Left Lobe First with Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation
Masato Fujiki1, Alejandro Pita1, Munkhbold Tuul1, Jiro Kusakabe1, Taesuk You1, Kazunari Sasaki2, Federico Aucejo1, Cristiano Quintini4, Bijan Eghtesad1, Antonio Pinna3, Charles Miller1, Koji Hashimoto1, Choon Hyuck D. Kwon*1
1Department of Surgery, Cleveland Clinic, Cleveland, OH; 2Department of Surgery, Stanford University, Stanford, CA; 3Cleveland Clinic Florida, Weston, FL; 4Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Objective: A left-lobe graft (LLG) first approach decreases the risk to donors in adult living donor liver transplantation (LDLT). Similarly, a purely laparoscopic approach has been used to reduce surgical insult for donors. We herein report our strategy to minimize donor risk by applying LLG first combined with a purely laparoscopic approach in a single north American transplant center.
Methods: From 2012-2022, 216 consecutive LDLT were performed with 104 laparoscopic and 112 open donations. LLGs with caudate lobe and middle hepatic vein (H1234-MHV) were considered first in adult LDLT when graft-to-recipient weight ratio ≥ 0.6%. Right-lobe grafts (RLG)(H5678) were our second choice when the remnant volume was ≥ 30%. After excluding left lateral segment graft and posterior section graft cases, 188 LDLT with 92 laparoscopic and 96 open hemiliver donations were included in the study.
Results: LLG first approach was implemented in 2013. All donations until August 2019 were done by open approach. Following 4 months of the adoption process, all donor hepatectomies since December 2019 were performed laparoscopically, including 19 grafts (21 %) with biliary and/or portal vein anatomical variance (Figure). There was only one intra-operative conversion to open (1 %) on a case with portal vein anatomical variance. Mean operative times were similar in laparoscopic and open cases (368 vs. 359 minutes) but the laparoscopic approach provided shorter hospital stay, lower blood loss, and lower peak AST. Peak bilirubin was lower in LLG donors compared to RLG donors (1.4 mg/dL vs. 2.4 mg/dL, p<0.01), and the laparoscopic approach further alleviated the hepatic insult in LLG donors (peak bilirubin, 1.1 vs. 1.6 mg/dL, p<0.01) (Table). The laparoscopic cases also afforded a lower 90-day complication rate (Clavien-Dindo grade ≥ II, 8% vs 20%, p=0.03) and a lower rate of late complications including hernia that required surgery (0% vs 10 %, p<0.01) compared to open cases. Transfusion was required in 2 open RLG-donors. In terms of graft outcomes, LLG was more likely to have a single duct than RLG (88 % vs. 59 %, p<0.01). By selecting LLG instead of RLG, multiple ducts could be avoided in 24 of 91 LDLT (26 %). Despite the aggressive use of LLG in 49 % of adult LDLT, small-for-size syndrome occurred in only one case (0.5%), and favorable 1-year graft survival of 92% was achieved without any differences due to graft (LLG vs. RLG) or donation type (laparoscopic vs. open).
Conclusions: The LLG first combined with a purely laparoscopic approach minimizes the insult to donors in adult LDLT and can maximize safety without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.
|Peak AST, IU/L [IQR]||430 [351- 529]||256 [232- 308]||<0.01||435 [283- 576]||223 [193- 265]||<0.01|
|Peak bilirubin,mg/dL||2.4 [1.8- 3.4]||2.5 [1.6- 3.7]||0.85||1.6 [1.4- 2.0]||1.1 [0.8- 1.5]||<0.01|
|Hospital stay, days||6 [5- 7]||5 [4- 6]||<0.01||6 [5-6]||5 [4- 5]||<0.01|
|90-day complication rate (%)|
|Clavien-Dindo Grade I||17||5||23||6|
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