|Year : 2019 | Volume
| Issue : 2 | Page : 170-173
Laparoscopic donor hepatectomy: First experience from Indian sub-continent
Natesan Anand Vijai1, Palanisamy Senthilnathan1, Vikram Annamaneni1, Sandeep C Sabnis1, Arvinder Singh Soin2, Chinnusamy Palanivelu1
1 Department of Surgical Gastroenterology, HPB Surgery and Liver Transplantation, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
2 Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicity, Gurugram, Haryana, India
|Date of Submission||08-Jun-2018|
|Date of Acceptance||19-Jun-2018|
|Date of Web Publication||12-Mar-2019|
Dr. Sandeep C Sabnis
Department of Surgical Gastroenterology, HPB Surgery and Liver Transplantation, GEM Hospital and Research Center, 45/A, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641 045, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Liver transplantation is a ray of hope for thousands of patients with end-stage liver disease but is currently challenged by the scarcity of donor organs worldwide. Unlike kidney transplantation where minimally invasive donor organ procurement has almost become a norm, laparoscopic procurement of hemi-liver from a living donor is still in the infancy of development, at least in the Indian sub-continent. Minimally invasive surgery has made its way into different procedures of hepatobiliary and pancreatic surgery, but only a few centres in the world are performing pure laparoscopic donor hepatectomy. We report two cases of total laparoscopic donor hepatectomy, and to the best of our knowledge, this is the first report from Indian sub-continent.
Keywords: Chronic liver disease, laparoscopic donor hepatectomy, laparoscopic liver resection, liver transplantation, living donor, transplantation
|How to cite this article:|
Vijai NA, Senthilnathan P, Annamaneni V, Sabnis SC, Soin AS, Palanivelu C. Laparoscopic donor hepatectomy: First experience from Indian sub-continent. J Min Access Surg 2019;15:170-3
|How to cite this URL:|
Vijai NA, Senthilnathan P, Annamaneni V, Sabnis SC, Soin AS, Palanivelu C. Laparoscopic donor hepatectomy: First experience from Indian sub-continent. J Min Access Surg [serial online] 2019 [cited 2019 Mar 23];15:170-3. Available from: http://www.journalofmas.com/text.asp?2019/15/2/170/238780
| ¤ Introduction|| |
The area of liver transplantation has witnessed many innovations since its active application to treat conditions of irreversible liver damage. It has been a life-saving procedure for patients with end-stage liver disease and liver malignancies but limited by the availability of donor's liver. The donor pool has been expanded with the legal permission to donate liver by living donors but is not without considerable anxiety to the donor and family members. Conventionally, organ procurement from live donors is performed using open surgical methods. The literature on the application of laparoscopy to liver transplantation is relatively sparse compared to other hepatobiliary and pancreatic procedures, with centres having a decent experience of laparoscopic liver resections being published their data.
India, predominantly dependent on cadaver organ pool, is moving towards live organ donation, and it is believed that minimal access surgery for donor hepatectomy can increase the contribution from living donors by alleviating the anxiousness to some extent due to its advantages of minimal morbidity, shorter hospital stay and cosmetic benefits. This article is to share our initial experience of two cases of laparoscopic living-donor hepatectomy, which is probably the earliest from the Indian subcontinent.
| ¤ Report of Cases|| |
A 36-year-old gentleman suffering from the chronic liver disease (alcohol-related) with a model for end-stage liver disease (MELD) score of 20 was planned for liver transplantation. His 34-year-old wife volunteered for liver donation, having a body mass index of 24.9 kg/m2. The next case, a 17-year-old girl, was found to have the chronic liver disease due to primary biliary cirrhosis (MELD score - 18) and scheduled for liver transplantation. Her 40-year-old mother with body mass index of 22.6 kg/m2 volunteered for liver donation. Both donors were evaluated, and no vascular or biliary anomalies were found on imaging. Ultrasound-guided tru-cut biopsy confirmed no evidence of steatosis or fibrosis.
Patient position and anaesthesia
Under general anaesthesia, the patient is placed in supine position with legs abducted, the left arm tucked in, and a sandbag is placed behind right hemi-thorax/shoulder. Central venous access and right radial artery cannulation are obtained for invasive blood pressure monitoring. After skin preparation with povidone-iodine solution, the patient is draped. Primary surgeon stands in between the legs and on the left side of the patient depending on the requirement of dissection while camera surgeon on the right side and assistant surgeon position on the left side of the patient.
Access and mobilisation
Pneumoperitoneum with carbon dioxide is created using a Veress needle, and a 12-mm umbilical port is placed. A general survey of the abdomen and liver is performed using 30° angled scope, and other ports are made under vision. A 10-mm port in the right subcostal region, one 5-mm port in the right axillary area, one 5-mm port in the right subcostal region and another 5-mm epigastric port are placed for liver retraction. Ports are shown in [Figure 1]a. Falciform ligament is mobilised and divided near umbilicus; right triangular and coronary ligaments are divided [Figure 2]a and the peritoneum over suprahepatic inferior vena cava is incised and the space created between right and middle hepatic vein.
|Figure 1: Position of the ports (a) (upper picture) and delivery of right hemi-liver (b) (lower picture)|
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|Figure 2: Clockwise from left upper corner, (a) division of right triangular ligament, (b) Foley's catheter is being passed for hanging manoeuver, (c) transection in progress using cavitron ultrasonic surgical aspirator and (d) demarcation of a line of the division after indocyanine green injection|
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Cholecystectomy is performed by retracting fundus of the gallbladder. Cystic duct and artery are skeletonised, clipped and divided. Cystic duct is cannulated, and cholangiogram is performed to confirm biliary anatomy.
