Diaphragmatic herniation following donor hepatectomy for living donor liver transplantation: a serious complication not given due recognition

Abstract

A clear appreciation of benefits and risks associated with living donor hepatectomy is important to facilitate counselling for the donor, family, and recipient in preparation for living donor liver transplant (LDLT). We report a life-threatening complication occurring in one of our live liver donors at 12 weeks following hemi-liver donation. We experienced five donor complications among our first 50 LDLT: Clavien Grade 1, n=1; Clavien grade 2, n=3; and Clavien grade 3B, n=1. The one with Clavien grade 3B had a life-threatening diaphragmatic hernia occurring 12 weeks following hepatectomy. This was promptly recognized and emergency surgery was performed. The donor is well at 1-year follow-up. Here we provide a review of reported instances of diaphragmatic hernia following donor hepatectomy with an attempt to elucidate the pathophysiology behind such occurrence. Life-threatening donor risk needs to be balanced with recipient benefit and risk on a tripartite basis during the counselling process for LDLT. With increasing use of LDLT, we need to be aware of such life-threatening complication. Preventive measures in this regard and counselling for such complication should be incorporated into routine work-up for potential live liver donor.

Adult Bochdalek hernia following living donor left hepatectomy repaired by thoracoscopy‐assisted surgery: A case report

“…The characteristics in reported cases with DH following living donor hepatectomy are summarized in Table 1. [2][3][4][5][6][7][8][9][10] The results including our case showed that DH developed following right hepatectomy in 11 donors and left hepatectomy in two donors. The interval between donor hepatectomy and the development of DH was from 20 days to 60 months.…”

“…3 Mostly, DH following liver resection could be caused by iatrogenic diaphragm injury during the mobilization of the liver with electrocautery. 4,5 In the field of living donor liver transplantation, the incidence of overall complications following donor hepatectomy has accounted for approximately 20% to 40% of cases. 6 Out of various donor complications, DH following donor hepatectomy is rare.…”

“…Thus far, there have been only nine publications with 12 cases reporting on acquired DH following living donor hepatectomy. [2][3][4][5][6][7][8][9][10] However, no study has reported on Bochdalek hernia following living donor hepatectomy.…”

Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

“…A possible explanation was that the excessive use of thermal electric cautery and argon beamer applied to the thin and vulnerable bare area during right liver mobilization in order to secure hemostasis might have led to the development of a secondary ADH, in addition to concomitant increase of post-operative abdominal pressure on an uncovered diaphragm (especially in the two cases of pregnancies). Up to now, 12 publications have described the occurrence of DH in 22 live donors [ 1 , 2 , 5 , 7 , 13 - 20 ], with an incidence ranging from 1.6% to 2.7% ( Table 2 ). Findings are concordant, as it is often a late complication after RH in living donor patients caused by chronic elevation of abdominal pressure on an uncovered diaphragm which is subjected to a thermic injury during surgery.…”

“…These observations underline the delayed occurrence and progressive enlargement of defect in a heathy population who undergo RH for live donation and interrogates about the need for systematic surgical repair. Literature is rather scare about ADH after RH for donation probably because of unrecognized cases and the lack of long term follow-up of these patients [ 13 ]. Based on observations of Oh et al [ 7 ], surgical repair of asymptomatic ADH should probably be mandatory before defects get larger and symptomatic.…”