Surgical innovation (whether a new procedure or improvement to an existing one) has been the cornerstone of advancing the science and art of surgery and improving the outcomes of patients with surgical diseases. A major advancement in surgery over the past three decades has been the introduction of laparoscopic procedures, which have rapidly gained acceptance and have replaced the open approach in many surgical disciplines. The observed advantages of minimally invasive procedures have been less postoperative pain, reduced morbidity and faster recovery. These observations have led to a wider acceptance of laparoscopic applications with a transition to systematic surgical training and continuous improvement in the instrumentation and technology. Indeed, commercially available robotic platforms are gaining traction and are gradually replacing some traditional laparoscopic applications.
In the field of transplantation, laparoscopic live donor nephrectomy has replaced the open approach for renal transplantation in many centers around the world. Broad acceptance of the procedure has contributed to the increased number of live donor kidney transplants performed since its inception. Potential living donors find this to be an attractive option associated with a reduction in morbidity, improved cosmesis and quicker return to normal activities.
Living donor liver transplantation is a relatively new surgical innovation that was developed to address the problem of organ shortage. Significant postoperative morbidity, reports of donor mortality and realization of the complexity of the procedure coupled with changes in organ allocation have resulted in a significant decrease in the number of centers performing this procedure after an initial burst of enthusiasm. Despite this, live donor liver transplantation remains an essential option in countries with limited availability of deceased donor organs or cultural impediments to deceased donation. Even in countries with adequate access to deceased donor organs, live donor liver transplantation offers a viable option for regions in the United States with long wait list time and higher wait list mortality.
Since starting our live donor liver transplant program in 1998, the donor operation has continued to evolve in an attempt to reduce donor morbidity while not compromising donor safety. Initially, a bilateral subcostal (Chevron) incision with an upper midline extension was eventually replaced by a smaller right subcostal incision and a midline extension. Improved instrumentation has been used to reduce blood loss and increase donor safety during resection whenever available. Over the past few years we have adopted a hybrid approach, well-described by others, utilizing laparoscopic mobilization of the right lobe and then completing the procedure through an upper midline incision . This has reduced postoperative pain for the donor without compromising exposure. More recently a 10 cm mini-incision living donor right hepatic lobectomy with or without laparoscopic assistance has been described . All of these innovative approaches are aimed at reducing donor morbidity and improving postoperative pain.
In the current issue of AJT, Samstein et al. , Soubrane et al.  and Troisi et al.  provide three independent, elegant reports of a total laparoscopic approach to live liver donation (two left lobes: Samstein and Soubrane, one right lobe: Triosi). Each manuscript provides a detailed description of the procedure and a thorough discussion of the rational for initiating these procedures, as well as the stepwise progression followed by the various teams in order to gain the required expertise and confidence. Their decades of experience in the management of liver disease, surgical expertise in liver transplantation and complex open and laparoscopic hepatic resections all provide the required “field strength” eloquently discussed by the late Dr. Francis Moore as one of the essential aspects making surgical innovations ethically acceptable .
The authors are to be congratulated on their ability to perform a technically challenging procedure while providing critical technical tips for others to follow in order to safely perform these procedures. These programs clearly possess the necessary expertise and judgment regarding selection of donors with favorable anatomy, adherence to the same surgical principles used in the “open” approach and the prompt recognition and management of postoperative complications. They obviously also possess the necessary skills and confidence to successfully deal with unexpected intraoperative events and other “near miss” events with potential catastrophic consequences.
Although the procedures as described appear to be relatively straightforward, the readers should understand that these are not “random mutations” but rather a gradual evolutionary process, decades in the making. The learning curve is clearly steep and the procedure is extremely complex and therefore should not be attempted by less experienced teams. A commitment to obtaining the necessary specialty training and technical expertise is paramount in advancing this innovation. The inability to do so will clearly jeopardize donor safety and may negatively impact living donation as a whole.
It is obvious that laparoscopic donor hepatectomy is in its infancy and experience as well as improvements in technique, instrumentation and patient care will continue to evolve. Perhaps one day laparoscopic (or robotic) live donor hepatectomy will become the standard of care, but enthusiasm should be tempered by the reality of the complexity of the process.
All new surgical innovations are met with initial skepticism and sometimes intense criticism. Most will agree that innovation for innovation sake is of little value. However, as with the concept of natural selection, those innovations that prove to be reproducible and result in improved patient outcome will survive and flourish. Those that do not will suffer the same fate as the Dodo bird.