Understanding the risk factors for surgical morbidities in laparoscopic living donor hepatectomy (LLDH)

Liver transplantation has evolved tremendously from an experimental surgery to being gold standard treatment for patients with liver failure and liver malignancies over the past 5 decades. In the meantime, due to a shortage of donated organs, living donor liver transplantation has emerged to be a safe alternative, particularly in the Asian countries. While most donor hepatectomies were performed in an open manner, selected centers explored using minimally invasive techniques to perform the surgery. The first laparoscopic liver donor hepatectomy (LLDH) was performed using a left lateral section (LLS) graft in 2002 (1). More than a decade later, pure LLDHs using right and left grafts were reported in 2013 (2,3). In the past decade, many centers have successfully established LLDH programs worldwide. Many studies comparing open and laparoscopic surgery have been published (4-8). While many studies have demonstrated the safety and efficacy of LLDH, the morbidities experienced by the donors deserves closer examination.

In 2023, Rhu et al. published an article entitled “Risk factors associated with surgical morbidities of laparoscopic living liver donors” in the Annals of Surgery (9). The authors originated from a center that started the LLDH program in 2013 in South Korea. They have successfully transited completely from open to LLDH after performing more than 500 cases of LLDH over a span of 8 years. First and foremost, I must congratulate the authors for publishing the outcomes of 636 donors who underwent LLDH, one of the largest series in the world. In addition to demonstrating zero mortality in LLDH, the authors were very transparent in reporting the morbidities experienced by the LLDH donors. It is by no means an easy feat, to openly scrutinise the outcomes of their LLDH cases and learn from those that had experienced significant complications in order to improve in the future. In this report, the open conversion rate was 1.6%, which means 98.4% of the cases had achieved the intended objective of having the surgery performed laparoscopically. At the first glance, this shows an extremely high success rate of the procedure, compared to the international benchmark. Rotellar et al. conducted a global minimally invasive donor hepatectomy (MIDH) experience of 2,370 cases and found that the open conversion rates of LLS and adult MIDH were 5.4% and 3.9% respectively (10).

When we look at the complications in Rhu’s series, many lessons could be learnt from them. The reported Grade IIIa and IIIb complication rates were 4.4% (n=28) and 1.9% (n=12) of patients, respectively. The most striking one was the portal vein (PV) stricture as it is often associated with technical issues during the LLDH. PV stricture requiring surgical or intravascular intervention occurred in 0.6% (n=4) of cases. All 4 cases resolved after intravascular interventions (3 cases after balloon angioplasty & 1 case required stent insertion). Although no statistical significance was found, 50% of cases with PV stricture occurred in type II PVs. Majority of those who developed PV stricture had the PV ligated during LLDH using vascular staplers. While the guideline states that staplers can be safely used for PV ligation (11), Rhu et al. considered vascular staplers to be dangerous for the PV as they occupy a significant amount of space and the damage is irreversible once fired. In addition, the limited space in laparoscopic surgery may also contribute to misplacement of the vascular stapler due to suboptimal view. On the contrary, polymer clips impart a large safety margin and can be removed with suture ligating for better portal flow.

The other morbidity that requires attention was the donor bile leak and biliary stricture post LLDH. In Rhu’s series, the donor bile leakage occurred in 3.3% of cases (n=21) and biliary stricture was 1.6% (n=10). All the biliary complications resolved within a median duration of 80 days. The majority of cases required surgical or radiologic intervention. Those with biliary strictures were managed with either endoscopic retrograde bile drainage or percutaneous transhepatic biliary drainage. In addition, multivariate analysis in Rhu’s study found the risk factors for biliary leakage, including two hepatic arteries in the liver graft, division-free margin <5 mm from the main duct and estimated blood loss during operation. Bile leakage was the only significant factor for developing biliary stricture. It is crucial to avoid any biliary complications in donor hepatectomy as it may lead to long-term sequelae that would compromise the quality of life of the donors.

Therefore, for the beginners, it is extremely crucial to select donors with normal anatomy to perform LLDH in order to minimise the risk of complications to the donors. Selection of appropriate donors for LLDH includes choosing the straightforward donor grafts (right or left) with normal vascular and biliary anatomy (such as single, long hepatic artery, type I PV, and single outflow on right hepatic vein. In addition, the estimated graft size should not be too large (some literature recommended <700 grams) in order to reduce the difficulties in mobilising the liver and transecting the parenchyma while preserving the vascular structures needed for reconstruction (12). One would notice that, in Rhu’s series, they deliberately chose donors with straightforward anatomy to build the initial experience before venturing into complex anatomy (9). This is essential to preserve good outcomes in LLDH program. Rhu et al. also reported on mounting the learning curve and suggested in an earlier report that a minimum of 50 cases is required to surmount the task and achieve competencies to perform LLDH safely (8).

Transiting from open donor hepatectomy (ODH) to LLDH requires careful planning and strategic thinking. In my opinion, to safely implement a LLDH program, a systematic approach to assess the team’s readiness is crucial. The complexity of LLDH requires liver surgeons with large experience in laparoscopic liver resection and ODH. There are fundamental differences between liver resection for tumours and donor hepatectomy, whereby the latter requires preservation of all the vascular structures (bile duct divided in the middle of the surgery) until the last step when the donor liver graft is ready to be retrieved, in contrast to resection of tumours where these pedicles are often transected during the process. It is suggested that centers keen on developing LLDH programs should stage the introduction in a stepwise manner, starting from laparoscopic LLS, to laparoscopic-assisted right or left lobe hepatectomy to finally fully laparoscopic right and/or left lobe procedure (13). This approach allows progressive accumulation of experience in performing LLDH and yet, ensuring safety and efficacy of the procedure. In addition, there must be adequate infrastructure support in the institution and systematic training of all the relevant personnels including nursing staff and others (13).

LLDH, if performed successfully, can confer a lot of benefits to the living donors. The long scars in the abdomen are often the deterring factor for donors to step forward. However, scars must not be the reason to compromise on safety as the donors are healthy individuals who would otherwise not be required to have the surgery. Protecting the donor safety and outcomes remain utmost importance, which is why many centers are still resisting the adoption of LLDH in fear of compromising donor safety and outcome. Within the safety limits of LLDH, the minimally invasive surgery (MIS) approach has been shown to improve the quality of life and body image scores of the donors as compared to those who had the surgery done via open method (14). Within 1 month after LLDH, the donors showed faster mobility recovery and body image satisfaction to the level of preoperative status compared to ODH (14).

The introduction of artificial intelligence and machine learning in LLDH with pre-operative simulation using 3D liver models (with mixed reality technology), intraoperative liver navigational tools, indocyanine green fluorescence imaging system as well as artificial intelligence-enabled software to perform segmentation of liver vascular and biliary anatomy, delineate safety zones for surgery etc., could potentially enhance the safety profile of LLDH in the future (15,16).

As LLDH becomes more widely adopted by the liver transplant surgeons worldwide, maintaining safety of the procedure to ensure minimal or no morbidities in these living liver donors is of utmost importance. Unpacking the myth of this complex procedure through deep dissection to understand the risk factors of the surgical morbidities in LLDH help us to learn from these high-volume centers, in order to guide others to perform this procedure safely in the future. LLDH should remain a procedure to be performed by surgeons with large experience in MIS liver resections and donor hepatectomy based on current recommendations.

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: The author has completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-565/coif). The author has no conflicts of interest to declare.

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