Minimally Invasive Donor Hepatectomy (MIDH): Recommendations
Primary Recommendation
Laparoscopic donor hepatectomy should be performed by experienced hepatobiliary surgeons trained in both living donor hepatectomy and minimally invasive techniques, with left lateral sectionectomy now considered standard practice and major hepatectomies (including right lobe donation) reserved for expert centers with documented proficiency in both disciplines. 1
Indications and Patient Selection
Left Lateral Sectionectomy
- Pure minimally invasive left lateral sectionectomy is now standard of care for pediatric living donor transplantation 1, 2
- International consensus conferences (Louisville, Morioka, Southampton) have established left lateral sectionectomy as routine practice with proven safety 1
- The risk of laparoscopic left lateral sectionectomy has been demonstrated to be lower than donor nephrectomy 1
Major Hepatectomies (Right Lobe Donation)
- Major hepatectomies via minimally invasive approach remain innovative procedures requiring exceptional expertise 1
- International registries demonstrate postoperative advantages of laparoscopy for major hepatectomies in expert centers, including reduced bleeding, shorter hospital stay, and lower morbidity 1
- Right hepatectomy should only be performed by surgical teams with substantial experience in both living donor hepatectomy and advanced laparoscopic liver surgery 1, 3
Technical Approaches Available
Pure Laparoscopic Technique
- Fully minimally invasive approach achieves comparable blood loss (169 vs 146 mL), complication rates (7.7% vs 9.3%), and donor liver function recovery compared to open surgery 4
- Operation time is significantly longer (596 vs 383 minutes) but results in faster return to work (52.9 vs 100 days) 4
Hybrid/Laparoscopic-Assisted Technique
- Currently the most commonly used approach due to shorter operative times compared to pure laparoscopy and better exposure than open transverse incision 5
- Median operation time of 355 minutes with mean blood loss of 346 mL 5
- Provides superior cosmetic outcomes (satisfaction score 9.80 vs 6.17 for conventional incisions) 5
Hand-Assisted Laparoscopic Technique
- Represents an intermediate approach between pure laparoscopy and open surgery 3, 2
- May facilitate hemostasis control during the learning curve 3
Robotic-Assisted Technique
- Robotic right hepatectomy demonstrates equivalent blood loss, complication rates, and liver function recovery compared to open surgery 4
- Requires longer operative time but provides reduced postoperative analgesia requirements (0.58 vs 0.84 ng/kg) 4
- However, robotic liver resection should be reserved for clinical trials as there is no proven advantage in enhanced recovery protocols 1
Documented Benefits of MIDH
Short-Term Outcomes
- Lower intraoperative blood loss compared to open surgery 1
- Reduced blood transfusion requirements 1
- Decreased postoperative complications 1
- Shorter hospital stay 1
- Lower postoperative morphine consumption 1
- Better quality of life 1
Recovery Metrics
- Faster return to work/school (52.9 vs 100 days for robotic approach) 4
- Earlier resumption of normal activities including sexual activity (100 vs 156 days) 4
- Superior cosmetic outcomes with minimal scarring 5
Recipient Outcomes
- Similar early allograft dysfunction rates compared to open donor procedures 4
- Equivalent complication rates in recipients 4
- Comparable 1-year recipient liver function 4
Critical Prerequisites and Barriers
Surgeon Requirements
- Surgeons must have expertise in three distinct domains: liver transplantation, hepatobiliary surgery, and advanced minimally invasive techniques 3
- A steep learning curve exists due to liver parenchymal fragility and the need for expert hemorrhage control 3
Institutional Requirements
- Centers must have established living donor programs with documented safety records 3
- Availability of advanced laparoscopic equipment and support staff 3
- Institutional commitment to donor safety as the paramount priority 3
Selection Criteria
- Appropriate donor selection is crucial to achieve optimal outcomes in complications, blood loss, operative time, and hospital stay 3
- Female donors with lower BMI (mean 21.1 kg/m²) may be particularly suitable candidates for minimally invasive approaches 5
Perioperative Management Specific to MIDH
Analgesia Strategy
- For laparoscopic donor hepatectomy, regional anesthesia techniques are not needed; multimodal analgesia combined with judicious IV opiates provides functional analgesia 6
- Early transition to oral analgesia is possible due to reduced analgesic requirements 6
- IV parecoxib infusion provides superior analgesia compared to IV fentanyl infusion for laparoscopic procedures 6
Postoperative Care
- Early oral intake with normal diet should be encouraged from postoperative day one 6
- Early mobilization (out of bed) from operative day until discharge 6
- Prophylactic nasogastric intubation is not recommended as it offers no benefits and may increase hospital stay 6, 7
Common Pitfalls and How to Avoid Them
Technical Challenges
- The fragility of liver parenchyma during minimally invasive dissection requires exceptional experience for adequate bleeding control 3
- Pure laparoscopic technique may result in prohibitively long operative times without adequate experience 5
- Open technique using only transverse incision without laparoscopic assistance creates exposure problems for the cephalic liver portion 5
Safety Considerations
- Donor safety must never be compromised for cosmetic benefits or recipient convenience 3, 2
- Centers should not attempt MIDH without documented proficiency in both open living donor hepatectomy and advanced laparoscopic liver surgery 3, 2
- Initial slow adoption of laparoscopic donor hepatectomy was appropriate due to legitimate concerns about hemostasis, donor safety, and graft quality 2
Learning Curve Management
- Begin with left lateral sectionectomy before progressing to major hepatectomies 1
- Consider hybrid techniques during the learning curve rather than attempting pure laparoscopic approaches 5
- Maintain low threshold for conversion to open surgery if donor safety is questioned 3
Current Evidence Limitations
- No randomized controlled trials exist comparing minimally invasive to open donor hepatectomy due to small procedure volumes and ethical considerations 1
- Evidence is primarily derived from international registries and propensity score studies 1
- More robust data and international registries are needed for further technique evaluation and global acceptance 3
- Long-term donor outcomes beyond 1 year require additional study 4