Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)

Introduction

Organ shortage remains a challenge in the development of liver transplantation. Living donor liver transplantation is a widely recognized and effective method for treating end-stage liver disease and for expanding the pool of available livers. Given that donors are healthy individuals who undergo surgery for non-pathological reasons, their quality of life, including postoperative pain, aesthetics, and hospital experience, should be carefully considered and subjected to stringent requirements. Minimally invasive surgical techniques with reduced trauma and invasiveness can alleviate pain, shorten recovery periods, and reduce postoperative complications. Achieving optimal surgical outcomes necessitates the use of cutting-edge surgical equipment and precise operative skills during this procedure. Since 2002, when Cherqui et al. (1) successfully performed the first laparoscopic left lateral sectionectomy from a living donor for pediatric liver transplantation in France, various minimally invasive techniques have gained widespread adoption globally and have gradually become the standard procedure for pediatric liver transplantation (2). However, adult living donor liver transplantation has progressed more slowly because of the larger liver volume required and increased surgical complexity. In 2006, Koffron et al. (3) pioneered laparoscopy-assisted living-donor right hepatectomy in the United States. In 2009, Kim et al. (4) from Korea reported a living donor right hepatectomy through a small upper midline abdominal incision. Since 2012, several teams (5-8) worldwide have reported successful outcomes with total laparoscopic living-donor left or right hepatectomy. In China, Yang et al. (9) independently reported laparoscopy-assisted living-donor right hepatectomy in 2012. In 2016, Li et al. (10) performed a total laparoscopic living donor right hepatectomy in China. These innovative techniques and developments have led to the accumulation of valuable experience for similar procedures in the future. Furthermore, with the rapid advancements in robotic technology, Giulianotti et al. (11) reported the first robot-assisted donor right hepatectomy in 2012. Subsequently, institutions in China, including the West China Hospital of Sichuan University, Huashan Hospital affiliated with Fudan University, and Tianjin First Central Hospital, have explored robot-assisted hepatectomy from living donors. Robotic technology has also been used in surgeries of living liver transplant donors.

Although many centers in China perform living donor liver transplantation, the number of centers that routinely perform minimally invasive donor hepatectomies is relatively small. Compared with top international centers (12-14), there remains a gap. Therefore, to foster a more standardized, safe, and effective development of minimally invasive surgery in various living donor liver transplant centers in China. In August 2023, in Chongqing, China, the Branch of Organ Transplant of Chinese Medical Association and the Branch of Organ Transplant Physicians of Chinese Medical Doctor Association organized national liver transplantation experts to establish a guideline development committee to begin formulating the “Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)” (hereinafter referred to as “this guideline”). The committee identified the safety and advantages of minimally invasive surgery for living donor liver transplantation, donor selection criteria, anesthesia strategies, surgical technical details, and learning curves as the main topics for discussion. The committee members conducted systematic reviews in PubMed, Embase, Cochrane, and three Chinese databases (CNKI, Wanfang, and CBM) based on these topics. The evidence grading of evidence-based medicine adopted in this guideline mainly refers to the “Oxford Centre for Evidence-Based Medicine: Levels of Evidence (2001 Edition)” (15), and the strength of the recommendation mainly refers to the “Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)” system (16) recommendation grading. Based on the evidence and its quality, the expert group developed corresponding recommendations for each key discussion area, and these were revised after discussion in two online meetings (December 2023 and January 2024). Finally, all content was revised and approved after two offline discussions by members of the Branch of Organ Transplant of Chinese Medical Association and the Branch of Organ Transplant Physicians of Chinese Medical Doctor Association. We present this article in accordance with the RIGHT reporting checklist (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-329/rc).

Safety and advantages of minimally invasive surgery for living liver transplant donors

The technique of minimally invasive surgery for living liver transplant donors has been widely used worldwide, and the types of grafts have expanded from the initial left lateral lobe to the left half of the liver and then to the right half of the liver (10,17). Compared to traditional open liver surgery, there was no statistically significant difference in the overall postoperative complication rate for minimally invasive liver surgery (18-20). In addition, minimally invasive liver surgery has advantages such as reduced intraoperative bleeding, lower incidence of postoperative incision complications, shorter total hospital stay, and better quality of life (21-23). These advantages are also reflected in the use of minimally invasive surgeries in living liver transplant donors (24-32). A meta-analysis of 31 studies (33) showed that laparoscopic left lateral donor hepatectomy was superior to open surgery in terms of blood loss [mean difference (MD) =79.03 mL], length of hospital stay (MD =2.47 days), and overall complication rate [relative risk (RR) =0.44]. Similarly, laparoscopic hemi-liver donor hepatectomy was superior to open surgery in terms of blood loss (MD =75.22 mL), length of stay (MD =1.35 days), and overall complication rate (RR =0.71); however, the operation time was longer than that of open surgery (MD =46.95 min).

Since organ donors are healthy individuals who do not need to undergo surgical trauma in the first place, their subjective satisfaction should be given more attention (34). For living donors who have undergone open surgery, 30–50% of postoperative complications are related to abdominal incisions, including incision infection, incisional hernia, chronic incision discomfort, delayed functional recovery, and psychological barriers caused by scars (30,35). A meta-analysis involving 60,829 organ donors showed that the overall incidence of postoperative complications in donors was 24.7%, with psychological complications (7.6%) and incision-related complications (5.2%) ranking as the top two (36). This makes some potential organ donors, especially young ones, hesitant before donation (1,37). The currently used minimally invasive surgery can significantly reduce the incidence of incision complications in these organ donors (14,30) while also alleviating incision pain and reducing the need for analgesics (38-42). Therefore, minimally invasive surgery for living liver transplant donors is considered an effective alternative solution for incision-related problems and psychological barriers of organ donors. These results suggest that minimally invasive surgery for living liver transplant donors is safe, feasible, and more suitable for living organ donors (24,43).

Simultaneously, minimally invasive surgery for living liver transplant donors does not significantly impact the long-term survival of recipients and the occurrence of postoperative complications (28,30,31,44-48). However, in the research conducted by Hong et al., it was observed that the incidence of both early and late postoperative biliary complications in the cohort undergoing pure laparoscopic donor right hepatectomy was higher compared to the conventional donor right hepatectomy group. The researchers postulated that this could be attributed to the surgeons’ propensity for excessive utilization of energy devices for biliary dissection during laparoscopic procedures (12). In contrast, another study encompassing 506 laparoscopic donor right hepatectomy cases posited that meticulous donor and recipient evaluation could effectively mitigate the incidence of biliary complications (44). Furthermore, no significant disparity was discerned in the incidence of postoperative biliary complications between the minimally invasive and open surgery groups in two separate meta-analyses (32,47).

Recommendation 1: Existing minimally invasive surgical techniques for living liver transplant donors (including small upper midline abdominal incision living donor hepatectomy, laparoscopic-assisted living donor hepatectomy, total laparoscopic living donor hepatectomy, and robotic living donor hepatectomy) are safe and feasible for donors (Evidence level: II; Recommendation strength: Strong).

Recommendation 2: Minimally invasive surgery for living liver transplant donors can reduce intraoperative bleeding, lower the incidence of postoperative complications in donors (especially incision and pulmonary complications), reduce total length of stay, and improve the quality of life and psychological satisfaction of donors (Evidence level: II; Recommendation strength: Strong).

Recommendation 3: Minimally invasive surgery for living liver transplant donors can reduce postoperative incision pain in donors and the need for analgesics (Evidence level: II; Recommendation strength: Strong).

Recommendation 4: Compared with open surgery, minimally invasive surgery for living liver transplant donors will not significantly impact the prognosis of recipients (Evidence level: II; Recommendation strength: Strong).

