratio of graft volume to estimated standard liver volume can be achieved [5]. Laparoscopic liver surgery (LLS) is considered to be safe and associated to less morbidity less pain and a shorter hospital stay compared to the open procedure [6]. Fully laparoscopic left lateral sectionectomy has been done exclusively in the setting of pediatric liver transplantations [7]. Hybrid techniques have been described to procure a right lobe [8, 9]. Considering that donor morbidity is essentially related to the amount of the liver mass resected and that overall donor morbidity could be reduced even further if a full laparoscopic technique is applied, we developed the concept of calculated small-for-size graft for A2ALDLT coupled to a full left laparoscopic donor hepatectomy (LLDH) as a way to reduce donor risks further [10]. To the best of our knowledge, A2ALDLT with full LDH in this setting has not been reported before. Proof of this concept is herein reported and discussed.

Clinical Cases

Four potential donors were selected for A2ALDLT. This preoperative evaluation was completed by means of the 3D Hepa-Vision software calculation (Mevis, Bremen, Germany; Figure 1). We considered as sufficient an estimated graft-to-recipient body weight ratio (GRWR) of at least 0.6 (segments 2–4).

Figure 1.

3D Hepa-Vision software calculation of the left liver including the middle hepatic vein and the planned section plans: (A) planned transection plane considering the left lobe graft with MHV without caudate lobe; the colors represent the areas drained by different hepatic veins (B) portal veins (turquoise) and biliary ducts (yellow), all together with the considered graft (pink); (C) hepatic artery (in color the inflow of different segments), interrupted stripes showing the transection plane and (D) biliary ducts (in color the drainage of different segments).

Donor procedure

The donor was placed in a supine position with the legs apart (Figure 2). After cholecystectomy and localization of the middle hepatic vein by ultrasonography, we started hilar dissection exposing the left hepatic artery and the left portal vein. Parenchymal transection was performed with the laparoscopic ultrasonic dissector and without applying a Pringle maneuver. The hem-o-lock clips (TFX Medical Ltd., Durham, NC) were systematically used during parenchymal transection. The Arantius ligament was then dissected, exposing the space below the common trunk of the middle and left hepatic veins. The trunk was encircled with a tape using the Goldfinger© device (Ethicon Endo Surgery, Cleveland, OH) which was later on applied for a “hanging-over” maneuver at the completion of the parenchymal liver division close to the caval vein (Figures 2 and 3). The site of transection of the left hepatic duct was chosen and marked with a titanium clip as a landmark. Afterwards, we divided and cut the portal vein and bile duct tributaries to the caudate lobe originating from the left portal pedicle between clips. Following the administration of systemic heparin (5000 units), the left hepatic artery was clipped and divided. Then, a prompt linear stapler division of the left portal vein (Endo TA 30 mm, Covidien, Mansfield, MA) and the common left and middle hepatic vein trunk (Endo GIA 60 mm curved, Covidien) was placed and fired, allowing a manual graft extraction through the 10-cm suprapubic incision site through a Gelport device (Applied Medical, USA; Figure 3). The graft was then flushed on the back table with 2 L of HTK solution. The check-up cholangiogram confirmed the integrity and normal anatomy of the right lobe of the donor, which was additionally checked with the methylene blue test (Figure 4). Graft characteristics and donor demographics are given in Tables 1 and 2.

Figure 2.

Position of the trocars: (A) 5 mm trocar; (B) 12 mm trocar; (C) Pfannestiel incision and (D) Gelport device to extract the graft while maintaining the pneumoperitoneum.

Figure 3.

Intraoperative view: (A) intraoperative view of the Gold Finger device through the space between the right (blue arrow) and the middle hepatic vein (white arrow); (B) intraoperative view of the titanium clips positioned as landmarks (green arrow-tissue adjacent to the biliary duct). The black star marks the middle hepatic vein; (C) cut of the left hepatic duct (white star). Left hepatic artery (yellow star); (D) hanging maneuver while dividing the parenchyma with the Gold Finger device (white arrow). Left hepatic duct open (yellow star). White clips on the major tributaries of segments 5 and 8; (E) artery clipped and divided (yellow arrow), stapler positioned for securing and dividing the left portal vein (firing position) and the middle and left hepatic veins (still open); (F) securing the left hepatic stump with titanium clips (blue arrow).

Figure 4.

