Pure 3-dimensional Laparoscopic Extended Right Hepatectomy in a Living Donor

Transcription

1 LETTERS FROM THE FRONTLINE Pure 3-dimensional Laparoscopic Extended Right Hepatectomy in a Living Donor TO THE EDITOR: adult living donor, using exclusively 3-dimensional laparoscopic extended right hepatectomy. For balancing demand of the recipient and safety of the donor, various alternative approaches have been attempted in living donor liver transplantation (LDLT). In the case of a right hepatectomy where the remnant donor liver has large volume and the graft-torecipient weight ratio (GRWR) is relatively low, the right liver containing the middle hepatic vein (MHV) can be used. At the same time, considering the donor s cosmetic and functional demands, the pure laparoscopic approach in both left and right hepatectomy has become a new option. Three-dimensional laparoscopy can be useful for better depth perception and tactile feedback and can thus greatly enhance laparoscopic proficiency. (1) Laparoscopic donor hepatectomy has been attempted recently, but there are no reports on pure laparoscopic extended right hepatectomy. We report here the first 2 cases of transplantation in an Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; CT, computed tomography; GRWR, graft-to-recipient weight ratio; HTK, histidine tryptophan ketoglutarate; IVC, inferior vena cava; LDLT, living donor liver transplantation; LFT, liver function test; MELD, Model for End- Stage Liver Disease; MHV, middle hepatic vein; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging; PV, portal vein; RBD, right bile duct; RHA, right hepatic artery; RHV, right hepatic vein; RIHV, right inferior hepatic vein; RPV, right portal vein; T. bil, total bilirubin. Address reprint requests to Kyung-Suk Suh, M.D., Department of Surgery, College of Medicine, Seoul National University, 101 Daehakro, Jongno-gu, Seoul , South Korea. Telephone: ; FAX: ; kssuh2000@gmail.com *These authors contributed equally to this work. Received March 30, 2016; accepted June 19, Copyright VC 2016 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. DOI /lt Potential conflict of interest: Nothing to report. Case Series The institutional review board of Seoul National University Hospital approved this study (institutional review board number ). Living donor extended right hepatectomy was performed in 2 donors, purely using 3-dimensional laparoscopy. The donors were evaluated step-by-step, according to the previously reported evaluation protocol for living donors in our hospital, which was approved by the institutional review board of Seoul National University Hospital. All laboratory results including liver function tests (LFTs); biochemistry; hematology; coagulation profile; urine analysis; hepatitis A, B, and C serology; chest radiography; and electrocardiography were within normal limits. The blood types of donor and recipient were also matched. Subsequently, the potential donor underwent a complete medical and anatomical evaluation. Liver volume was estimated by computed tomography (CT) volumetry. Vascular anatomy was assessed by CT, and the biliary anatomy was assessed by magnetic resonance imaging (MRI). MRI fat fraction was checked without preoperative liver biopsy. Case 1 A 62-year-old male presented with liver cirrhosis due to alcohol and hepatitis B and hepatocelllular carcinoma. He had previously received 4 cycles of transarterial chemoembolization. The Model for End-Stage Liver Disease (MELD) score was His body weight was 69.7 kg; height was cm; body mass index (BMI) was 24.1 kg/m 2 ; and standard liver volume was cm 3. His 57-year-old wife had volunteered for a living donation. Volumetric evaluation using liver dynamic CT revealed that the total volume of the donor s liver was 1009 cm 3, with the right liver volume being 601 cm 3, leaving a remnant liver volume of 40.4% in case of a right liver donation. GRWR was LETTERS FROM THE FRONTLINE 1431

