Right or left hepatectomy: a continuing question in the era of pure laparoscopic donor hepatectomy

We read with great interest the article by Fujiki et al. published in the Annals of Surgery (1), which advocates for the use of a left liver graft with a pure laparoscopic donor hepatectomy (PLDH) approach to reduce the burden on living donors.

Minimally invasive techniques, including laparoscopic surgery, have been increasingly adopted in donor hepatectomy for liver transplantation. This reflects a broader trend in various surgical fields to enhance patient outcomes both cosmetically and functionally. Since the first report of a PLDH in the form of a left lateral sectionectomy in 2002 (2), this approach has expanded to include full left and full right hepatectomies (3,4). With advancements in laparoscopic instruments and growing experience, PLDH has become a standard practice for left lateral section grafts, as recognized by the most recent international consensus guideline (5). However, PLDH for full left and full right grafts has not yet reached the same level of acceptance. Predominantly performed in Asian countries, PLDH for these grafts highlights differences in donor and recipient characteristics compared to Western countries. Further studies and evidence are required to confirm the safety and feasibility of PLDH for full left and full right grafts on a broader scale.

The use of full right or full left lobe grafts continues to be debated due to the widely varying complication rates. However, a recent large-scale study found comparable outcomes for both right and left lobe donations (6-9). Left hepatectomy preserves more donor liver volume, whereas right hepatectomy provides a higher graft-to-recipient weight ratio (GRWR), ensuring adequate volume for the recipient. Balancing the safety and needs of both donor and recipient is essential. However, the choice between left and right lobe grafts may also be influenced by the expertise of the surgical center and the general policies within the country. According to the Korean national registry report from April 2014 to December 2015, there were 59 left lobe donors (7.1%) and 773 right lobe donors (92.9%), indicating a predominance of right lobe donations in Korea (8). The study did not identify any significant risk factors for overall, biliary, or major complications in donor based on graft type due to the small number of complications reported. Specifically, there were no biliary or major complications in left lobe grafts, while the biliary and major complication rates for right lobe grafts were 1.8% and 2.1%, respectively.

The differences between the open technique and the PLDH technique during a left lobectomy in donors can differ from those observed during a right lobectomy. Most recent studies on PLDH focus on right lobectomy, while few address left lobectomy (10-14). It is noteworthy that the authors performed a significant number of donor left lobectomies (n=49) and a similar number of donor right lobectomies (n=42) using a pure laparoscopic approach within the same time period, minimizing potential time bias. They compared the characteristics and outcomes of these two groups. However, caution is needed when interpreting the authors’ results.

Firstly, there are statistically significant differences in the baseline characteristics of donors and recipients between the pure laparoscopic left lobectomy group and the pure laparoscopic right lobectomy group. The left lobectomy group had a higher proportion of female recipients and male donors compared to the right lobectomy group, resulting in more male donor and female recipient pairs. This pairing may be more suitable for left lobectomy in terms of the donor’s remnant liver volume and the GRWR for the recipient. Additionally, donors in the pure laparoscopic right lobectomy group were older than those in the left lobectomy group. The authors reported that their findings clearly indicate that the left lobe imposes less stress on the donor, as evidenced by reduced peak levels of total bilirubin. This improvement is further enhanced with PLDH, as demonstrated by lower peak levels of aspartate aminotransferase (AST) and alanine transaminase (ALT). However, it is important to note that baseline levels of AST, ALT, and bilirubin, as well as the sensitivity and extent of liver enzyme changes due to stress or surgical trauma, can vary according to sex and age (15). Without comparing preoperative levels and considering the higher number of male donors and younger donors in the left lobe group, the discussion on peak levels alone is less objective.

Secondly, the proportion of grade IIIa or IIIb early complications in donors within 90 days is 4.1% in pure laparoscopic left lobe donation and 7.1% in pure laparoscopic right lobe donation, which is higher compared to previous reports, as noted by the authors (10,12). This discrepancy may be due to differences in the characteristics of donors and recipients, including body mass index.