Evaluation and selection criteria for donors in minimally invasive surgery for living liver transplant

The safety of organ donors is the cornerstone of minimally invasive surgery for living liver transplant donors (49), and the preoperative evaluation and selection of living organ donors are of paramount importance when planning minimally invasive surgery for living liver transplant donors. The goals of evaluating living organ donors are (I) to ensure the safe procurement of a sufficient volume of the donor’s liver; (II) to ensure that no donor-derived diseases are transmitted to the recipient; and (III) to ensure that organ donors are aware of the entire donation process and can overcome potential psychological consequences (50,51). Therefore, organ donors are generally required to be between the ages of 18 and 60 years, and the estimated residual liver volume should not be less than 30–35% of the initial liver volume to avoid postoperative liver dysfunction or even more serious complications (52,53). Simultaneously, to avoid the occurrence of small-for-size syndrome in recipients, a graft-to-recipient weight ratio (GRWR) of ≥0.8% is recommended (51,54). In addition, for donors with risk factors (including obesity, diabetes, and dyslipidemia) and/or imaging findings of fatty liver, liver biopsy should be performed before transplantation (55). Because a degree of macrovesicular steatosis exceeding 30% is generally believed to increase the risk of graft dysfunction in the recipient (56-59). However, using steatotic liver grafts from living donors remains controversial regarding donor safety and recipient outcome (60-62). The studies demonstrated that with approximately 20–50% macrovesicular steatosis did not compromise graft function or recipient outcomes and were safe in donors for right hepatic lobectomy (63,64). Despite all this, when frequently encountering donor candidates with mild to moderate macrovesicular steatosis in the living donor liver transplantation setting, weight loss before donation may be a good strategy for increasing donor safety and confidence in the recipient’s outcome, except when the urgent condition of recipient does not allow for it (65-68).

Compared with open donor hepatectomy, minimally invasive surgery for living liver transplant donors is more technically challenging and is also undergoing rapid development, especially minimally invasive living donor right hepatectomy. Therefore, compared with open surgery, minimally invasive surgery for living liver transplant donors has stricter selection criteria, especially in terms of acquired experience, and selecting as many cases as possible is necessary to ensure the safety of organ donors and recipients to a greater extent (69). Studies (39,70,71) have shown that organ donors with anatomical variations have a significantly increased probability of postoperative complications, especially at the initial stages. Therefore, preoperative evaluation should improve abdominal three-dimensional (3D) computed tomography examination and magnetic resonance cholangiopancreatography (MRCP) as much as possible to clarify the liver anatomical structure of the donor, and in the early stage of minimally invasive technology, choose organ donors without anatomical structure variation as much as possible. Additionally, because the operating space for laparoscopic surgery is relatively small, especially for living donor right hepatectomy, choosing organ donors with a preoperative evaluation of grafts <700 g in the early stage is recommended to facilitate the exposure of the field of vision and the operation of the surgeon (72,73). In some transplant centers, to ensure the safety of organ donors and recipients, a GRWR >1% and residual liver volume >35% are required (2). With the accumulation of experience, some studies have shown that organ donors with anatomical variations can safely undergo minimally invasive surgery for living liver transplantation (44,45,74-78). Therefore, the criteria for donor selection can be expanded based on the careful judgment of the primary surgeon (69,78).

In summary, any situation that could cause severe complications during the perioperative period and the long-term recovery process of organ donors is a contraindication for living organ donation. Simultaneously, recipient safety should be considered as much as possible during the selection process.

Recommendation 5: The goals of the evaluation of living organ donors are to (I) ensure the safe procurement of a sufficient volume of the donor’s liver; (II) ensure that no donor-derived diseases are transmitted to the recipient; and (III) ensure that organ donors are aware of the entire donation process and can overcome potential psychological consequences (Evidence level: II; Recommendation strength: Strong).

Recommendation 6: Abdominal 3DCT and MRCP preoperatively should be used to evaluate the volume of the donor’s liver and the variation of blood vessels and bile ducts to ensure the safety of the donor and the smooth recovery of the recipient after surgery (Evidence level: II; Recommendation strength: Strong).

Recommendation 7: For transplant centers that just started performing minimally invasive surgery for donors, donors without obvious anatomical variations should be prioritized; experienced transplant centers can try to obtain transplants with anatomical variations with minimal invasion (Evidence level: II; Recommendation strength: Strong).

Anesthesia strategy for minimally invasive surgery in living liver transplant donors

The primary goal of anesthesia management is to minimize risk and effectively control pain (79). Endotracheal intubation under general anesthesia is typically performed during minimally invasive surgeries in living liver transplant donors. Depending on the extent of liver resection, epidural blockade techniques can be appropriately combined to alleviate the surgical stress response. When choosing anesthetic induction agents and muscle relaxants, drugs that are rapidly metabolized, accumulate less in the body, and have minimal impact on hepatic blood flow should be preferred. Standard anesthesia monitoring includes electrocardiography, blood oxygen saturation, invasive arterial blood pressure, body temperature, neuromuscular blockade, bispectral index, and central venous pressure monitoring. Mechanical ventilation settings should follow lung-protective strategies; that is, the tidal volume should be set at 6–8 mL/kg body weight, end-expiratory positive pressure should be maintained at 6–8 cmH₂O (1 cmH₂O = 0.098 kPa), and lung recruitment maneuvers should be intermittently applied (79-81).

During the entire surgical process, where pneumoperitoneum needs to be established, the intra-abdominal pressure is usually maintained at 12–14 mmHg (1 mmHg = 0.133 kPa). During the hepatic parenchymal transection stage, the central venous pressure should be actively controlled, usually maintained at 0–5 mmHg, to reduce bleeding from the hepatic section. After completion of hepatic parenchymal transection, aggressive fluid resuscitation should be immediately performed to restore the donor’s blood volume, and the blood pressure should be adjusted back to the preoperative level (82).

In minimally invasive surgery for living liver transplant donors, owing to the establishment of carbon dioxide (CO₂) pneumoperitoneum, maintenance of low central venous pressure, and potential venous injury during the hepatic parenchymal transection process, the probability of detecting CO₂ gas embolism in donors is relatively high. Although in most cases, donors do not have obvious clinical symptoms after experiencing a gas embolism and do not require special intervention, a severe gas embolism can seriously impact the respiratory and circulatory systems and, in extreme cases, cause cardiac arrest. Therefore, early detection and timely treatment are crucial to prevent the serious consequences of gas embolism (83). Transesophageal echocardiography is recommended as a tool to monitor CO₂ gas embolism and is of great value for the early identification of gas embolism. Once a gas embolism is detected, the pressure in the abdominal cavity should be immediately reduced, and venous rupture should be quickly repaired. In necessary cases, the transition to open surgery should be considered to ensure donor safety (84).

Recommendation 8: In minimally invasive surgery where pneumoperitoneum needs to be established, a lower central venous pressure level (0–5 mmHg) should be maintained during liver graft procurement to reduce bleeding (Evidence level: III; Recommendation strength: Strong).

Recommendation 9: Transesophageal echocardiography should be used as a tool for monitoring CO₂ gas embolism (Evidence level: III; Recommendation strength: Weak).

Recommendation 10: Once a gas embolism is detected, the pressure inside the abdominal cavity should be reduced immediately, and venous rupture should be quickly repaired. In necessary cases, transitioning to open surgery should be considered to ensure the safety of the donor (Evidence level: IV; Recommendation strength: Strong).

Types and methods of minimally invasive surgery for living liver transplant donors

Types of techniques

Small upper midline incision living donor hepatectomy

This surgery involves the use of a midline incision above the navel to complete liver graft procurement. It can reduce pain and lower the incidence of incision-related complications while performing hepatic parenchymal and ductal transection under direct vision (4,85). Compared with the traditional subcostal incision, the small upper midline incision can avoid separation of the rectus abdominis without affecting the postoperative quality of life of the organ donor. However, this procedure has certain limitations. For example, owing to the narrowed field of vision, freeing the liver becomes relatively difficult and is more challenging to perform on donors with excessive body weight or large liver volume.

Laparoscopic-assisted donor hepatectomy

This type of surgery mainly includes laparoscopic-assisted, hand-assisted, and hybrid methods of donor hepatectomies. The most common method is to complete liver mobilization under laparoscopic conditions (with or without hand-assisted methods) and then make a small midline incision in the upper abdomen to complete hepatic parenchymal transection and ductal anatomical transection. This surgical method is often used as a transitional surgical method to gain experience in minimally invasive donor hepatectomy techniques in the early stages of establishing a laparoscopic donor hepatectomy center (86,87). Currently, this surgery is rarely performed at experienced transplant centers.

