Laparoscopic donor hepatectomy.

Laparoscopic liver resection has been applied to treat most indications for liver resection during the past two decades. According to the literature, patient numbers have increased exponentially as a result, and surgical difficulty has increased as well. In expert centers, laparoscopic anatomical hemihepatectomy and major liver resection more than 3 segments have become the acceptable treatment. Moreover, with surgical innovations and accumulated experience, living donor liver transplantation has become an established treatment choice for patients on the transplant waiting list. It is even considered an inevitable choice in regions with limited access to organs from deceased donors. However, significant morbidity and rare but catastrophic mortality are associated with donor hepatectomy and remain major concerns. Therefore, to decrease the incidence of complications, a minimally invasive approach in donor hepatectomy was adopted in the early 2000s. Initially, a minimally invasive approach was used for left lateral sectionectomy for pediatric liver transplant, then for laparoscopy-assisted hemihepatectomy and pure laparoscopic/robotic right donor hepatectomy, and more recently, for adult living donor liver transplantation. The extent of procedure complexity and potential complications depends on the approach and the size of the graft to be harvested. Early results from expert teams have seemed promising in terms of shortened donor recovery and improved perioperative outcomes. However, the combination of these two highly sophisticated surgical procedures raise more concerns about donor safety, especially with regard to unexpected events during the operation. A high level of evidence is very difficult to achieve in this highly specialized surgical practice with limited penetration. Therefore, an international registry has been suggested to determine the risks and benefits before the use of laparoscopic right donor hepatectomy spreads.

Totally laparoscopic living donor right hepatectomy in a donor with trifurcation of bile duct.

Donor operation in adult living donor liver transplantation is associated with significant postoperative morbidity. To avoid laparotomy wound complications and shorten postoperative recovery, laparoscopic liver graft harvest has been developed recently. However, to determine the cut point of bile duct is challenging. Herein, we report the application of totally laparoscopic approach for right liver graft harvest in a donor with trifurcation of the bile duct. A19-year-old man volunteered for living donation to his father who suffered from hepatitis B virus-related cirrhosis of liver and hepatocellular carcinoma. The graft was 880 mL with a single right hepatic artery and portal vein. The graft to recipient weight ratio was 1.06. The middle hepatic vein was preserved for the donor and the liver remnant was 42.3%. Two branches of middle hepatic veins were > 5 mm in diameter and needed reconstruction with cryopreserved allograft. Ductoplasty using laparoscopic intracorporeal suture technique was done to achieve single orifice of the graft bile duct. The postoperative course was uneventful for the donor. This report adds evidence of the feasibility of pure laparoscopic right donor hepatectomy and describes the necessary steps for bile duct division in donors with trifurcation of bile duct.

Robotic left hepatectomy with revision of hepaticojejunostomy.

Laparoscopic hepatectomy and hepaticojejunostomy remain a surgical challenge despite the recent advances in minimally invasive surgery. A robotic surgical system has been developed to overcome the inherent limitations of the traditional laparoscopic approach. However, techniques of robotic hepatectomy have not been well described, and a description of robotic major hepatectomy with bilioenteric anastomosis can be found only in two previous reports. Here, we report a 33-year-old man with a history of choledochocyst resection. The patient experienced repeat cholangitis with left hepatolithiasis during follow-up. Robotic left hepatectomy and revision of hepaticojejunostomy were performed smoothly. The patient recovered uneventfully and remained symptoms-free at a follow-up of 20 months. The robotic approach is beneficial in the fine dissection of the hepatic hilum and revision of hepaticojejunostomy in this particular patient.