The liver is retracted with the help of the FLEXLAP ® Gold Finger Retractor (Endoscopy Superstore™, CA, USA) which is introduced through the 5-mm epigastric port. The peritoneum over the porta hepatis is opened, and common bile duct is identified. Arterial dissection is done, and right hepatic artery is looped after separating from bile duct and portal vein. Portal vein further mobilised using sharp and blunt dissection using harmonic shears (Ethicon Endo-surgery, Cincinnati, USA) and looped. Anterior caval dissection is done and intervening right inferior hepatic veins clipped. Now, the gold finger is passed anterior to the cava and brought out in the space created between the right hepatic vein and middle hepatic vein in the suprahepatic space. Foley's catheter is passed in the space created by the gold finger which helps achieve hanging, useful for parenchymal transection [Figure 2]b. Right portal vein and right hepatic artery are temporarily clamped with bulldog clamp. Indocyanine green (ICG) is injected intravenously, ICG camera is switched on and line of demarcation between right and left liver marked with monopolar cautery using a hook dissector [Figure 2]d. Clamps on the right portal vein and right hepatic artery are removed.
Parenchymal dissection is done using cavitron ultrasonic surgical aspirator (CUSA, Tyco Healthcare, Mansfield, MA, USA) and harmonic shears, managing small tributaries with 5-mm titanium clips wherever required [Figure 2]c. Segmental veins of V and VIII were delineated, clipped and divided preserving the middle hepatic vein with the donor. Caudate lobe is divided along the proposed line of transection. Now, gold finger is used to encircle the entire right portal pedicel, and Foley's catheter is brought in this space which helps in completing the remaining parenchymal transection by hanging manoeuver.
A Pfannenstiel incision is made and deepened without opening the peritoneum. Now, 5000 IU heparin given intravenously. Right hepatic duct is encircled with hilar sheath using ICG guidance and divided with scissors sharply after placing a clip to the right hepatic duct orifice. The right hepatic artery clipped, right portal vein stapled and divided while the right hepatic vein is divided using a stapler [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. The right hemi-liver is retrieved through previously placed suprapubic incision [Figure 1]b and is handed over for perfusion with University of Wisconsin solution. Warm ischemia phase lasted for 4 min and 4 min 30 s in these cases, with graft weight of 594 g and 544 g in the first and second cases, respectively.
|Figure 3: Clockwise from left upper corner, (a) right bile duct clipped, (b) the right hepatic artery being clipped, (c) right hepatic vein during transection and (d) stapled division of right portal vein|
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Management of liver remnant
Right hepatic duct orifice clip is removed and sutured with 4-0 Polydioxanone (PDS). Methylene blue is injected through cystic duct catheter to observe leaks from the cut surface, and no leaks were noted. Remnant liver is fixed by suturing falciform ligament to its original position. A 24Fr drain is placed near the remnant liver and the pneumoperitoneum deflated.
Donor and recipient were given intensive care support in the immediate post-operative by a dedicated team of intensivists and trained nursing personnel. The donor was monitored in the Intensive Care Unit for 1 day and shifted to the room. In the post-operative period, donor reported lower pain score and was ambulated. Donors were allowed diet from the 1st post-operative day and were comfortable in the post-operative period. The drain was removed on the 4th post-operative day and was discharged on the 4th and 5th post-operative day.
In the post-operative period, recipients were started on immunosuppression along with hemodynamic monitoring. Liver function tests were followed up and showed a downtrend. The recipients were allowed diet from the 2nd post-operative day and were monitored in intensive care facility for 4 days. The drains were removed on the 5th and 6th post-operative day and the patients were discharged on the 10th and 11th post-operative day, respectively. Both donors have completed 6-month follow-up without any complications.
| ¤ Discussion|| |
The first report of the use of laparoscopy for donor hepatectomy came from Cherqui et al. in 2002 in which left lateral sectionectomy was done for a paediatric recipient. In 2006, the first series of 16 cases of laparoscopic lateral sectionectomy mainly for paediatric transplants and hand-assisted laparoscopic right hepatectomy for an adult was reported., Since then, for the last decade, there is rapid adaptation of this technique, especially in Eastern Asia. The only meta-analysis published reports comparable safety and effectiveness of laparoscopic donor retrieval to open counterpart, additionally offering advantages of minimally invasive approach.
In a developing country like India, performing laparoscopic hepatectomy is associated with cost and logistical issues. Very few centres in India perform a laparoscopic liver resection, which, according to us, is an essential prerequisite for successful donor hepatectomy programme. The present institute is a high-volume centre, catering to various gastrointestinal and hepatobiliary conditions. The successful donor organ recovery by total laparoscopic means was achieved after two attempts of hybrid approach, where the critical steps such as mobilisation, vascular control, parenchymal transection and organ delivery were planned and performed through minimally invasive approach. Our earlier experience of laparoscopic hepatectomies for various benign and malignant conditions significantly shortened the learning curve.
Reducing hospital stay, early recovery and better cosmesis could improve the organ donor pool, and this can narrow the gap between requirement and availability to some extent. Unlike laparoscopic donor nephrectomy, laparoscopic donor hepatectomy is a yet to master kind of procedure with only limited case series being available; while most of them are hand-assisted hepatectomies, few centres are regularly performing total laparoscopic procedure too. To the best of our knowledge, this is the first report from the Indian sub-continent where laparoscopic right donor hepatectomy is performed and implanted successfully.
| ¤ Conclusion|| |
Total laparoscopic donor hepatectomy may be feasible in the hands of expert, experienced and determined laparoscopic surgeon with the aid of appropriate technology.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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Initial outcomes of pure laparoscopic living donor right hepatectomy in an experienced adult living donor liver transplant center. Transplantation 2017;101:1106-10.
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[Figure 1], [Figure 2], [Figure 3]