Department of General Surgery, Cleveland Clinic, Cleveland, OH.
Department of Surgery, Division of Abdominal Transplant, Stanford University, Palo Alto, CA.
Ann Surg. 2023 Oct 1;278(4):479-488. doi: 10.1097/SLA.0000000000005988. Epub 2023 Jul 11.
Evaluate outcome of left-lobe graft (LLG) first combined with purely laparoscopic donor hemihepatectomy (PLDH) as a strategy to minimize donor risk.
An LLG first approach and a PLDH are 2 methods used to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). But the risk associated with application LLG first combined with PLDH is not known.
From 2012 to 2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a 4-month adoption process, all donor hepatectomies, since December 2019, were performed laparoscopically.
There was one intraoperative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs 371 minutes). PLDH provided shorter hospital stays, lower blood loss, and lower peak aspartate aminotransferase. Peak bilirubin was lower in LLG donors compared with right-lobe graft donors (1.4 vs 2.4 mg/dL, P < 0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs 1.6 mg/dL, P < 0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs 22%, P = 0.007) and late complications, including incisional hernia (0% vs 13.7%, P < 0.001), compared with open cases. LLG was more likely to have a single duct than a right-lobe graft (89% vs 60%, P < 0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between the type of graft and surgical approach.
The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.
评估左外叶移植物（LLG）与单纯腹腔镜供体半肝切除术（PLDH）联合应用作为降低供者风险的策略的效果。
左外叶移植物优先（LLG）和单纯腹腔镜供体半肝切除术（PLDH）是成人活体肝移植（LDLT）中减少供者手术应激的两种方法。但是，应用 LLG 优先联合 PLDH 的相关风险尚不清楚。
2012 年至 2023 年，186 例成人 LDLT 采用半肝移植物，其中 95 例采用开腹手术，91 例采用 PLDH 获得。当供受者体重比≥0.6%时，考虑优先采用 LLG。经过 4 个月的采用过程，自 2019 年 12 月以来，所有供体肝切除术均采用腹腔镜进行。
术中仅有 1 例（1%）转为开腹。腹腔镜组和开腹组的平均手术时间相似（366 分钟比 371 分钟）。PLDH 提供了更短的住院时间、更低的出血量和更低的天门冬氨酸转氨酶峰值。与右外叶移植物供者相比，LLG 供者的胆红素峰值较低（1.4mg/dL 比 2.4mg/dL，P＜0.01），而 PLDH 进一步改善了 LLG 供者的胆红素水平（1.2mg/dL 比 1.6mg/dL，P＜0.01）。与开腹组相比，PLDH 还具有较低的早期并发症发生率（Clavien-Dindo 分级≥Ⅱ级，8%比 22%，P=0.007）和晚期并发症发生率，包括切口疝（0%比 13.7%，P＜0.001）。LLG 更有可能有单个胆管，而不是右外叶移植物（89%比 60%，P＜0.01）。重要的是，在 47%的成人 LDLT 中采用积极的 LLG，在不影响受者结果的情况下，实现了有利的移植物存活率。
在成人 LDLT 中，左外叶移植物优先与 PLDH 联合应用可最大限度地降低供者的手术应激，而不影响受者的结果。这种策略可以减轻活体供者的负担，有助于扩大供者库。
