Mini-incision right hepatic lobectomy with or without laparoscopic assistance for living donor hepatectomy

Abstract

Minimally invasive procedures are considered to be safe and effective approaches to the management of surgical liver disease. However, this indication remains controversial for living donor hepatectomy. Between 2000 and 2011, living donor right hepatectomy (LDRH) was performed 58 times. Standard right hepatectomy was performed in 30 patients via a subcostal incision with a midline extension. Minimally invasive procedures began to be used for LDRH in 2008. A hybrid technique (hand-assisted laparoscopic liver mobilization and minilaparotomy for parenchymal dissection) was developed and used in 19 patients. In 2010, an upper midline incision (10 cm) without laparoscopic assistance for LDRH was innovated, and this technique was used in 9 patients. The perioperative factors were compared, and the indications for minimally invasive LDRH were investigated. The operative blood loss was significantly less for the patients undergoing a minimally invasive procedure versus the patients undergoing the standard procedure (212 versus 316 mL, P ¼ 0.001), and the operative times were comparable. The length of the hospital stay was significantly shorter for the minimally invasive technique group (5.9 versus 7.8 days, P < 0.001). The complication rates were 23% and 25% for the standard technique and minimally invasive technique groups, respectively (P ¼ 0.88). Patients undergoing minilaparotomy LDRH had a body mass index (24.0 kg/m 2 ) similar to that of the hybrid technique patients (25.8 kg/m 2 , P ¼ 0.36), but the graft size was smaller (780 versus 948 mL, P ¼ 0.22). In conclusion, minimally invasive LDRH can be performed without safety being impaired. LDRH with a 10-cm upper midline incision and without laparoscopic assistance may be appropriate for donors with a smaller body mass. Laparoscopic assistance can be added as needed for larger donors. This type of LDRH with a 10-cm incision is innovative and is recommended for experienced centers.

Evolution and revolution of laparoscopic liver resection in Japan

“…Although current evidence does not indicate which of these approaches is best, HALS and hybrid method are claimed by their proponents to be beneficial for large lesions,9, 56 posterior lesions57, 58 and donor hepatectomy 59, 60, 61, 62, 63, 64. HALS and the hybrid method can be used to manage intraoperative difficulties and can theoretically decrease the frequency of conversion to full open incision.…”

A hybrid method of laparoscopic-assisted open liver resection through a short upper midline laparotomy can be applied for all types of hepatectomies

“…Some authors reported the feasibility of major hepatectomy under midline incision including living donor hepatectomy (18,19). Lee et al concluded that the procedure after an upper midline incision is more difficult in male donors with large fatty livers and deep truncal cavities.…”

Minimally Invasive Living Donor Hepatectomy

“…Specifically in patients with low BMI (< 25 or less) and small anterior/posterior diameter, certain surgeons have described an upper midline approach through which they are able to accomplish complete mobilization of the right lobe from its retroperitoneal attachments and off the right side of the vena cava [22]. They then proceed with hilar dissection and transection of the liver using a hanging maneuver similar to what is described in the laparoscopically assisted approach.…”

“…-laparoscopic left lateral segmentectomy [1,2] -laparoscopic hand-assisted right hepatectomy [13,16] -laparoscopic hand-assisted right hepatectomy using midline incision "Hybrid Method" [17,18,19•] -laparoscopic hand-assisted right hepatectomy using a transverse or subcostal incision [13,20] -single port laparoscopic-assisted right hepatectomy using a right subcostal incision [20] -right hepatectomy through upper midline laparotomy [11,21] -right hepatectomy through an upper midline minilaparotomy with or without laparoscopic assistance [22] -totally laparoscopic full left hepatectomy [23•] -pure laparoscopic right hepatectomy [3] -robot-assisted right hepatectomy [24•] In this chapter, we will describe the advantages and disadvantages of some of the important variations of these minimally invasive approaches to donor hepatectomy. Table 1 provides a descriptive overview and comparison of these approaches.…”