Laparoscopy was introduced in liver surgery in the 1990s and was rapidly adopted worldwide.1 The minimally invasive approach for a purely ablative procedure was appealing with respect to limiting patient trauma and eventually reducing total morbidity. The operation was extended from simple resections in benign disease to more complex interventions in patients with abnormal livers. Laparoscopic hepatectomy (LH) in cirrhosis was appealing as a minimally morbid way of controlling local disease in hepatocellular carcinoma with complete anatomic resection. A recent meta-analysis has collected over 9000 cases of LH in the world literature.2
The appeal of laparoscopy for live donor liver transplantation (LDLT) includes a smaller scar and decreased surgical trauma with more rapid return to normal activities. Although removal of a tumor bearing section of liver can be accomplished with limited anatomic precision and stapled transection, the dissection and extraction of a transplantable graft requires a much more sophisticated technical approach. The extension of laparoscopic hepatectomy to living donation was first reported by Cherqui et al3 in 2002. Due to its peripheral position, accessibility of the vascular pedicle, and relatively thin parenchymal section, the left lateral section is the most readily performed of the formal hepatectomies. With subsequent evolution, it has been proposed that LH should become the standard for pediatric live donor transplantation, and that safety approaches that of donor nephrectomy for renal transplantation.4
Although left lateral sectionectomy is standard for LDLT in children graft size is rarely adequate for adult recipients. For adult to adult LDL, the right or left hemiliver is required, and the hepatectomy has a much larger plane of transection, a more complex vascular and biliary dissection, and a larger specimen to remove from the body. The large graft must be removed rapidly and atraumatically from the donor to ensure optimal function in the recipient. The first attempts to extend LH in adult to adult LDLT were done using a hybrid approach, in which the dissection is begun laparoscopically, completed with an open incision through which the graft is extracted.5 Although the hybrid operation results in a smaller incision, it is not clear that the procedure is less morbid overall than a highly regimented open procedure.6 The final step was the development of fully laparoscopic resection of the left or right lobe for donation. Fully laparoscopic left hepatectomy has been successfully performed with demonstration of more rapid recovery from surgery when compared with open resection.7 Fully laparoscopic right hepatectomy has also been reported by Soubrane et al8 in 2013.
In this issue of Transplantation, we are pleased to publish the first series of fully laparoscopic right lobe donor hepatectomies compared with a reference group of open right hepatectomies for donation from a single center.9 The authors have rightly emphasized that this is not simply a technical achievement, but the result of a highly effective team effort. Though the experience is small, the results are promising although several cautions are in order. The operation is highly technically challenging, and only a small number of teams currently possess the capability to carry this out. Second, the feasibility of LH for both right and left hepatectomy is affected by the size of the patient and the size, texture, and shape of the liver. This issue affects patient selection and might limit the applicability of LH to a small fraction of the candidate pool.
The demonstration of the safety of LH will require much larger numbers than the pilot experiences we have seen to date, with generalizability to a large number of centers. This important work must continue to increase the safety of donation, and by creating a less morbid procedure, to increase the acceptability of liver donation for a larger number of potential candidates. In addition to LH, other technologies, such as robotic hepatectomy,10 might prove to be an alternative means to the end of safe, minimal harm donation of the liver.
1. Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg
2. Ciria R, Cherqui D, Geller DA, et al. Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. Ann Surg
3. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet
4. Soubrane O, de Rougemont O, Kim KH, et al. Laparoscopic living donor left lateral sectionectomy: a new standard practice for donor hepatectomy. Ann Surg
. 2015;262:757–761. discussion 61–3.
5. Baker TB, Jay CL, Ladner DP, et al. Laparoscopy-assisted and open living donor right hepatectomy: a comparative study of outcomes. Surgery
. 2009;146:817–823. discussion 23–5.
6. 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
7. 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
8. Soubrane O, Perdigao Cotta F, Scatton O. Pure laparoscopic right hepatectomy in a living donor. Am J Transplant
9. Rotellar F, Benito A, Zozaya G, et al. Totally laparoscopic right hepatectomy for living donor liver transplantation. Analysis of a preliminary experience on 5 consecutive cases. Transplantation
10. Chen PD, Wu CY, Hu RH, et al. Robotic liver donor right hepatectomy: a pure, minimally invasive approach. Liver Transpl