Living donor safety during the performance of hepatectomy

The popularity of describing techniques for ‘‘improved’’ living donor hepatectomy for both left and (more recently) right lobectomy procedures is growing. In this issue of Liver Transplantation, Nagai et al. describe a hybrid laparoscopy-assisted technique as well as a minilaparotomy technique for performing living donor right hepatectomy for the purpose of living donor liver transplantation. The authors are to be congratulated on presenting their experiences as they develop and modify these procedures. The reasoning and technical highlights that they present are important. Their methods seem so simple that nearly any competent hepatic surgeon could easily adapt them and achieve the endpoints of improvements in postoperative pain, the perception of recovery speed, and the hospital length of stay. For this reason, I implore the readership of this journal to pay special attention to the statements in the Discussion section about the experience of this very talented team, its 10-year progression toward the development of these techniques, and its great care to always leave open the option of a conversion to a standard and larger incision for exposure. This team has great judgment as a result of more than a decade of hepatic surgery with both open and laparoscopic techniques. It should be emphasized that progressing to smaller incisions with limited exposure does indeed increase the risk to these heroic patients who otherwise do not require this operation at all. Furthermore, this team has performed the new 10-cm midline incision technique in only 9 patients, and another 4 patients have undergone a hybrid procedure adding laparoscopic assistance to minilaparotomy. This volume is far too small to make recommendations for the adoption of these techniques by others at this time. In addition, the operative time for these cases was 6 hours on average with a mean length of stay of 5.9 days. The rates of donor complications were 25% in this study and 23% in their previous series with the standard open technique. Lee et al. reported 143 consecutive donor hepatectomy cases with an upper midline incision; however, their incisions were 12 to 15 cm, the median operative time until graft retrieval was 3 hours, and the complication rate was 6.7%. The authors of that study suggested that large right lobe grafts (>900 g), fatty livers (>10% steatosis), and deep truncal cavities (celiac axis depth ratio > 0.35) led to significantly longer warm ischemia times because of longer extraction times and should be considered relative contraindications. In my opinion, only very experienced centers performing liver surgery and donor hepatectomy should consider extending these types of advanced techniques to improve donor outcomes. As a surgeon who has performed more than 125 living donor right hepatectomies (all open through the standard right subcostal approach), I have concerns when I am contemplating a change to improve outcomes for my patients. Fortunately, my colleagues and I have enjoyed an average operative time of 3.5 to 4 hours from incision to closure and a mean length of stay of 5 days for our donor population, which has demographic characteristics similar to those of the authors’ patients. I do appreciate the postoperative pain issue and the recovery from such a morbid incision; however, concerns about the increased difficulty of controlling an unexpected vascular injury make me