Comparing purely laparoscopic versus open living donor right hepatectomy: propensity score-matched analysis

Dear Editor Living donor liver transplantation has been widely accepted as an effective treatment modality for end-stage liver disease in the setting of shortage of cadaveric organ donations. Because donor hepatectomy is not a surgical procedure under pathological conditions, it is important to consider the quality of life of living donors, such as postoperative complications, pain, and the cosmetic effect. Since its initiation in 20021, laparoscopic donor hepatectomy has been performed increasingly in some centres2–4. The aim of this study was to compare the results of purely laparoscopic living donor right hepatectomy (LLDRH) and conventional open living donor right hepatectomy (OLDRH) to evaluate the safety and efficacy of laparoscopy in this setting. Among donor candidates who satisfied the criteria for donation of the right liver at Asan Medical Centre, candidates for LLDRH were selected according to defined criteria: single and longer segments (at least 1 cm) in the right hepatic artery, right portal vein, and right hepatic duct; three or fewer inferior hepatic veins to be reconstructed; and graft weight 700 g or less5. Between November 2014 and November 2019, a total of 90 LLDRHs and 1593 OLDRHs were performed. For comparison and to reduce selection bias, 1 : 1 propensity score matching was done. The perioperative clinical outcomes are summarized in Table 1. There was no conversion to open surgery during LLDRH. Operating time was longer, estimated blood loss was lower, and hospital stay was shorter in the laparoscopic cohort. There were no reported complications and no readmissions to hospital in the LLDRH group. There were two instances of fever of unknown origin and two wound problems in the OLDRH group. No statistically significant difference was demonstrated in complication rates between the two groups. Preoperative characteristics and postoperative outcomes of donor and recipient cohorts Values in parentheses are percentages unless indicated otherwise; *values are mean(s.d.). LLDRH, laparoscopic living donor right hepatectomy; OLDRH, open living donor right hepatectomy. χ2 test, except Indepentent t-test and Fisher’s exact test. Preoperative characteristics and postoperative outcomes of donor and recipient cohorts Values in parentheses are percentages unless indicated otherwise; *values are mean(s.d.). LLDRH, laparoscopic living donor right hepatectomy; OLDRH, open living donor right hepatectomy. χ2 test, except Indepentent t-test and Fisher’s exact test. Careful case selection is believed to be the reason for absence of conversions to open surgery and the lack complications in the LLDRH group. The authors sometimes offer LLDRH beyond the reasonable criteria when donors and their families express a strong wish for laparoscopic donor hepatectomy. However, unlike the left liver graft, the right graft has a large volume and many variations in biliary and vascular anatomy, so a reasonable indication is required. Additionally, it is more important to do well without complications than to undertake LLDRH without contraindications. Biliary complication is one of the most common morbidities of living donor liver transplantation, and bile duct division is a crucial step in the donor hepatectomy. The authors usually employ indocyanine green (ICG) near-infrared fluorescence cholangiography and conventional real-time fluoroscopic intraoperative cholangiography, with use of the C-arm to determine bile duct structure accurately. With these efforts, it was possible to reduce biliary complications among both recipients and donors to the level of those in OLDRH. According to another report in which ICG cholangiography was used only during bile duct division4, the biliary complication rate among recipients was higher in laparoscopic group, and the number of patients with multiple bile duct openings was almost twice as high in the laparoscopic group as expected based on preoperative magnetic resonance cholangiopancreatography findings. To see the biliary tree clearly under ICG cholangiography, the bile duct surrounded by the capsule should be dissected, which may lead to biliary complications in donors and recipients. ICG cholangiography may miss an aberrant bile duct and may not provide a clean biliary tree. Therefore, it may be better to combine both ICG cholangiography and intraoperative cholangiography. Based on the present series, the authors recommend laparoscopy in carefully selected patients following a set of criteria. Disclosure. The authors declare no conflict of interest.