Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation

Abstract

Objective: The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority. Background: Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines. Methods: A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience. Results: Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee. Conclusions: The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Robotic donor hepatectomy: Are we there yet?

“…With a proficiency of over 70 robotic hepatectomy for various indications, Giulianotti et al [ 29 ] from Chicago successfully performed the first right lobe RDH. Several other units, including those from Taiwan and Saudi Arabia have successfully replicated the results and safety of RDH since that first report[ 6 , 14 - 16 , 21 , 27 , 28 , 30 ].…”

“…The undeniable benefits of MIS have led to its acceptance across various surgical specialties, making it an integral component of a surgeon’s armamentarium[ 1 - 4 ]. As expected, even in the field of hepatobiliary surgery, the benefits of minimally invasive hepatectomy (MIH) have been unequivocally demonstrated by meta-analyses, consensus guidelines and recommendations, and the procedure is becoming a standard practice[ 5 , 6 ].…”

“…However, most of these complications are related to the operative wound (hernia, obstruction, wound infection, chronic pain, etc. ) and despite increased self- esteem and satisfaction in various quality of life analyses on live donor (LD), the most common grievance is that of the scar[ 6 - 10 ]. Considering the advantages of MIH, it is but intuitive to try and transfer these benefits to the LD operation.…”

“…To this an end, minimally invasive DH (MIDH) using conventional laparoscopy was introduced. Nonetheless, performing a safe and precise DH operation through a conventional laparoscopic approach remains a formidable task with a precipitous learning curve for the whole team[ 5 , 6 , 11 ]. Due to the ramifications the donor operation carries for the donor, the recipient, the transplant team and for the LDLT program in general, the development and acceptance of MIDH has been slow.…”

“…These systems are now gaining traction and are replacing the conventional laparoscopic operation. However, many questions especially with regards to standardization of surgical technique, comparison of outcomes, understanding of the learning curve, etc., remain unanswered[ 6 , 11 - 14 ]. The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH (RDH), appreciating the existing challenges and its future role.…”