Standard intraoperative donor cholangiogram: (A) landmark clips before cutting the biliary duct in the donor (red arrow); (B) methylene blue test at the end of the donor procedure showing no contrast leak on the cutting edge and on the biliary stump (white arrow).

Table 1. Donor graft characteristics
HAType BDGV (mL3)eGW (g)RL (%)eGRWR
  1. HA, hepatic artery; Type BD, biliary duct anatomy; GV, graft volume; egw, estimated graft weight; RL, remnant liver; eGRWR, estimated graft to body weight ratio.
Table 2. Donor demographics and operative data
SexAge (year)BMIAn time (min)Op time (min)LR time (min)Blood loss (mL)WIT1 (min)
  1. An time, total anesthesia time; Op time, total operation time; LR time, liver resection time; WIT1, first warm ischemia (during donor procurement).

Recipient procedure

Indications for liver transplantation were PSC in 2 of the cases, and toxic cholestatic hepatitis and HCC in the others (Table 3). The recipient hepatectomy was performed with the preservation of the caval vein and the use of a temporary hemi-portocaval shunt. Continuous infusion of 6 mg somatostatin/24 h (Eumedica SA, Manage, Belgium) was given at the beginning of the second warm ischemia time during the first 5 days [11]. Microsurgical technique was used for the arterial anastomosis. The graft inflow and portal vein pressure were checked by transit time flow measurement (Medistim, Oslo, Norway). No early complication occurred in the donors. Postoperative analgesia consisted of paracetamol and tramadol infusion therapy. The nasogastric tube was withdrawn 12 h after surgery; the drainage was stopped on the second day. The median hospital stay was 5 days [4-6]. Comparing this small cohort of LLDH with our historical open procedure group (n = 14), we noticed a statistically longer hospital stay in the open group (median of 9 days, range 6–31; p = 0.0009) and a trend for higher early complication rates (n = 4/14, 29%). Indeed, 2 biliary fistulas, 1 hemorrhagic stomach ulcer and 1 nerve palsy were recorded. During donor follow-up we were surprised to record an increased in cholestatic enzymes with normal serum bilirubin in a donor who had a type C1 biliary anatomy. The cholangio-MRCP confirmed a sectoral dilation of the right posterior duct (Figure 5). Although no symptoms where present, we decided to drain this duct with a Roux-en-Y loop following unsuccessful percutaneous dilation. Portal inflow modulation was considered necessary in two cases to lower portal hyperperfusion according to our algorithm (Table 4) [12]. The first recipient developed moderate cholestasis followed by a gradual normalization of the tests and the patient was discharged on the 4th week. The second patient underwent a redo-laparotomy for an intima dissection of the recipient common hepatic artery. Despite the fact that a good arterial flow was reestablished, intrahepatic septic abscesses developed with increased bilirubinemia and was retransplanted (Figure 6). The third and the fourth recipients had an uneventful postoperative course.

Table 3. Recipient operative data
SexAge (year)BMIMELDChild's classGW (g)aGRWROp time (min)Blood loss (mL)WIT2 (min)CIT (min)
  1. GW, graft weight; aGRWR, actual graft recipient weight ratio; Op time, operation time; WIT2, second warm ischemia (anastomosis time until portal reperfusion); CIT, cold ischemia time. Average radiological overestimation of 12% of graft weight and GRWR was acknowledged respect to the intraoperative values (411 ± 102 g vs. 362 ± 80 g and 0.73 ± 0.09 vs. 0.64 ± 0.07, p = 0.01 and 0.09, respectively).
Figure 5.

Donor with right posterior duct stenosis. (A) Check-up cholangiogram during operation (type C1 biliary donor anatomy); (B) dilation of the postero-lateral sector at the MRI follow-up (white arrow).

Table 4. Systemic and hepatic hemodynamic data in the recipients
CIMAPPVF1 (mL/min)PVF2 (mL/min)PVP1 (mmHg)PVP2 (mmHg)HVPG1 (mmHg)HVPG2 (mmHg)HAF1 (mL/min)HAF2 (mL/min)
  • CI, cardiac index; MAP, mean arterial pressure; PVF1, portal vein flow without modulation; PVF2, portal vein flow with inflow modulation; PVP1, portal vein pressure without inflow modulation; PVP2, portal vein pressure with inflow modulation; HVPG1, hepatic vein portal gradient pressure without inflow modulation; HVPG2, hepatic vein portal gradient pressure with inflow modulation; HAF1, hepatic artery flow without inflow modulation; HAF2, hepatic artery flow with inflow modulation.
  • 1Graft inflow modulation by splenic artery ligation.
  • 2Graft inflow modulation by hemiportocaval shunt.
Figure 6.