2 SUH ET AL. LIVER TRANSPLANTATION, October 2016 FIG. 1. Photographs of the operation room: (A) patient position: supine position with legs apart, (B) trocar position, (C) operator with 3-dimensional glasses. 0.8%. Fat fraction estimated by MRI was 3.5%. Liver vasculature anatomy of the portal vein and hepatic artery was conventional, and MRI showed a normal biliary confluence with a single right bile duct (RBD). With a relatively small MHV, there was a scissural vein draining segment IV and 1 small right inferior hepatic vein (RIHV). Case 2 A 44-year-old male presented with hepatitis B associated liver cirrhosis and hepatocellular carcinoma. He had received 3 cycles of radiofrequency ablation and 1 of transarterial chemoembolization. The MELD score was His body weight was 59.8 kg; height was cm; BMI was 20.8 kg/m 2 ; and standard liver volume was cm 3. His 40-year-old wife offered to donate to her husband; she weighed 53.0 kg. The volume of the donor s right liver was 669 cm 3, which was 39.3% of the total liver volume. With a recipient weight of 59.8 kg, GRWR was 1.1%. Fat fraction calculated by MRI was 2.1%. The right liver had a single portal vein, and there was no remarkable right bile duct variation. There were remarkable scissural veins draining segments IVa and IVb. In November 2015, both surgeries were performed under general anesthesia. The donor was placed in a supine position, with her legs apart (Fig. 1A). The surgeon stood between the patient s legs. The pneumoperitoneum was established at 12 mm Hg pressure, using 5 trocars (Fig. 1B). Viewing under 3-dimensional laparoscopy, the abdominal cavity was inspected, and the right liver was mobilized by dividing the round ligament, falciform ligament, right coronary ligament, and the triangular ligaments (Fig. 1C). Next, the MHV and right hepatic vein (RHV) were exposed. The right part of segment I was mobilized to enable dissecting the anterior aspect of the inferior vena cava (IVC) by dividing small venous branches between clips. RIHV was divided between clips, with a Hem-o-lok clip being used at the IVC end. The dissection was performed as high as possible. The cystic artery and duct were clipped and divided. With a delicate leftward traction from the cystic stump, the right side of the hilum was exposed and dissected, identifying the main portal vein. The right hepatic artery (RHA) was identified, and vessel loops were placed around the right portal vein (RPV) and RHA. After temporary clamping of the right portal and hepatic artery using laparoscopic bulldog clamps, the ischemic demarcation line on the liver surface was marked with a Bovie. After cholecystectomy was performed, the liver was transected using a laparoscopic ultrasonic aspirator (CUSA) and clipped 1432 LETTERS FROM THE FRONTLINE

3 LIVER TRANSPLANTATION, Vol. 22, No. 10, 2016 SUH ET AL. FIG. 2. Transecting MHV: (A) transection plane: MHV kept with the graft, (B) transected level: up to the junction of scissural vein. in a plane that was demarcated on the liver surface. The inflow vascular occlusion was not used during the liver transection. The MHV was identified and kept with the graft side (Fig. 2). While dividing the caudate lobe, the RPV, RHA, and the RBD obstructed visualization. Therefore, they were held in gentle traction in the craniocaudal direction. Following this, the Goldfinger dissector was placed through the space between the anterior surface of the vena cava and the posterior surface of the liver, to lift the cuttingareaoftheliverfromtheposteriortotheanterior direction (a modified hanging method). When liver transection reached the hilar plate, the right hepatic bile duct was carefully divided while rechecking the magnetic resonance cholangiopancreatography (MRCP) image. The whole length of MHV was dissected up to the junction of the scissural vein and was transected using a vascular endostapler (ECHE- LON FLEX Powered Vascular Stapler, Ethicon, Somerville, NJ; Fig. 2). At this point, the right liver was attached only with its vascular structures (Fig. 3). FIG. 3. Steps of procedure: (A) after completion of donor hepatectomy, the right liver attached only with its vascular structures, (B) graft on the back table: tube in the RPV for perfusion, venoplasty with RHV and MHV to make one orifice, (C) intraoperative photograph of case 2 recipient: the common orifice of the reconstructed hepatic vein using recipient portal vein graft for MHV and RVH of the donor was anastomosed to the recipient RHV, which was enlarged by cutting some part of the IVC next to it. Next, a 10-cm suprapubic incision, minus the muscular section, was made without opening the peritoneum. The RHA was ligated with a 2/0 silk tie and a clip. The RPV was transected with an endostapler (ECHELON FLEX Powered Vascular Stapler, LETTERS FROM THE FRONTLINE 1433

