Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

Objective: We present the largest, most comprehensive, single center experience to date of minimally invasive liver resection (MILR). Ann Surg 2007;246: 385-394)

Background & Aims-Reports of complications among adult right hepatic lobe donors have been limited to single centers. The rate and severity of complications in living donors were investigated in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL).

The major impediment to a wider application of living donor hepatectomy, particularly of the right lobe, is its associated morbidity. The recent interest in a minimally invasive approach to liver surgery has raised the possibility of applying these techniques to living donor right lobectomy. Herein, we report the first case of a laparoscopic, hand-assisted living donor right hepatic lobectomy. We describe the technical aspects of the procedure, and discuss the rationale for considering this option. We propose that the procedure, as described, did not increase the operative risks of the procedure; instead, it decreased potential morbidity. We caution that this procedure should only be considered for select donors, and that only surgical teams familiar with both living donor hepatectomy and laparoscopic liver surgery should entertain this possibility.

Hypothesis: Multiple centers have reported on bile duct injuries after cholecystectomy, but few have reported on the impact of concomitant vascular injuries. Design: Twenty-seven life-threatening complex injuries (CIs) (Bismuth level III, IV, or V or combined arterialductal injuries) were retrospectively compared with 22 noncomplex injuries (NCs) (level I or II). Setting: Tertiary referral center. Main Outcome Measures: The incidence and level of biliary and arterial injuries and their resulting morbidity and mortality. Results: Bismuth classifications of all injuries were as follows: level I in 6 patients (12%), II in 19 (39%), III in 12 (24%), IV in 8 (16%), and V in 4 (8%). Diagnosis was based on peritonitis (n = 13 [27%]), endoscopic retrograde pancreatography (n = 19 [39%]), and percutane-ous transhepatic cholangiography (n = 7 [14%]). Delayed referral was more common in levels I through IV (100 days) than in level V (15 days) (PϽ.001). Repairs were attempted in level IV (75%), III (67%), V (25%), and II (11%). Thirteen arterial injuries (26%) occurred irrespective of ductal injury level: I (n=1), II (n=3), III (n=1), IV (n=5), and V (n=3). There was, however, a higher incidence of repairs before referral in the CI group (59% vs 5%; PϽ.01), with resulting higher rates of complication (70% vs 23%; PϽ.01). Five deaths occurred in the CI group vs 1 in the NC group (P =.14). In univariate analysis, the presence of arterial injury vs no arterial injury was a predictor of mortality (5 [38%] of 13 patients vs 1 [3%] of 36 patients; PϽ.001). Conclusion: Bile duct injuries after cholecystectomy can be morbid and lethal with the incidence of arterial injury grossly underestimated.