Post LDLT hyperbilirubinemia. Evolution of postoperative conjugated serum bilirubine. Peak ALT case 1: 326 ng/mL; case 2: 419 ng/mL; case 3: 848 ng/mL and case 4: 392 ng/mL.


Donor left hepatectomy is associated with an overall decreased risk of morbidity and mortality as compared to right hepatectomy [2, 5]. For this reason, some groups are in favor of left-lobe LDLT between adults [9, 13, 14]. Donor morbidity is indeed intensely scrutinized in Western countries where liver transplantation from a living donor is not considered a first choice treatment. The laparoscopic approach has reached a number of targets such as bleeding control, reduced biliary fistula and, especially, comparable oncological outcomes as those in the open approach [6, 15]. The concept of applying a laparoscopic technique is attractive because it can potentially further reduce donor morbidity. Unfortunately, two main disadvantages have to be anticipated: the long learning curve of laparoscopy and the specific experience of partial liver transplants from living donors. LLDH must be considered as the ultimate evolution of the laparoscopic technique. However, it is difficult to predict at what time one has the expertise needed to be ready for such an operation. Probably, the learning curve also depends on the background in general laparoscopic surgery that would facilitate laparoscopic HPB procedures (provided one has already gained experience in open HPB and transplant surgery). The rationale behind the concept of pure laparoscopic fully left living donor hepatectomy for calculated small-for-size living donor liver transplantation is based on the possibility that the laparoscopic technique could further reduce donor morbidity, enabling a successful transplantation in selected recipients. This means that a real GRWR of <0.8 should be anticipated. We know that important parameters other than graft volume can potentially influence the outcome [12, 14]. In such cases, even grafts with a GRWR <0.6 can be transplanted successfully [11, 13, 14]. In case of portal hypertension, different surgical techniques are available to reduce or eliminate the rate of postoperative complications related to the small-for-size syndrome (SFSS) [12, 16]. The signs of SFSS observed in our patients with hyperbilirubinemia could obviously be related to a small graft volume. However, a possible influence of the additional warm ischemia and the CO2 pressure on the graft function could not be completely excluded. Finally, cholestasis spontaneously recovered in all technically successful cases. In our opinion there are two critical points for fully laparoscopic procurement: the small size of the left hepatic artery and the exact localization of the cutting place of the left bile duct. The first condition can increase the risk of intima damage during dissection while the second can induce late biliary stenosis in the donors, especially in case of anatomical variations. A relation between these complications and the laparoscopic approach can neither be confirmed nor denied at this point but living donor safety may possibly suffer in this type of procedure. An increased risk of hepatic thrombosis has been indeed recorded in laparoscopic LLS for pediatric liver transplantations [7]. Provided a careful laparoscopic dissection is performed, the routine application of microscopic hepatic artery reconstruction should strongly be considered [17]. The major problematic issue during laparoscopic donor operations is the optimal intraoperative visualization of the biliary duct anatomy and the cutting point. Anatomical variations and the possibility of devascularization while dividing the parenchyma may increase the risk of duct injury that may possibly evolve to stenosis. The need for a surgical treatment of these, although exceptional, has also been reported in open surgery [18, 19]. How can we improve the view during laparoscopic resection? The standard cholangiogram is not always easy to perform and to interpret; the clips used as landmarks can potentially be displaced. One possibility could be the use of indocyanine green dye with a fluorescent imaging system. Unfortunately, the images are still biased by different factors that interfere with the uptake of contrast in the blood vessels and in the biliary ducts [20]. In conclusion, our small experience proves the feasibility of laparoscopic full left liver procurement for A2LDLT. This is true even if we are still far from a standardization of the procedure. Full LLDH is a consistent attempt to reduce donor morbidity: the potential of this technique and the long-term results in donors and recipients but especially its reproducibility must be validated.


M.W. is a recipient of a Short Stay and Study Grant from the European Society of Organ Transplantation. The authors wish to thank Prof. Stan Monstrey, head of the local Dept. of Plastic Surgery for his logistic assistance.


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