Total laparoscopic donor hepatectomy

This surgery involves the completion of liver mobilization, hepatic parenchymal transection, liver supply pipeline anatomy, and transection under laparoscopy, with another small incision made for specimen retrieval. This type of surgery requires high technical skills.

Robotic donor hepatectomy

Compared with laparoscopy, robotic donor hepatectomy has significant advantages in the identification of vascular structures and hepatic segment anatomy during non-injurious liver mobilization, hepatic hilum dissection, and hepatic parenchymal transection, and its learning curve is shorter. Compared with traditional laparoscopy, the robot has the following advantages: (I) stable and excellent visual effects, with up to 10 times the magnification of a microscope; (II) the best ergonomic design, equipped with tremor-free surgical instruments, with a wider range of motion and higher degrees of freedom; (III) precise anatomical ability; (IV) can suture more conveniently and quickly; and (V) clinical practice and research (88,89) have confirmed that the robot can reduce surgeon fatigue compared with traditional laparoscopy. However, robotic hepatectomy technology has certain shortcomings, including a lack of operative tactile feedback, the need for experienced assistants with laparoscopic skills, the need to reinstall the bedside robotic arm to adapt to different positions or operative holes, longer operation times, and higher operation costs (90).

Recommendation 11: Total laparoscopic donor hepatectomy and robotic donor hepatectomy have high technical requirements and should be performed in experienced transplant centers (Evidence level: II; Recommendation strength: Strong).

Recommendation 12: For transplant centers that are still in the early stages, starting with a small upper midline incision living donor hepatectomy or laparoscopic-assisted donor hepatectomy is recommended. Under the core premise of ensuring donor safety, they can gradually transition to total laparoscopic and robotic donor hepatectomies (Evidence level: II; Recommendation strength: Strong).

Surgical methods

Surgical methods included minimally invasive donor left lateral sectionectomy, minimally invasive donor right posterior sectionectomy, minimally invasive donor left hepatectomy (with or without the middle hepatic vein), and minimally invasive donor right hepatectomy (with or without the middle hepatic vein). The choice of the surgical method was based mainly on the aforementioned donor evaluation results. Ensuring donor safety is a primary requirement for minimally invasive donor hepatectomy. Therefore, with the transplant surgeons’ deepening understanding of surgical instruments, surgical techniques, anatomy, and preoperative evaluation, minimally invasive donor hepatectomy has successfully transitioned from a relatively simple donor left hepatectomy or left lateral sectionectomy to a minimally invasive donor right hepatectomy (especially laparoscopic right hepatectomy). In 2022, Cho et al. (91) first reported the results of seven cases of laparoscopic donor right posterior sectionectomy, showing that three out of seven donors (43%) had vascular or biliary complications. In 2023, Cho et al. (92) included the results of a multicenter laparoscopic donor right posterior sectionectomy series in Korea (a total of 16 cases), showing that compared to laparoscopic donor right hepatectomy, the postoperative complication rate of donors who underwent laparoscopic donor right posterior sectionectomy was not statistically significant, thereby confirming its feasibility and safety. Presently, few reports exist on laparoscopic donor right posterior sectionectomy, and the implementation of this surgical procedure still requires caution.

Recommendation 13: The choice of surgical method should be based on the safety of the donor, follow a scientific learning curve, and fully consider the evaluation results of the donor and the experience and habits of the surgical team (Evidence level: II; Recommendation strength: Strong).

Surgical techniques for minimally invasive surgery for living liver transplant donors

Laparoscopic surgical equipment and instruments

Equipment

These include laparoscopic imaging systems, pneumoperitoneum devices, irrigation suction devices, and video- and image-storage devices. In terms of laparoscopic imaging systems, recent clinical randomized controlled studies and retrospective studies (14,93-101) have confirmed that 3D laparoscopy has the advantages of shortening surgical time, improving accuracy, and reducing operational errors during surgical procedures compared to 2D laparoscopy. Moreover, the literature (102) reports that the use of 3D laparoscopy can reduce intraoperative bleeding and the incidence of postoperative complications. In addition, studies (14,95) have confirmed that using a flexible 3D scope in 3D laparoscopic donor hepatectomy is more conducive to performing donor right hepatectomy. This is because the flexible 3D scope can provide a larger field of view to fully reveal the space of the right posterior lobe of the liver, and it is more convenient to handle the second hepatic portal area. In addition, compared to traditional high-definition laparoscopic systems, 4 K laparoscopic systems can provide a more high-definition and realistic surgical field of view. However, because of the short clinical application time of the 4 K laparoscopic surgical equipment, it is not seen in relevant clinical reports on laparoscopic donor hepatectomy, and its advantages need to be further studied and demonstrated.

Recommendation 14: Compared with traditional 2D laparoscopy, 3D and 4K laparoscopic equipment can help improve the comfort of the surgeon in laparoscopic donor hepatectomy; 3D laparoscopy shortens surgical time and reduces intraoperative bleeding, among which the advantage of flexible 3D scope is more prominent (Evidence level: III; Recommendation strength: Weak).

Instruments

General instruments include pneumoperitoneum needles, puncture needles, separation forceps, non-traumatic grasping forceps, scissors, needle holders, monopolar coagulation, bipolar coagulation, titanium clips, and disposable tissue closure clips, in addition to routinely prepared open hepatectomy surgical instruments. Special instruments, mainly referring to separation and liver transection instruments, include laparoscopic cutter staplers, ultrasonic scalpels, Cavitron ultrasonic surgical aspirators (CUSA), Ligasure, microwave scalpels, water-jet scalpels, and argon scalpels.

Robotic surgical equipment and instruments

Equipment

These include robotic surgical systems, mechanical surgical arms, surgical consoles, vision systems, and system control software.

Instruments

Surgical instruments include 8 mm metal cannulas and puncture devices, cross-calibrators, monopolar hooks, Maryland or Fenestrated bipolar coagulation forceps, pericardial forceps, ultrasonic scalpels, needle holders, monopolar electric scissors, and disposable tissue-closure clips. The surgeon can select other instruments according to the hospital facilities and personal preferences for use with robots and laparoscopes.

Hepatic parenchymal transection and instrument selection

Instrument selection

Minimally invasive hepatectomy requires the use of various instruments to cut the liver tissue, each with unique advantages and disadvantages. These can be flexibly selected for use based on the actual hospital situation and the proficiency of the surgeon. Because CUSA is more precise in distinguishing blood vessels and bile ducts during hepatic parenchymal transection, it is currently the most commonly used technique in laparoscopic donor hepatectomy (69,103-107). Ultrasonic scalpels are more commonly used in robotic donor hepatectomies than in laparoscopic donor hepatectomies. During the surgical process, energy instruments are first used to determine the pre-cut line of the liver and to cut open the liver capsule. Thereafter, instruments such as the CUSA are gradually used to carefully perform hepatic parenchymal transection.

Recommendation 15: When transecting the hepatic parenchyma, the surgeon can choose one or more surgical instruments according to the conditions of the hospital and personal habits, with a preference for using CUSA for hepatic parenchymal transection (Evidence level: III; Recommendation strength: Weak).

Determination of hepatectomy line

When performing donor left lateral sectionectomy, the diaphragmatic resection line is usually 1 cm to the left of the round and falciform ligaments, and the hepatic parenchyma is generally transected using a CUSA or ultrasonic scalpel. When performing hemihepatectomy or right posterior sectionectomy, the resection line should be determined by the ischemic line on the surface of the liver after the corresponding hepatic pedicle is occluded, and the course of the hepatic vein should be determined using intraoperative ultrasound. When performing a right hepatectomy without the middle hepatic vein and an enlarged left hepatectomy, the resection line should be on the right side of the ischemic line. When performing a right hepatectomy with the middle hepatic vein, the resection line should be on the left side of the ischemic line. When resecting the right posterior lobe of the donor liver, which includes the right hepatic vein, the resection line should be set inside the right anterior lobe slightly to the left of the ischemic line. Recently, there have been reports on the use of indocyanine green (ICG) to assist in the positioning of the hepatectomy line. For example, Kim et al. (108) reported in 2021 that using ICG fluorescence staining in laparoscopic hemihepatectomy can accurately display the left and right midplanes of the liver, shorten the operation time, and reduce the postoperative levels of alanine aminotransferase and aspartate aminotransferase. Li et al. (109) reported that in laparoscopic S2 left lateral monosegmentectomy, after ligating the S3 Glisson pedicle, a negative staining method was used to display the boundary between S2 and S3 and that S3 was resected to perform in situ volume reduction.

