Impact of abdominal shape on living liver donor outcomes in mini‐incision right hepatic lobectomy: Comparison among 3 techniques

Abstract

Although minimally invasive techniques for living donor hepatectomy have been developed, the surgical feasibility and limitations remain to be elucidated. The risks and outcomes involved need to be better understood prior to their widespread application. The aim of this study was to assess feasibility of minimally invasive donor hepatectomy by reviewing our experience. A total of 99 living donor liver transplantations performed between 2000 and 2016 were retrospectively reviewed. All 99 living liver donors underwent right hepatectomy. The breakdown of the techniques is as follows: the standard technique in 33 patients; the laparoscopic-assisted minilaparotomy technique (hybrid technique group) in 19 patients; and the upper midline incision technique without laparoscopic assistance (minilaparotomy group) in 47 patients. An association between donor operative outcomes and body habitus, such as body mass index (BMI), abdominal truncal depth (approximated by celiac axis [CA] depth ratio), and umbilical circumference (UC) were assessed. Perioperative factors were compared between the standard technique and the minimally invasive technique. The minilaparotomy group had significantly shorter operative time (P = 0.046) and hospital stay (P = 0.005) than the standard technique group. Postoperative complication rates were similar between the 3 groups (P = 0.16). In the minilaparotomy group, greater BMI (P = 0.02), CA depth ratio (P = 0.04), and UC (P = 0.004) were found to be risk factors for postoperative complications. In the minilaparotomy group, CA depth ratio > 0.41, UC > 90 cm, and BMI > 30 kg/m were significantly associated with longer operative time and hospital stay. In the standard technique group, none of the body size factors were associated with postoperative outcomes. In conclusion, the minilaparotomy technique is safe and feasible, though technical difficulties may be encountered when performed on donors with larger body habitus. Ongoing efforts are required to ensure living donor safety. Liver Transplantation 24 516-527 2018 AASLD.

Laparoscopic donor hepatectomy

“…evaluated the impact of body habitus on perioperative donor outcomes in procedures using one of three different incisions (standard technique, hybrid technique, and mini‐laparotomy without laparoscopic assistance) and found that donors with a high BMI (>30), a large umbilical circumference (>90 cm), and a high celiac axis depth ratio (>0.41) had a longer operation time and hospital stay. These larger body habitus parameters were risk factors for higher postoperative complications in the mini‐laparotomy group .…”

“…Although the most challenging aspects of donor right hepatectomy can be performed through a midline incision in LADH, managing unexpected intraoperative events remains a major concern, especially in cases of vascular injury in the deep area . Indeed, surgical exposure in LADH depends largely on the thickness of the donor's abdominal wall and visceral fat.…”

Influence of Body Mass Index ≥30 on Pure Laparoscopic Donor Right Hepatectomy

“…Moreover, there are other factors that affect operative time other than the liver size. Anatomical variation in portal vein, hepatic vein, or bile duct may also prolong operative time [34,35] Abdominal muscularity or abdominal shape can also affect operative time [36]. Abdominal muscularity in donors with a low BMI could make abdominal inflation difficult, thereby providing a small working space.…”

The evolution of minimally invasive surgery in liver transplantation for hepatocellular carcinoma

“…Similarly, the muscle layer is not interrupted, and, as a result, patients feel less abdominal wall pain than with the open hepatectomy [69] . However, the small incision of these techniques has drawbacks for obese patients with deep body cavities, such as longer operative duration, postoperative complications, and longer hospital stay, as it is difficult for surgeons to manage vascular injuries in these deeper areas [68,70,71] . Recent meta-analyses associated laparoscopic-assisted hepatectomy with fewer complications, less blood loss and pain, no mortality, faster recovery, better cosmetic result, and longer operation time [70,72] .…”

“…However, the small incision of these techniques has drawbacks for obese patients with deep body cavities, such as longer operative duration, postoperative complications, and longer hospital stay, as it is difficult for surgeons to manage vascular injuries in these deeper areas [68,70,71] . Recent meta-analyses associated laparoscopic-assisted hepatectomy with fewer complications, less blood loss and pain, no mortality, faster recovery, better cosmetic result, and longer operation time [70,72] . In other words, laparoscopic-assisted hepatectomy is a safe and feasible alternative to open hepatectomy for well-selected donors when performed by experienced teams [73] and can be gradually adopted by less-experienced groups [74,75] .…”