Pure Three-Dimensional Laparoscopic Full Left Hepatectomy of a Living Donor for an Adolescent in China
Living donor liver transplantation (LDLT) has emerged as a critical solution to address the shortage of cadaveric organs, particularly in regions with low organ donation rates. In pediatric and adolescent recipients, a left-side liver allograft is often sufficient and safe. The advent of laparoscopic technology in live hepatectomy, first introduced in 2002, has significantly improved donor outcomes by meeting cosmetic demands and facilitating early functional recovery. The use of three-dimensional (3D) visualization in laparoscopy has further enhanced surgical precision by providing superior depth perception and tactile feedback compared to traditional two-dimensional (2D) laparoscopy. This article presents a detailed account of a pure 3D laparoscopic full left hepatectomy performed on a living donor for an adolescent recipient in China, highlighting the technical aspects, outcomes, and implications of this advanced surgical approach.
Case Presentation
The case involved a 39-year-old mother who volunteered to donate the left side of her liver to her 13-year-old son. The donor weighed 56 kg, stood 158 cm tall, and had a body mass index (BMI) of 22.4 kg/m². The recipient, weighing 34 kg and standing 148 cm tall, had a BMI of 15.5 kg/m². The adolescent was diagnosed with cryptogenic decompensated cirrhosis, severe portal hypertension, refractory ascites, splenomegaly, hypersplenism, and a history of recurrent esophageal gastric variceal bleeding. His Child-Pugh class was B-10, and his model for end-stage liver disease (MELD) score was 11.
Preoperative Evaluation
The donor underwent comprehensive preoperative evaluation, including liver volume and vascular anatomy assessment using computed tomography (CT) angiography with 3D reconstruction (IQQA-liver software, EDDA Technology, Princeton, NJ, USA). Biliary anatomy was evaluated using magnetic resonance cholangiopancreatography (MRCP). The donor’s left liver volume, excluding the middle hepatic vein (MHV) and caudate lobe, was 414 cm³, with a graft-to-recipient weight ratio (GRWR) of 1.22% and a remnant liver volume of 65.7%. The left liver had one portal vein and two branches of arteries. MRCP revealed normal biliary confluence with one bile duct from the left liver.
Surgical Procedure
The donor was fully informed of the risks associated with laparoscopic liver procurement and 3D visual surgery. Written informed consent was obtained from both the donor and recipient. All procedures adhered to the ethical standards of the Ethics Committee of West China Hospital of Sichuan University.
Under general anesthesia, the donor was positioned in a 30° reverse Trendelenburg position with arms abducted. Five optic trocars were placed, and an Endoeye Flex 3D video laparoscope (Olympus, Tokyo, Japan) was used for visualization. The peritoneal cavity was inspected, and the left lobe was mobilized. Cholecystectomy was performed, followed by dissection and taping of the two branches of the left hepatic arteries (LHA) and the left portal vein (LPV) with vessel loops. The common trunk of the left hepatic vein (LHV) and MHV was encircled by dissecting the tunnel between the trunk of the hepatic vein and the retrohepatic inferior vena cava.
The ischemic demarcation line on the liver surface was marked as the transection line by transiently clamping the left inflow vessels. Intraoperative ultrasound was used to identify the MHV, which was preserved in the donor. Parenchymal transection was performed using a laparoscopic Harmonic scalpel (Ethicon, Somerville, NJ, USA) and an ultrasonic aspirator (CUSA Excel+, Integra, New Jersey, USA). Intrahepatic vessels were divided between Hem-o-Lok clips (Weck, Teleflex Medical, North Carolina, USA). At the hilar plate, the left hepatic bile duct was clamped and divided at the branch point of the left and common hepatic duct, with reference to the MRCP image.
A 10 cm subumbilical median incision was prepared without opening the peritoneum. After administering heparin to the donor, the LHAs and LPV were clamped and divided using Hem-o-Loks. The LHV was divided using a vascular stapler. The graft was extracted through the incision, hemostasis was achieved, and one drainage tube was left in place. The recipient underwent splenectomy and piggy-back transplantation.
Outcomes
The donor’s operation time was 495 minutes, with blood loss of less than 100 mL and no need for transfusion. The graft weighed 400 g, with a GRWR of 1.18%, and the remnant liver volume was 66.8% of the donor’s total liver volume. The donor was discharged on the sixth postoperative day with normal liver function. The recipient’s operation time was 460 minutes, and he was discharged on the 38th postoperative day with normal graft function.
Discussion
The primary concern in LDLT is the safety of the healthy living donor. Left lobe donation is associated with lower morbidity compared to right lobe donation. Although there is a potential risk of insufficient allograft volume, left lobe allografts can be safely transplanted to selected adult and adolescent recipients. In this case, the remnant liver volume of 66.8% for the donor and a GRWR of 1.18% for the recipient balanced donor safety and recipient need.
Laparoscopic liver donation has been shown to be technically feasible and safe in experienced centers, offering greater cosmetic satisfaction and fewer wound complaints. From October 2015 to August 2018, the authors completed 18 laparoscopic living donor hepatectomies, including six left lateral lobes, five left lobes (including this case), and seven right lobes.
However, laparoscopic liver donation presents technical challenges and requires a prolonged learning curve. One major limitation of conventional 2D laparoscopy is the lack of depth perception and tactile feedback. In contrast, 3D laparoscopy provides a stereoscopic view of the operative field, improving the speed and precision of laparoscopic procedures. The 3D high-definition imaging system, using videoscopes with flectional tips, allows surgeons to view anatomy from ideal angles without restriction. The enhanced depth perception and hand-eye coordination of 3D laparoscopy contribute to accurate hilum dissection, better identification of intracorporeal vessels, and effective hemostasis.
Conclusion
This case report presents the initial experience with pure 3D laparoscopic left hepatectomy for LDLT in China. The use of 3D laparoscopy offers significant advantages in terms of surgical precision and donor safety. However, laparoscopic donor hepatectomy should only be performed in select cases with normal anatomy by an experienced surgical team with expertise in both laparoscopic liver surgery and living donor hepatectomy. The successful outcomes in this case underscore the potential of 3D laparoscopic techniques to enhance the safety and efficacy of living donor liver transplantation.
doi.org/10.1097/CM9.0000000000000052
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