Recommendation 16: When transecting the hepatic parenchyma, it is recommended to use the ischemic line on the surface of the liver or ICG fluorescence staining method after the hepatic pedicle occlusion and combine with intraoperative ultrasound to determine the resection line (Evidence level: III; Recommendation strength: Strong).

The Pringle maneuver

Currently, commonly used energy instruments such as the CUSA and ultrasonic scalpels have extremely low work efficiency in the case of bleeding at the cut surface. Reducing bleeding shortens the time of hepatic parenchymal transection and improves efficiency. In addition, bleeding at the cut surface increases the risk of scope contamination, requiring frequent scope wiping and prolonging the operation time. Therefore, Imamura et al. (110) first proposed a method of intermittent hepatic pedicle occlusion in traditional open-living donor hepatectomy to improve the efficiency of hepatic parenchymal transection. A randomized controlled trial conducted by Park et al. (111) in 2012 showed that in the process of obtaining an open living right half of the liver, the Pringle maneuver was used, and only the postoperative peak value of alanine aminotransferase was higher than that in the non-occlusion group; however, the total bleeding volume of the donor and the postoperative length of stay were both better than those in the non-occlusion group. The organ transplant team from the West China Hospital of Sichuan University (75) also reported that the Pringle maneuver may increase the peak value of aminotransferase in the early postoperative period of the donor, but it returned to normal on the 5th day after surgery and had no effect on long-term prognosis. In 2021, the Asian-Pacific Hepato-Pancreato-Biliary Association and International Laparoscopic Liver Society asked an expert group for their opinion on whether to perform Pringle maneuver. The current consensus on intermittent hepatic pedicle occlusion is that there is no evidence to show that it has adverse effects on the graft. The Pringle maneuver helps to shorten the operation time and reduce the amount of bleeding (25). However, for minimally invasive donor left lateral sectionectomy, experienced transplant centers can use the non-occlusion liver transection method; however, there is currently insufficient evidence and further research is needed.

Recommendation 17: Currently, there is no evidence to suggest that use of Pringle maneuver during surgery has adverse effects on the graft. The Pringle maneuver helps to shorten the operation time and reduce the amount of bleeding. For minimally invasive donor left lateral sectionectomy, experienced transplant centers can use the non-occlusion liver transection method (Evidence level: IV; Recommendation strength: Weak).

Vascular anatomy and transection

Arterial anatomy and transection

Since approximately 1/5 of donors have an accessory left hepatic artery originating from the left gastric artery, it should be checked preoperatively or carefully identified intraoperatively to determine whether there is a large accessory left hepatic artery when performing a living donor left hepatectomy or left lateral sectionectomy. If present, the vessel should be protected as much as possible, and a sufficient length of the vessel should be preserved for subsequent anastomotic reconstruction. By contrast, multiple right hepatic arteries are less common and often have advantageous variations. Usually, the right hepatic artery originates from the superior mesenteric artery. Therefore, the right liver graft has a separate and longer artery, which is more conducive to anastomotic reconstruction. During intraoperative exposure of the hepatic artery anatomy, frequent clamping or violent traction of the hepatic artery should be avoided to prevent damage to the arterial intima. After systemic heparinization, when transecting the hepatic artery, ligation or vascular clamp closure can be used, and then sharp laparoscopic scissors can be used to transect the artery at an appropriate breakpoint.

Recommendation 18: During the arterial anatomy exposure process of minimally invasive donor hepatectomy, the variant arteries should be carefully and accurately identified, the operation should be performed carefully and gently to avoid causing damage to the arterial intima, and a sharp laparoscopic scissors can be used to transect the artery after ligation or vascular clamp closure of the artery (Evidence level: III; Recommendation strength: Strong).

Portal vein anatomy and transection

As far as the portal vein is concerned, there are fewer variations in the left branch of the portal vein; therefore, it is usually easier to obtain sufficient portal vein length for the left graft. If multiple branches of the right portal vein are present, the resection risk and transection length should be fully evaluated for subsequent reconstruction. In minimally invasive donor hepatectomies, a disposable tissue closure clip or vascular cutting closure device can be used for portal vein transection. However, compared with the traditional open surgery cut-suture method, the above methods lose an additional 2–3 mm of vessel length; therefore, more portal vein transection margins should be left during the operation.

Recommendation 19: During the portal vein anatomy exposure process in minimally invasive donor hepatectomy, variations should be carefully and accurately identified, and a disposable tissue closure clip or vascular cutting closure device should be used for portal vein branch transection. The impact of the above methods on the loss of vessel length should be fully considered (Evidence level: III; Recommendation strength: Strong).

Hepatic vein anatomy and transection

Evaluating the course of the hepatic vein and possible variations through CT, MRI, and 3D imaging before surgery is recommended, and intraoperative ultrasound can better locate the hepatic vein. The necessary anatomy and exposure of the hepatic vein are performed according to the type of graft. The middle hepatic vein is an important structure that must be fully dissected during the splitting of the hemi-liver graft. The key operation is to accurately locate and protect the main trunk of the middle hepatic vein while properly exposing and transecting the middle hepatic vein branch on the side to be cut. Additionally, the use of low central venous pressure technology during surgery can effectively prevent and control venous bleeding. Because during the operation under laparoscopy or robot, after the main trunk of the hepatic vein is transected, it is difficult to control the venous end. To prevent the risk of major bleeding caused by the slipping of the vascular remnant, the use of a vascular cutter stapler to transect a large hepatic vein is recommended.

Biliary anatomy and transection

Biliary management is a major challenge in minimally invasive living-donor hepatectomy (112). It is generally believed that the anatomy of the bile duct, determination of the bile duct transection point, and treatment of bile duct remnants are crucial for the prevention of postoperative biliary complications in recipients. Generally, the left bile duct is longer and can be handled more properly, whereas the right bile duct has more variations, and the convergence position of the right anterior and right posterior hepatic ducts is uncertain. Therefore, management of the right liver graft bile duct is difficult, and its complexity is far higher than that of the left liver graft.

Biliary anatomy

Regarding bile duct anatomy in minimally invasive surgeries, surgeons are more likely to use energy instruments near the bile duct. This heat transfer may damage the endothelium and affect the microvessels around the bile duct, leading to ischemic injury of the bile duct (12,39). Therefore, when dissecting the first hepatic portal, energy instruments should be used cautiously, and excessive dissection should be avoided to reduce the occurrence of biliary complications.

Biliary transection

During biliary transection, if the surgeon places the transection point closer to the donor side, donor safety may be jeopardized, thereby increasing the risk of postoperative biliary complications. If the transection point is placed closer to the graft side, out of concern for preserving the length of the donor bile duct stump, it may increase the number of openings in the bile duct of the graft, increase the difficulty of recipient bile duct anastomosis, and increase the risk of postoperative bile leakage (12,13). Therefore, surgeons should accurately determine the appropriate biliary transection point to reduce the occurrence of biliary complications (113). Traditional living liver transplantation routinely uses preoperative MRCP combined with intraoperative cholangiography to accurately assess variations in the donor bile duct. Recently, ICG cholangiography under fluorescent laparoscopy has been widely used as a functional antegrade cholangiography method for laparoscopic donor hepatectomy. Owing to the characteristic ICG concentration in bile, fluorescent laparoscopy can be used to clearly observe the bifurcation point of the left and right hepatic ducts, thereby more accurately determining the biliary transection point in real-time (114,115).