Thirdly, the authors mentioned portal vein thrombosis, biliary complications, small-for-size syndrome, and early allograft dysfunction in recipient outcomes. However, more detailed information about recipient outcomes is needed to confirm the safety of PLDH using the left lobe. Simultaneous splenectomy, an additional procedure in certain cases to modulate portal inflow, was more frequently performed in left lobe grafts (62%) compared to right lobe grafts (44%). According to a Korean multicenter study, recipients of left lobectomies experienced 36.0% early major complications and 84.0% late major complications, while recipients of right lobectomies had 19.8% early major complications and 32.2% late major complications (14). In our previous study, there were no postoperative complications in pure laparoscopic donor left hepatectomy (13). However, among recipients, 62.5% experienced early major complications, defined as postoperative complications above grade III occurring within 30 days after transplantation, whereas 27.8% of recipients of pure laparoscopic right lobectomy experienced major complications.

In conclusion, a pure laparoscopic approach starting with the left lobe can be a viable option for donor hepatectomy, especially in Western countries. However, the critical factors to consider are the center’s prior experience with specific graft types using the open technique and the baseline characteristics of both donors and recipients, including age, sex, estimated graft volume, and body mass index.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-310/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Fujiki M, Pita A, Kusakabe J, et al. Left Lobe First With Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation. Ann Surg 2023;278:479-88. [Crossref] [PubMed]
2. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392-6. [Crossref] [PubMed]
3. Samstein B, Cherqui D, Rotellar F, et al. Totally laparoscopic full left hepatectomy for living donor liver transplantation in adolescents and adults. Am J Transplant 2013;13:2462-6. [Crossref] [PubMed]
4. Han HS, Cho JY. Total laparoscopic right liver donor hepatectomy. Seoul, Republic of Korea: Korean Liver Transplant Society; 2012.
5. Cherqui D, Ciria R, Kwon CHD, et al. Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA). Ann Surg 2021;273:96-108. [Crossref] [PubMed]
6. Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in living donors for liver transplantation. Transplantation 2010;89:1276-82. [Crossref] [PubMed]
7. Abecassis MM, Fisher RA, Olthoff KM, et al. Complications of living donor hepatic lobectomy--a comprehensive report. Am J Transplant 2012;12:1208-17. [Crossref] [PubMed]
8. Lee JG, Lee KW, Kwon CHD, et al. Donor safety in living donor liver transplantation: The Korean organ transplantation registry study. Liver Transpl 2017;23:999-1006. [Crossref] [PubMed]
9. Uchiyama H, Shirabe K, Nakagawara H, et al. Revisiting the safety of living liver donors by reassessing 441 donor hepatectomies: is a larger hepatectomy complication-prone? Am J Transplant 2014;14:367-74. [Crossref] [PubMed]
10. Rhu J, Choi GS, Kim JM, et al. Complete transition from open surgery to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomies. Liver Transpl 2022;28:1158-72. [Crossref] [PubMed]
11. Hong SK, Choi Y, Yi NJ, et al. Insights from Seoul National University Hospital's experience: a systematic review of pure laparoscopic donor hepatectomy progression. Hepatobiliary Surg Nutr 2024;13:293-300. [Crossref] [PubMed]
12. Hong SK, Kim JY, Lee J, et al. Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital. Am J Transplant 2024;24:222-38. [Crossref] [PubMed]
13. Hong SK, Suh KS, Kim KA, et al. Pure Laparoscopic Versus Open Left Hepatectomy Including the Middle Hepatic Vein for Living Donor Liver Transplantation. Liver Transpl 2020;26:370-8. [Crossref] [PubMed]
14. Hong SK, Choi GS, Han J, et al. Pure Laparoscopic Donor Hepatectomy: A Multicenter Experience. Liver Transpl 2021;27:67-76. [Crossref] [PubMed]
15. Kim AH, Son DH, Moon ME, et al. Sex differences in the relationship between serum total bilirubin and risk of incident metabolic syndrome in community-dwelling adults: Propensity score analysis using longitudinal cohort data over 16 years. Cardiovasc Diabetol 2024;23:92. [Crossref] [PubMed]