Open to robotic right donor hepatectomy: A tectonic shift in surgical technique

Abstract

Robotic right live donor hepatectomy (r‐LDRH) has been reported with reduced morbidity compared to open donor right hepatectomy (o‐LDRH) in few recent series. Nevertheless, its routine use is debated. We present a large series comparing pure r‐LDRH with o‐LDRH. Consecutive r‐LDRH performed from June 2018 to June 2020 (n = 102) were compared with consecutive donors undergoing o‐LDRH (n = 152) from February 2016 to February 2018, a period when r‐LDRH was not available at this center. Propensity score matched (PSM) analysis of 89 case‐control pairs was additionally performed. Primary endpoints were length of high dependency unit (HDU) and hospital stay and Clavien‐Dindo graded complications among donors. Although r‐LDRH took longer to perform (540 vs. 462 min, P < .001), the postoperative peak transaminases levels (P < .001), the length of HDU (3 vs. 4 days, P < .001), and hospital stay (8 vs. 9 days, P < .001) were lower in in donors undergoing r‐LDRH. Clavien‐Dindo graded complications were similar (16.67% in r‐LDRH and 13.16% in o‐LDRH). The rates of early allograft dysfunction (1.6% vs. 3.3%), bile leak (14.7% vs. 10.7%), and 1‐year mortality (13.7% vs. 11.8%) were comparable between r‐LDRH and o‐LDRH recipients. PSM analysis yielded similar results between the groups. These data support the safety and feasibility of r‐LDRH in select donors.

International experts consensus guidelines on robotic liver resection in 2023

“…We systematically reviewed 4 studies that investigated the safety and feasibility of robotic and open living donor hepatectomy, with a total of 972 patients being included in the meta-analysis[ 41 , 66 - 68 ]. The pooled results suggested that RLR had lower postoperative peak serum bilirubin (SMD = -0.59, 95%CI: -0.81 to -0.37; P < 0.0001), shorter postoperative hospital stays (SMD = -0.53, 95%CI: -0.90 to -0.17; P = 0.004) and a longer operative time (SMD = 1.45, 95%CI: 0.66 to 2.25; P = 0.003) compared to the open group[ 41 , 66 - 68 ]. There were no significant differences in terms of other donor and recipient outcomes.…”

“…For robotic living donor hepatectomy, there is a better body image, improved cosmetic appearance, and fewer wound-related complications[ 41 ]. Living donor hepatectomy is considered to be the pinnacle of hepatobiliary surgery, which requires assurance of donor survival, good graft status and minimization of associated complications[ 66 ]. Based on the currently available studies, RLR reduced postoperative pain, resulted in rapid donor recovery and with similar postoperative complications[ 41 , 66 - 68 ].…”

“…Living donor hepatectomy is considered to be the pinnacle of hepatobiliary surgery, which requires assurance of donor survival, good graft status and minimization of associated complications[ 66 ]. Based on the currently available studies, RLR reduced postoperative pain, resulted in rapid donor recovery and with similar postoperative complications[ 41 , 66 - 68 ]. However, studies comparing RLR with LLR are insufficient[ 41 ].…”

“…However, studies comparing RLR with LLR are insufficient[ 41 ]. In summary, RLR for living donor hepatectomy is feasible and safe when performed by surgeons with both excellent knowledge of liver anatomy and long experience of open living donor hepatectomy[ 41 , 66 ]. However, biliary complications are a problem that should never be ignored.…”

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

“…[66][67][68][69] In a retrospective observational study, the SFSS rate was 6.6% in robotic (n = 102) and 4.6% in open (n = 152) RL donor hepatectomy, which was not statistically significant. 70 Although there is currently no evidence to suggest that minimally invasive donor hepatectomy impacts on the SFSS in the recipients, caution should be exercised in selecting these donors because an SFSG in this setting may also be associated with additional graft factors, including longer donor warm ischemia time, short vessels, and potentially higher biliary complications. [71][72][73] As part of the donor factors, the working group also reviewed the evidence for donor ethnicity as a variable influencing SFSS.…”