Biliary stump management

In the management of biliary stumps, both clamping and suturing are viable methods (25). Although some researchers (70,116) have reported that suturing under laparoscopy increases the chances of bile leakage, for donors with shorter biliary stumps, forced clamping can increase the risk of postoperative biliary stricture; therefore, suturing should be used.

Recommendation 20: During biliary dissection, excessive dissection should be avoided, and energy instruments should be used cautiously to protect the blood supply around the bile duct (Evidence level: IV; Recommendation strength: Strong).

Recommendation 21: In the process of managing the biliary stump, both clamping and suturing are viable methods (Evidence level: IV; Recommendation strength: Strong).

Recommendation 22: During the evaluation of biliary variation, MRCP should be performed preoperatively to assess the condition of the bile duct. Except for left lateral sectionectomy, intraoperative cholangiography or ICG cholangiography should be performed to determine the biliary transection point (Evidence level: IV; Recommendation strength: Weak).

Indications and timing for conversion to open surgery in minimally invasive surgery

Ensuring donor safety is a primary task during minimally invasive surgeries for living liver transplant donors. Any event that may jeopardize donor safety or graft integrity should prompt rapid intraoperative conversion to open surgery. These include difficulties in controlling bleeding, the inability to accurately expose important anatomical structures, the inability to accurately identify variations in the bile duct or vascular anatomy, the occurrence of bile duct or vascular injury, and severe gas embolism. A study (117) involving 34 centers worldwide and 2,370 patients found that the intraoperative conversion rate reached 3.86–5.37%. Therefore, surgeons should rationally consider intraoperative conversion, and its occurrence should not represent surgical failure (118).

Recommendation 23: Any event that may jeopardize the donor’s safety or graft integrity should prompt a rapid conversion to open surgery. These include difficulty in controlling bleeding, inability to accurately expose important anatomical structures and identify variations in the bile duct or vascular anatomy, occurrence of bile duct or vascular injury, and severe gas embolism. (Evidence level: IV; Recommendation strength: Strong).

Learning curve of minimally invasive surgery for living liver transplant donors

The implementation of minimally invasive surgery for living donor liver transplantation requires physicians with extensive experience in laparoscopic and open living donor hepatectomy (2,39,78). According to the literature (25,44,119), the incidence of postoperative complications in donors is significantly higher in the early stages of laparoscopic donor hepatectomy than in the later stages. Broering et al. demonstrated that the learning curve for pure laparoscopic donor left lateral sectionectomy was completed after 25 procedures (120). However, due to the deeper positioning, anatomical complexity, and larger graft weight of the right hemiliver than the left lateral sectionectomy, more cases need to be learned. Hong et al. (121) used the cumulative sum method to analyze the operation time of laparoscopic living donor right hepatectomy by the same surgeon and believed that the learning curve of this operation is 65–70 cases and that the formulation of standardized procedures and sharing of experience can shorten the learning curve. Medical institutions and physicians who have just started performing laparoscopic donor hepatectomy should choose donors with good anatomical structures (25,122). Before safely handling donors with more challenging anatomical variations, good anatomical structure can enable surgeons to accumulate experience and standardize techniques (123).

Currently, the application of robotic surgical systems in donor hepatectomy of living donor liver transplantation is relatively limited, and support from prospective clinical studies is lacking. Although its technical feasibility has been demonstrated, it has not been widely adopted in various transplant centers. Robots have multiple advantages over laparoscopy in minimally invasive liver surgery, making robotic living-donor hepatectomy an emerging research focus in liver transplantation. For institutions planning to perform robotic living-donor hepatectomy, having physicians with extensive experience in both open-living donor and robotic liver surgeries is essential. Additionally, establishing a dedicated robotic team, including the primary surgeon, assistants, and surgical nurses, can enhance donor safety and surgical efficiency and accelerate learning. Seeking collaborative teaching from experienced teams is beneficial, as this can significantly shorten the learning curve (30).

Recommendation 24: The implementation of minimally invasive surgery for living liver transplant donors requires physicians with extensive experience in minimally invasive and open living donor hepatectomy (Evidence level: V; Recommendation strength: Strong).

Recommendation 25: For transplant centers that lack experience in minimally invasive surgery for living liver transplant donors, starting with laparoscopic donor left lateral sectionectomy is recommended. With donor safety as the primary goal, a steady transition to laparoscopic donor hemihepatectomy surgery can be made (Evidence level: V; Recommendation strength: Strong).

Recommendation 26: Before mastering minimally invasive surgery for living liver transplant donors, it is advisable to avoid selecting donors with anatomical variations for surgery (Evidence level: III; Recommendation strength: Strong).

Acknowledgments

A great appreciation for the Guideline Committee for their active advice and peer-review that greatly improved the guidelines. Members of the Guideline Committee included Shusen Zheng, Xiaoping Chen, Jiahong Dong, Kefeng Dou, Qiang Xia, Lvnan Yan, and Wujun Xue.

Funding: This study was supported by grants from National Key R&D Program of China (No. 2022YFC2304705 to Jiayin Yang); National Natural Science Foundation of China (No. 82270691 to Jiayin Yang); Sichuan Province Key Research and Development Project (Nos. 2023YFS0026 and 23ZDYF2182 to Jiayin Yang); Chengdu Province Key Research and Development Project (No. 2022YF0900009SN to Jiayin Yang); and 1.3.5 Project for Disciplines of Excellence from West China Hospital of Sichuan University (No. ZYGD24002 to Jiayin Yang).

Footnote

Reporting Checklist: The authors have completed the RIGHT reporting checklist. Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-329/rc

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-329/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-329/coif). S.D. serves as an unpaid editorial board member of HepatoBiliary Surgery and Nutrition. Z.G. serves as an unpaid Assistant Editor of HepatoBiliary Surgery and Nutrition. Jiayin Yang reports grants from National Key R&D Program of China (No. 2022YFC2304705); National Natural Science Foundation of China (No. 82270691); Sichuan Province Key Research and Development Project (No. 2023YFS0026); and Chengdu Province Key Research and Development Project (No. 2022YF0900009SN). The other 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.

