Establishing a safe and efficient pure laparoscopic donor hepatectomy program: a retrospective propensity score-matched cohort study from a second-generation adopter

Background: Pure laparoscopic donor hepatectomy (PLDH) is the most advanced minimally invasive approach for living donor liver transplantation (LDLT). However, concerns regarding donor safety, steep learning curve, and biliary complications have limited their broader use. We report on the structured implementation of PLDH at a second-generation adopting institution. Methods: This study was a retrospective review of 107 consecutive living donor hepatectomies performed between March 2018 and July 2025, including 75 PLDHs and 32 open donor hepatectomies (ODHs). Propensity score matching (1:1) was performed to compare donor and recipient outcomes. Operative metrics, major donor complications (Clavien–Dindo ≥IIIa), recipient biliary complications, and survival were analyzed. Learning curve assessment employed a cumulative sum (CUSUM) analysis. Results: After matching, major complications occurred in 3.1% of PLDH donors and 9.4% of ODH donors ( P = 0.606; absolute risk difference, −6.3 percentage points; 95% CI, −18.7 to 6.2). PLDH was associated with significantly lower estimated blood loss and shorter operative time. Dual CUSUM analysis identified inflection points at 25 and 50 cases in this institutional cohort. No independent predictors of major donor complications were identified in this study. Recipient biliary complications occurred in 12.5% of patients in the PLDH group. Using standardized protocols, PLDH may be feasibly implemented in selected second-generation centers as a minimally invasive alternative in LDLT. Conclusions: A structured, protocol-driven approach may support the safe implementation of PLDH in selected second-generation centers. In this institutional cohort, the observed learning curve inflection points at 25 and 50 cases may provide practical, institution-specific guidance for the structured implementation of PLDH in similar high-volume settings.