Is laparoscopic liver resection applicable to donor hepatectomy?
Roberto I. Troisi
Ki Hun Kim
2014. To date, neither systematic reviews nor meta-analysis have been published on that matter.
TheMEDLINE,Embase,PubMedandCochranedatabasesweresearched. Thefollowingkeywordswereused:laparoscopic liver resection, laparoscopic donor hepatectomy, hybrid donor hepatectomy, fully laparoscopic living donor hepatectomy, single incision living donor hepatectomy, hand-assisted living donor hepatectomy, laparoscopic left lateral sectionectomy for living donor hepatectomy.
The literature search shows that 26 publications were found on that subject after withdrawal of few previous preliminary experiences from the same center. Most of the publications are single-center experience; there are only 9 comparative studies (one prospective), case-control studies and some casereports. Therefore, the level of evidence is classified as “LEVEL III”. The transplants performed with minimally invasive technique are both in pediatric (initial reports) and adult recipient population.
But, what stands out most from the analysis is the type of technique used. In fact, in addition to those previously defined in Louisville, minimally invasive (MI) techniquesare divided in: hybrid/hand-assisted, laparoscopic assisted including single-port incision and pure laparoscopic.
Both groups of techniques are divided for intraoperative and postoperative data. Two additional tables concerning comparative analysis are attached.
The publication year range from 2006 to 2014, with a peak between 2012 and 2014.
From the summarized tables (attached pdf file, tables 1 to 6) concerning the available data on case series of minimally invasive living donor hepatectomy, we can observe that:
-In the HALS-Hybrid procedures most of the grafts were right lobes (n=147, vs.13 Left lobes-LH). The blood loss (BL) range from 212 to 520 ml (1 extra U transfusion) with and operative time (OT) of 265 -702 min. No conversions were reported (Table 1). Postoperative data shows an hospital stay (HS) from 4.3-12 d, 0% mortality, complication rates between 0-25% and a reoperation rate ranging from 0-6.7% (Table 2).
-In the lap assisted/single incision groups, again more right lobes (n=88, vs. 37 LH and 18 LLS). The blood loss (BL) range from 200 to 870 ml (Transfusion 0-1.25 U). The OT is ranging from 278-435 min and the conversion rate is 0-10% (Table 3). The HS is 8-12 d, reoperation rate 0-5%, complications from 7.7-30% and no mortality reported (Table 4).
-Looking to the pure (fully laparoscopic) procedures, we notice that the great majority of grafts are LLS (n=110, vs. 12LH and 4RH). The BL is ranging from 18-410ml and no transfusions have been done. The OT is 275-605 ml and conversion rate of 0-13.3% (Table 5). The HS is ranging from 4-10.8 days, the reoperation rates from 0-25%, the complications rate from 0-33% and, again, no mortality has been reported (Table 6).
Nine comparative series between open and minimally invasive (MI) procedures (a mix of HA, hybrid and pure laparoscopic) are available at that moment, 2 out of 9 focusing on pure LLS for pediatric LDLT. Most of the grafts retrieved were right lobes (essentially performed with the HA and/or hybrid procedures), and precisely: 129 RH, 31 LH and 51 LLS.
From the 7 comparative series (table 7) including RH, LH and LLS using HA, lap assist and single-port incision, several end-points have been addressed as per below:
1-Morbidity: this was ranging from 0-28% (open) vs. 0-21.3% (MI);
2-Mortality: no mortality has been reported so far in that series;
3-Operation time: this was ranging from 303-383 min (open) vs. 265-435 min (MI). In 4/7 center series MI procedures taken a longer time; in three experiences a statistical significance was reached;
4-Blood loss: this was ranging from 250-733 ml (open) vs. 290-1033 ml (MI). In 4/7 of the comparative series, blood loss was less for MI procedures (in one experience, a statistical significance was reached);
5-Blood transfusions: only one series described differences in BT (0.5 U for open vs. 0.25 U for MI). In three other, no additional BT were required;
6-Regarding the management of postoperative pain, 4 out of 5 studies shows a less analgesics use in MI procedures (stat sign); two studies showed less need of additional analgesia (stat signif). Analgesia for pain: 5/7 series reported data. Need for epidural/analgesics ranging from 3.2-4.4 days in open vs. 2.4 vs. 3.2 in MI in three studies. Another showed a difference in hrs. between open and MI (56h vs. 47h respectively). A fifth group reported no differences. Time for extra analgesia was described in two studies showing a shorter treatment in MI (3.8 vs. 1.2 days respectively for open vs. MI), no differences in the second (2.4 and 2.5 days respectively for open and MI).
7-Hospital stay: this was ranging from 3.9 -18.3 days in open vs. 4.3 -11.8 days in MI;
8-Costs: this issue was assessed in 3 studies, all showing slightly increased costs with the MI procedures.
Two comparative seriesare available between pure laparoscopic LLS and standard procedures for pediatric LDLT (Table 8).
In one the morbidity is higher in open procedures (stat not signif) and the OT time is longer in pure laparoscopic procedures; BL is significantly less in the first study, almost comparable in the second study. Postoperative pain is comparable, HS shorter in one study in case of laparoscopic approach whereas the costs are slightly increased in case of open procedures (probably reflecting a longer hospital stay) in the other study.
Experts recommendations on Q6
-Different techniques for minimally invasive living donor hepatectomy have been used;
-Pure laparoscopic technique especially in LLS for pediatric LDLT, increasing procedure for LH grafts in A2ALDLT;
-Allavailable dataarecaseseries,case–controlstudies,comparative studies (only one prospective)
- An exponential increase of number of procedures and center experiences has been observed since 2012
- Despite the use of different MI techniques, no mortality has been reported with a comparable or lower morbidity respect to the standard approach
- Presently,there is a trend in favor of pure laparoscopicapproachfor LLS for pediatric LDLT which could be considered as a safe procedure with potential advantages brought by the laparoscopic technique
- Pure right donor hepatectomy still under evaluation (pending issues: higher morbidity linked to the graft volume retrieved or less stress and pain due to the MI technique)
- Comparativestudiessuggeststhat MI living donor hepatectomy is feasible with possibly less morbidity in teams that are familiar with both open living donor and laparoscopic liver resections
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Q6: Laparoscopic donor hepatectomy
Table 1. Hybrid (Living Donor) ~ Intra-operative data~
Table 2. Hybrid (Living Donor) ~ post-operative data~
Table 3. Pure (Living Donor) ~ Intra-operative data~
Table 4. Pure (Living Donor) ~ Post-operative data~