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References

1. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392-6. [Crossref] [PubMed]
2. Han HS, Cho JY, Kaneko H, et al. Expert Panel Statement on Laparoscopic Living Donor Hepatectomy. Dig Surg 2018;35:284-8. [Crossref] [PubMed]
3. Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522-5. [Crossref] [PubMed]
4. Kim SH, Cho SY, Lee KW, et al. Upper midline incision for living donor right hepatectomy. Liver Transpl 2009;15:193-8. [Crossref] [PubMed]
5. Troisi RI, Wojcicki M, Tomassini F, et al. Pure laparoscopic full-left living donor hepatectomy for calculated small-for-size LDLT in adults: proof of concept. Am J Transplant 2013;13:2472-8. [Crossref] [PubMed]
6. 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]
7. Soubrane O, Perdigao Cotta F, Scatton O. Pure laparoscopic right hepatectomy in a living donor. Am J Transplant 2013;13:2467-71. [Crossref] [PubMed]
8. Rotellar F, Pardo F, Benito A, et al. Totally laparoscopic right-lobe hepatectomy for adult living donor liver transplantation: useful strategies to enhance safety. Am J Transplant 2013;13:3269-73. [Crossref] [PubMed]
9. Yang J, Li B, Wang W, et al. Laparoscopic-assisted right hepatectomy in living donors of liver transplantation(video). Chinese Journal of Transplantation 2012;6:11-4. (Electronic Edition).
10. Li H, Wei Y, Li B. Total laparoscopic living donor right hemihepatectomy: first case in China mainland and literature review. Surg Endosc 2016;30:4622-3. [Crossref] [PubMed]
11. Giulianotti PC, Tzvetanov I, Jeon H, et al. Robot-assisted right lobe donor hepatectomy. Transpl Int 2012;25:e5-9. [Crossref] [PubMed]
12. Hong SK, Tan MY, Worakitti L, et al. Pure Laparoscopic Versus Open Right Hepatectomy in Live Liver Donors: A Propensity Score-matched Analysis. Ann Surg 2022;275:e206-12. [Crossref] [PubMed]
13. Rhu J, Choi GS, Kwon CHD, et al. Learning curve of laparoscopic living donor right hepatectomy. Br J Surg 2020;107:278-88. [Crossref] [PubMed]
14. Samstein B, Griesemer A, Halazun K, et al. Pure Laparoscopic Donor Hepatectomies: Ready for Widespread Adoption? Ann Surg 2018;268:602-9. [Crossref] [PubMed]
15. Centre for Evidence-Based Medicine. Levels of evidence. Available online: https://www.cebm.ox.ac.uk/resources/levels-of-evidence
16. Brozek JL, Akl EA, Jaeschke R, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3. The GRADE approach to grading quality of evidence about diagnostic tests and strategies. Allergy 2009;64:1109-16. [Crossref] [PubMed]
17. Han HS, Cho JY, Yoon YS, et al. Total laparoscopic living donor right hepatectomy. Surg Endosc 2015;29:184. [Crossref] [PubMed]
18. Xu J, Hu C, Cao HL, et al. Meta-Analysis of Laparoscopic versus Open Hepatectomy for Live Liver Donors. PLoS One 2016;11:e0165319. [Crossref] [PubMed]
19. Zhu P, Liao W, Zhang WG, et al. A Prospective Study Using Propensity Score Matching to Compare Long-term Survival Outcomes After Robotic-assisted, Laparoscopic, or Open Liver Resection for Patients With BCLC Stage 0-A Hepatocellular Carcinoma. Ann Surg 2023;277:e103-11. [Crossref] [PubMed]
20. Di Benedetto F, Magistri P, Di Sandro S, et al. Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma. JAMA Surg 2023;158:46-54. [Crossref] [PubMed]
21. Park JI, Kim KH, Lee SG. Laparoscopic living donor hepatectomy: a review of current status. J Hepatobiliary Pancreat Sci 2015;22:779-88. [Crossref] [PubMed]
22. Simillis C, Constantinides VA, Tekkis PP, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms--a meta-analysis. Surgery 2007;141:203-11. [Crossref] [PubMed]
23. Koffron AJ, Auffenberg G, Kung R, et al. Evaluation of 300 minimally invasive liver resections at a single institution: less is more. Ann Surg 2007;246:385-92; discussion 392-4. [Crossref] [PubMed]
24. Gao Y, Wu W, Liu C, et al. Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis. Medicine (Baltimore) 2021;100:e26708. [Crossref] [PubMed]
25. 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]
26. Coelho FF, Bernardo WM, Kruger JAP, et al. Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis. HPB (Oxford) 2018;20:687-94. [Crossref] [PubMed]
27. Park JH, Suh S, Hong SK, et al. Pure laparoscopic versus open right donor hepatectomy including the middle hepatic vein: a comparison of outcomes and safety. Ann Surg Treat Res 2022;103:40-6. [Crossref] [PubMed]
28. Hong SK, Choi GS, Han J, et al. Pure Laparoscopic Donor Hepatectomy: A Multicenter Experience. Liver Transpl 2021;27:67-76. [Crossref] [PubMed]
29. Soubrane O, Eguchi S, Uemoto S, et al. Minimally Invasive Donor Hepatectomy for Adult Living Donor Liver Transplantation: An International, Multi-institutional Evaluation of Safety, Efficacy and Early Outcomes. Ann Surg 2022;275:166-74. [Crossref] [PubMed]
30. Broering D, Sturdevant ML, Zidan A. Robotic donor hepatectomy: A major breakthrough in living donor liver transplantation. Am J Transplant 2022;22:14-23. [Crossref] [PubMed]
31. Pei J, Shen C, Li R, et al. Comparison of Two Donor Liver Procurement Methods for Treatment of Pediatric Acute Liver Failure. Front Pediatr 2022;10:816516. [Crossref] [PubMed]
32. Zhang W, Xu L, Zhang J, et al. Safety and feasibility of laparoscopic living donor right hepatectomy for adult liver transplantation: a meta-analysis. HPB (Oxford) 2021;23:344-58. [Crossref] [PubMed]
33. Ziogas IA, Kakos CD, Moris DP, et al. Systematic review and meta-analysis of open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy. Liver Transpl 2023;29:1063-78. [Crossref] [PubMed]
34. 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]
35. 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]
36. Xiao J, Zeng RW, Lim WH, et al. The incidence of adverse outcome in donors after living donor liver transplantation: A meta-analysis of 60,829 donors. Liver Transpl 2024;30:493-504. [Crossref] [PubMed]
37. Lee SK, Han YS, Ha H, et al. A Single Center Experience for a Feasibility of Totally Laparoscopic Living Donor Right Hepatectomy. J Minim Invasive Surg 2019;22:61-8. [Crossref] [PubMed]
38. Broering DC, Elsheikh Y, Shagrani M, et al. Pure Laparoscopic Living Donor Left Lateral Sectionectomy in Pediatric Transplantation: A Propensity Score Analysis on 220 Consecutive Patients. Liver Transpl 2018;24:1019-30. [Crossref] [PubMed]
39. Park J, Kwon DCH, Choi GS, et al. Safety and Risk Factors of Pure Laparoscopic Living Donor Right Hepatectomy: Comparison to Open Technique in Propensity Score-matched Analysis. Transplantation 2019;103:e308-16. [Crossref] [PubMed]
40. Jeong JS, Wi W, Chung YJ, et al. Comparison of perioperative outcomes between pure laparoscopic surgery and open right hepatectomy in living donor hepatectomy: Propensity score matching analysis. Sci Rep 2020;10:5314. [Crossref] [PubMed]
41. Li H, Zhang JB, Chen XL, et al. Different techniques for harvesting grafts for living donor liver transplantation: A systematic review and meta-analysis. World J Gastroenterol 2017;23:3730-43. [Crossref] [PubMed]
42. Mu C, Chen C, Wan J, et al. Minimally Invasive Donors Right Hepatectomy versus Open Donors Right Hepatectomy: A Meta-Analysis. J Clin Med 2023;12:2904. [Crossref] [PubMed]
43. Sha M, Zong ZP, Shen C, et al. Pure laparoscopic versus open left lateral hepatectomy in pediatric living donor liver transplantation: a review and meta-analysis. Hepatol Int 2023;17:1587-95. [Crossref] [PubMed]
44. 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]
45. Rhu J, Kim MS, Choi GS, et al. Laparoscopic Living Donor Right Hepatectomy Regarding the Anatomical Variation of the Portal Vein: A Propensity Score-Matched Analysis. Liver Transpl 2021;27:984-96. [Crossref] [PubMed]
