Advancing RAPID Toward Minimally Invasive Surgery: The First Proof of Concept of Laparoscopic Second-Stage Completion Hepatectomy

Background: The RAPID procedure combines partial liver transplantation with delayed completion hepatectomy, allowing transplantation of small left-sided grafts while limiting living-donor hepatectomy. Although minimally invasive techniques are increasingly applied in liver transplantation, the second stage of RAPID has been performed through an open approach. We report a single-center case series of seven consecutive patients who underwent RAPID, with emphasis on laparoscopic second-stage completion hepatectomy. Methods: The RAPID procedure consists of left hepatectomy and implantation of a living-donor left lateral section or left lobe graft followed, after graft regeneration, by completion hepatectomy. Technical refinements include microwave ablation along the transection plane, reinforcement of the hepatic venous anastomosis with an autologous saphenous vein ring, and a laparoscopic approach to the second stage whenever technically feasible. The study was conducted within the RAPID-Padova protocol (NCT04865471). Results: Seven patients underwent RAPID: six for unresectable colorectal liver metastases and one for unresectable neuroendocrine liver metastasis. The median graft-to-body-weight ratio increased from 0.51% after step 1 to 0.92% before step 2, with a median graft-volume increase of 90%. Median time to step 2 was 19 days. Step 2 was completed laparoscopically in six of seven patients without conversion; one patient underwent a planned open completion hepatectomy to reposition and anchor the graft. Major complications (≥IIIa) occurred in five patients (median CCI 39.7), including three hepatic vein stenoses requiring endovascular stenting. Median follow-up was 30.7 months. Recurrence occurred in five of six patients with CRLM; 1-year and 3-year overall survival were 85.7% and 71.4%. Conclusions: In this selected series, laparoscopic completion hepatectomy within the RAPID procedure was technically feasible. No complication was directly attributable to the laparoscopic access, although the small sample does not allow a comparison with the open approach.