46. Lincango Naranjo EP, Garces-Delgado E, Siepmann T, et al. Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis. J Clin Med 2022;11:2603. [Crossref] [PubMed]
47. Peng Y, Li B, Xu H, et al. Pure Laparoscopic Versus Open Approach for Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2022;32:832-41. [Crossref] [PubMed]
48. He K, Pan Y, Wang H, et al. Pure Laparoscopic Living Donor Hepatectomy With/Without Fluorescence-Assisted Technology and Conventional Open Procedure: A Retrospective Study in Mainland China. Front Surg 2021;8:771250. [Crossref] [PubMed]
49. Lo CM, Fan ST, Liu CL, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004;240:151-8. [Crossref] [PubMed]
50. Trotter JF, Wachs M, Everson GT, et al. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002;346:1074-82. [Crossref] [PubMed]
51. Brown RS Jr. Live donors in liver transplantation. Gastroenterology 2008;134:1802-13. [Crossref] [PubMed]
52. Taner CB, Dayangac M, Akin B, et al. Donor safety and remnant liver volume in living donor liver transplantation. Liver Transpl 2008;14:1174-9. [Crossref] [PubMed]
53. Cho JY, Suh KS, Kwon CH, et al. Outcome of donors with a remnant liver volume of less than 35% after right hepatectomy. Liver Transpl 2006;12:201-6. [Crossref] [PubMed]
54. Chen YS, Cheng YF, De Villa VH, et al. Evaluation of living liver donors. Transplantation 2003;75:S16-9. [Crossref] [PubMed]
55. Barr ML, Belghiti J, Villamil FG, et al. A report of the Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines. Transplantation 2006;81:1373-85. [Crossref] [PubMed]
56. Iwasaki M, Takada Y, Hayashi M, et al. Noninvasive evaluation of graft steatosis in living donor liver transplantation. Transplantation 2004;78:1501-5. [Crossref] [PubMed]
57. Hwang S, Lee SG, Lee YJ, et al. Lessons learned from 1,000 living donor liver transplantations in a single center: how to make living donations safe. Liver Transpl 2006;12:920-7. [Crossref] [PubMed]
58. Rinella ME, Alonso E, Rao S, et al. Body mass index as a predictor of hepatic steatosis in living liver donors. Liver Transpl 2001;7:409-14. [Crossref] [PubMed]
59. Zhao X, He Y, Liu J, et al. Impact of living donor liver with steatosis and idiopathic portal inflammation on clinical outcomes in pediatric liver transplantation: Beijing experience. Hepatobiliary Surg Nutr 2022;11:340-54. [Crossref] [PubMed]
60. McCormack L, Dutkowski P, El-Badry AM, et al. Liver transplantation using fatty livers: always feasible? J Hepatol 2011;54:1055-62. [Crossref] [PubMed]
61. Doyle MB, Vachharajani N, Wellen JR, et al. Short- and long-term outcomes after steatotic liver transplantation. Arch Surg 2010;145:653-60. [Crossref] [PubMed]
62. Nagai S, Fujimoto Y, Kamei H, et al. Mild hepatic macrovesicular steatosis may be a risk factor for hyperbilirubinaemia in living liver donors following right hepatectomy. Br J Surg 2009;96:437-44. [Crossref] [PubMed]
63. Bhangui P, Sah J, Choudhary N, et al. Safe Use of Right Lobe Live Donor Livers With up to 20% Macrovesicular Steatosis Without Compromising Donor Safety and Recipient Outcome. Transplantation 2020;104:308-16. [Crossref] [PubMed]
64. Yoon YI, Song GW, Lee SG, et al. Safe use of right lobe living donor livers with moderate steatosis in adult-to-adult living donor liver transplantation: a retrospective study. Transpl Int 2021;34:872-81. [Crossref] [PubMed]
65. Doyle A, Adeyi O, Khalili K, et al. Treatment with Optifast reduces hepatic steatosis and increases candidacy rates for living donor liver transplantation. Liver Transpl 2016;22:1295-300. [Crossref] [PubMed]
66. Chung JH, Ryu JH, Yang KH, et al. Efficacy and Safety of Weight Reduction of the Donor in Hepatic Steatosis for Living Donor Liver Transplantation. Ann Transplant 2020;25:e923211. [Crossref] [PubMed]
67. Pamecha V, Patil NS, Parthasarathy K, et al. Expanding donor pool for live donor liver transplantation: utilization of donors with non-alcoholic steatohepatitis after optimization. Langenbecks Arch Surg 2022;407:1575-84. [Crossref] [PubMed]
68. Yoon YI, Lee SG, Hwang S, et al. Safety of right liver donation after improving steatosis through weight loss in living donors: a retrospective study. Hepatol Int 2024;18:1566-78. [Crossref] [PubMed]
69. Kwon CHD, Choi GS, Joh JW. Laparoscopic right hepatectomy for living donor. Curr Opin Organ Transplant 2019;24:167-74. [Crossref] [PubMed]
70. Park J, Kwon CHD, Choi GS, et al. One-Year Recipient Morbidity of Liver Transplantation Using Pure Laparoscopic Versus Open Living Donor Right Hepatectomy: Propensity Score Analysis. Liver Transpl 2019;25:1642-50. [Crossref] [PubMed]
71. Kwon CHD, Choi GS, Kim JM, et al. Laparoscopic Donor Hepatectomy for Adult Living Donor Liver Transplantation Recipients. Liver Transpl 2018;24:1545-53. [Crossref] [PubMed]
72. Chen KH, Siow TF, Chio UC, et al. Laparoscopic donor hepatectomy. Asian J Endosc Surg 2018;11:112-7. [Crossref] [PubMed]
73. Cho HD, Kim KH, Yoon YI, et al. Comparing purely laparoscopic versus open living donor right hepatectomy: propensity score-matched analysis. Br J Surg 2021;108:e233-4. [Crossref] [PubMed]
74. Chen KH, Huang CC, Siow TF, et al. Totally laparoscopic living donor right hepatectomy in a donor with trifurcation of bile duct. Asian J Surg 2016;39:51-5. [Crossref] [PubMed]
75. Song JL, Yang J, Wu H, et al. Pure laparoscopic right hepatectomy of living donor is feasible and safe: a preliminary comparative study in China. Surg Endosc 2018;32:4614-23. [Crossref] [PubMed]
76. Lu L, Wang ZX, Zhu WW, et al. Left Hepatic Vein Preferential Approach Based on Anatomy Is Safe and Feasible for Laparoscopic Living Donor Left Lateral Sectionectomy. Liver Transpl 2021;27:88-95. [Crossref] [PubMed]
77. Park K, Shehta A, Lee JM, et al. Pure 3D laparoscopy versus open right hemihepatectomy in a donor with type II and III portal vein variations. Ann Hepatobiliary Pancreat Surg 2019;23:313-8. [Crossref] [PubMed]
78. Song JL, Wu H, Yang JY. Laparoscopic donor right hepatectomy in a donor with type III portal vein anomaly: A case report. Medicine (Baltimore) 2019;98:e16736. [Crossref] [PubMed]
79. Sakai T, Ko JS, Crouch CE, et al. Perioperative management of living donor liver transplantation: Part 2 - Donors. Clin Transplant 2022;36:e14690. [Crossref] [PubMed]
80. Lee EK, Bang YJ, Kwon JH, et al. Change of Anesthetic Management From Open to Laparoscopic Living Donor Right Hepatectomy After Learning Curve. Transplant Proc 2022;54:406-8. [Crossref] [PubMed]
81. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013;369:428-37. [Crossref] [PubMed]
82. Akbulut A, Alim A, Karatas C, et al. Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey. Transplant Proc 2023;55:1166-70. [Crossref] [PubMed]
83. Otsuka Y, Katagiri T, Ishii J, et al. Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy? J Hepatobiliary Pancreat Sci 2013;20:137-40. [Crossref] [PubMed]
84. Li J, Deng J, Li S, et al. Risk factors and clinical management of CO2 gas embolism in laparoscopic hepatectomy. Chinese Journal of Hepatic Surgery 2021;10:197-200. (Electronic Edition).
85. Ikegami T, Shirabe K, Yamashita Y, et al. Small upper midline incision for living donor hemi-liver graft procurement in adults. J Am Coll Surg 2014;219:e39-43. [Crossref] [PubMed]
86. Li J, Huang J, Wu H, et al. Laparoscopic living donor right hemihepatectomy with venous outflow reconstruction using cadaveric common iliac artery allograft: Case report and literature review. Medicine (Baltimore) 2017;96:e6167. [Crossref] [PubMed]
87. Zhang B, Pan Y, Chen K, et al. Laparoscopy-Assisted versus Open Hepatectomy for Live Liver Donor: Systematic Review and Meta-Analysis. Can J Gastroenterol Hepatol 2017;2017:2956749. [Crossref] [PubMed]
88. Rodrigues Armijo P, Huang CK, Carlson T, et al. Ergonomics Analysis for Subjective and Objective Fatigue Between Laparoscopic and Robotic Surgical Skills Practice Among Surgeons. Surg Innov 2020;27:81-7. [Crossref] [PubMed]
89. Armijo PR, Huang CK, High R, et al. Ergonomics of minimally invasive surgery: an analysis of muscle effort and fatigue in the operating room between laparoscopic and robotic surgery. Surg Endosc 2019;33:2323-31. [Crossref] [PubMed]
90. Liu R, Bie P, Hong D, et al. Clinical practice guidelines for robotic hepatopancreatobiliary surgery. Journal of Clinical Hepatology 2019;35:1459-71.
91. Cho CW, Choi GS, Kim KS. Surgical Techniques and Outcomes of Pure Laparoscopic Donor Right Posterior Sectionectomy for Living Donor Liver Transplantation. Liver Transpl 2022;28:325-9. [Crossref] [PubMed]
92. Cho CW, Choi GS, Lee DH, et al. Comparison of pure laparoscopic donor right posterior sectionectomy versus right hemihepatectomy for living donor liver transplantation. Liver Transpl 2023;29:1199-207. [Crossref] [PubMed]
93. Gómez-Gómez E, Carrasco-Valiente J, Valero-Rosa J, et al. Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects. Actas Urol Esp 2015;39:229-35. [PubMed]
94. Poudel S, Kurashima Y, Watanabe Y, et al. Impact of 3D in the training of basic laparoscopic skills and its transferability to 2D environment: a prospective randomized controlled trial. Surg Endosc 2017;31:1111-8. [Crossref] [PubMed]
95. Hong SK, Shin E, Lee KW, et al. Pure laparoscopic donor right hepatectomy: perspectives in manipulating a flexible scope. Surg Endosc 2019;33:1667-73. [Crossref] [PubMed]
96. Hong SK, Suh KS, Kim HS, et al. Pediatric Living Donor Liver Transplantation Using a Monosegment Procured by Pure 3D Laparoscopic Left Lateral Sectionectomy and In situ Reduction. J Gastrointest Surg 2018;22:1135-6. [Crossref] [PubMed]
97. Hong SK, Suh KS, Lee JM, et al. New Technique for Management of Separate Right Posterior and Anterior Portal Veins in Pure 3D Laparoscopic Living Donor Right Hepatectomy. J Gastrointest Surg 2020;24:462-3. [Crossref] [PubMed]
98. Hong SK, Suh KS, Kim HS, et al. Pure 3D laparoscopic living donor right hemihepatectomy in a donor with separate right posterior and right anterior hepatic ducts and portal veins. Surg Endosc 2017;31:4834-5. [Crossref] [PubMed]
99. Song JL, Wu H, Yang JY. Pure three-dimensional laparoscopic full left hepatectomy of a living donor for an adolescent in China. Chin Med J (Engl) 2019;132:242-4. [Crossref] [PubMed]
100. Tian F, Cao L, Chen J, et al. 3D laparoscopic anatomical hepatectomy guided by 2D real-time indocyanine green fluorescence imaging for hepatocellular carcinoma. Hepatobiliary Surg Nutr 2024;13:494-9. [Crossref] [PubMed]
101. Lim JSH, Shelat VG. 3D laparoscopy and fluorescence imaging can improve surgical precision for hepatectomy. Hepatobiliary Surg Nutr 2024;13:544-7. [Crossref] [PubMed]
102. Qiu D, Zhuang H, Han F. Effect and influence factor analysis of intrahepatic Glisson's sheath vascular disconnection approach for anatomical hepatectomy by three-dimensional laparoscope. J BUON 2017;22:157-61. [PubMed]
103. Au KP, Chok KSH. Minimally invasive donor hepatectomy, are we ready for prime time? World J Gastroenterol 2018;24:2698-709. [Crossref] [PubMed]
104. Cho JY, Han HS, Kaneko H, et al. Survey Results of the Expert Meeting on Laparoscopic Living Donor Hepatectomy and Literature Review. Dig Surg 2018;35:289-93. [Crossref] [PubMed]
105. Soubrane O, Kwon CH. Tips for pure laparoscopic right hepatectomy in the live donor. J Hepatobiliary Pancreat Sci 2017;24:E1-5. [Crossref] [PubMed]
106. Kim KH, Yu YD, Jung DH, et al. Laparoscopic living donor hepatectomy. Korean J Hepatobiliary Pancreat Surg 2012;16:47-54. [Crossref] [PubMed]
107. Zeng Y, Yang J, Liao M, et al. Key technique of laparoscopic living donor hepatectomy for liver transplantation. Chinese Journal of Practical Surgery 2017;37:500-4.
108. Kim J, Hong SK, Lim J, et al. Demarcating the Exact Midplane of the Liver Using Indocyanine Green Near-Infrared Fluorescence Imaging During Laparoscopic Donor Hepatectomy. Liver Transpl 2021;27:830-9. [Crossref] [PubMed]
109. Li H, Zhu Z, Wei L, et al. Laparoscopic Left Lateral Monosegmentectomy in Pediatric Living Donor Liver Transplantation Using Real-Time ICG Fluorescence In Situ Reduction. J Gastrointest Surg 2020;24:2185-6. [Crossref] [PubMed]
110. Imamura H, Kokudo N, Sugawara Y, et al. Pringle's maneuver and selective inflow occlusion in living donor liver hepatectomy. Liver Transpl 2004;10:771-8. [Crossref] [PubMed]
111. Park JB, Joh JW, Kim SJ, et al. Effect of intermittent hepatic inflow occlusion with the Pringle maneuver during donor hepatectomy in adult living donor liver transplantation with right hemiliver grafts: a prospective, randomized controlled study. Liver Transpl 2012;18:129-37. [Crossref] [PubMed]
112. Zhang HM, Wei L, Li HY, et al. Impact of pure laparoscopic surgery on bile duct division of living donor left lateral section procurement. Hepatobiliary Surg Nutr 2023;12:328-40. [Crossref] [PubMed]
113. Hong SK, Lee KW, Kim HS, et al. Optimal bile duct division using real-time indocyanine green near-infrared fluorescence cholangiography during laparoscopic donor hepatectomy. Liver Transpl 2017;23:847-52. [Crossref] [PubMed]
114. Meng X, Wang H, Xu Y, et al. Indocyanine green fluorescence image-guided total laparoscopic living donor right hepatectomy: The first case report from Mainland China. Int J Surg Case Rep 2018;53:406-9. [Crossref] [PubMed]
115. Lu L, Zhu WW, Shen CH, et al. The application of real-time indocyanine green fluorescence cholangiography in laparoscopic living donor left lateral sectionectomy. Hepatobiliary Surg Nutr 2024;13:575-85. [Crossref] [PubMed]
116. Rhu J, Kim MS, Choi GS, et al. A Novel Technique for Bile Duct Division During Laparoscopic Living Donor Hepatectomy to Overcome Biliary Complications in Liver Transplantation Recipients: "Cut and Clip" Rather Than "Clip and Cut". Transplantation 2021;105:1791-9. [Crossref] [PubMed]
117. Rotellar F, Ciria R, Wakabayashi G, et al. World Survey on Minimally Invasive Donor Hepatectomy: A Global Snapshot of Current Practices in 2370 Cases. Transplantation 2022;106:96-105. [Crossref] [PubMed]
118. Wu H, Yang J, Wei Y, et al. The application and surgical technique of laparoscopic hepatectomy in living donor liver transplantation:A report of 12 cases. Chinese Journal of Practical Surgery 2017;37:559-64.
119. Rhu J, Choi GS, Kim JM, et al. Feasibility of total laparoscopic living donor right hepatectomy compared with open surgery: comprehensive review of 100 cases of the initial stage. J Hepatobiliary Pancreat Sci 2020;27:16-25. [Crossref] [PubMed]
120. Broering DC, Berardi G, El Sheikh Y, et al. Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation. Ann Surg 2020;271:542-8. [Crossref] [PubMed]
121. Hong SK, Suh KS, Yoon KC, et al. The learning curve in pure laparoscopic donor right hepatectomy: a cumulative sum analysis. Surg Endosc 2019;33:3741-8. [Crossref] [PubMed]
122. Kim KH, Kang SH, Jung DH, et al. Initial Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy in an Experienced Adult Living Donor Liver Transplant Center. Transplantation 2017;101:1106-10. [Crossref] [PubMed]
123. Au KP, Chok KSH. Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm. World J Gastroenterol 2018;24:5081-94. [Crossref] [PubMed]