4 SUH ET AL. LIVER TRANSPLANTATION, October 2016 FIG. 4. Posttransplant early LFTs of donor and recipient: (A) case 1, (B) case 2. Ethicon), with due consideration being that the direction of the stapler did not result in any torsion. A unilateral linear stapler (endota, Covidien, Dublin, Ireland) was used to seal the proximal RHV, which was then divided with scissors. The graft was extracted after completing the suprapubic fascia and peritoneum incision. The graft was immediately taken to the back table and flushed with histidine tryptophan ketoglutarate (HTK) solution through the RPV. The bile duct and hepatic artery were also washed from within using the HTK solution. The suprapubic incision was then closed and the pneumoperitoneum was reinsufflated. The distal end of the divided right hepatic bile duct was closed with a running suture. Hemostasis was checked, and the falciform ligament was sutured to avoid torsion of the remnant liver. In case 1, the total operative time was 408 minutes with no transfusion, and intraoperative complications did not occur. The graft weighed 630 g. With the recipient weight of 69.7 kg, GRWR was 0.9%. On the back table, venoplasty of MHV and RHV was performed to achieve a single orifice (Fig. 3). The common trunk of the donated liver s hepatic vein was then anastomosed to the recipient s RHV. Next, the portal vein was anastomosed end-to-end between the recipient s main portal vein and the graft RPV. Finally, the RHA of the graft was anastomosed to the recipient s RHA, and a ductto-duct biliary anastomosis was performed. The donor s total bilirubin (T. bil) level was slightly elevated, up to 1.8 mg/dl, at postoperative day 2, but the patient was discharged with normal liver function on postoperative day 9. As per the protocol, CT examinations of the donor and recipient livers were performed on postoperative day 7; we observed patent vascular structures, without any abnormal findings. The recipient was discharged at postoperative day 12, with no complications. The results of early LFTs until discharge day of both donor and recipient are shown in Fig. 4A. In case 2, the total operative time was 409 minutes with no transfusion, and there were no intraoperative complications. The graft was 565 g. With the recipient weight of 59.8 kg, GRWR was 0.9%. On the back table, MHV was anastomosed to the proximal end of the portal vein graft from the recipient in an end-to-end fashion using a 6-0 Prolene suture. Venoplasty of this distal end of the portal vein and RHV was performed to form a common orifice (Fig. 3). The portal vein, hepatic artery, and bile duct were anastomosed in the same manner as in case 1. The donor st.billevelwas1.8mg/dlatpostoperative day 1 and continuously dropped down. The donor was discharged with normal liver function on postoperative day 8. Protocol CT was done on postoperative day 7 and showed patent hepatic vessels with no remarkable findings. The recipient s postoperative day 7 CT showed only mild periportal edema, and the patient was discharged on postoperative day 12. Figure 4B shows the results of LFTs until discharge day of both donor and recipient LETTERS FROM THE FRONTLINE

5 LIVER TRANSPLANTATION, Vol. 22, No. 10, 2016 SUH ET AL. Discussion Since the initiation of our LDLT program in January 1999, more than 1100 LDLTs have been performed in our hospital, without any irreversible disabilities or mortalities reported. The primary concern in LDLT is donor safety. To ensure donor safety, the minimal required volume of the liver needs to be resected, leaving sufficient remaining liver volume to sustain the metabolic demands of the donor. Several studies have reported increased morbidity and the possibility of mortality in donors with small remnant liver volumes, and therefore, most centers suggest a minimum 30% remnant liver volume. (2) At the same time, GRWR should also be considered to meet the metabolic, synthetic, and hemodynamic demands of the recipient. When the GRWR is <0.8%, this small graft is known to be a major risk factor for early graft dysfunction. (3) Thus, balancing between the donor s safety and recipient s demand is crucial. In the 2 cases we presented, the donors remnant liver volumes were approximately 40%, which are big enough; the existence of the scissural veins was confirmed based on the evaluation of the preoperative CT. The scissural veins would be useful in draining segment IV, which could get congested when performing the extended right hepatectomy. In case 1 particularly, the GRWR was <0.8% when evaluated through volumetry; this made it necessary to select a different graft type, one that included the MHV, rather than the casual right hemiliver. Hence, the selection of the extended right hemiliver graft which contained the MHV was necessary in both cases, considering the donor s remnant liver volume, vascular anatomies, and the recipient s body size. As cases of LDLT increase, the cosmetic and functional demand by young, female donors is increasing too. To meet the demand, laparoscopic major hepatectomies are being performed. Laparoscopic major hepatectomy can be performed using 3 main techniques: pure laparoscopy, the hand-assisted technique, and the hybrid technique. Currently, there are no published data that establish the superiority of one technique over the others. However, there are reports showing that pure laparoscopy may decrease intraoperative blood loss and the subsequent need for transfusion, as well as the postoperative morbidity of liver resections (including in living donors) as compared to open surgery. (4,5) Pure laparoscopy technique can mostly satisfy the donor with respect to the wound because the suprapubic incision is not visible. However, the method of exclusively using laparoscopy is the most technically challenging. One of the major limitations of conventional laparoscopy is the lack of depth perception and tactile feedback. The introduction of 3-dimensional imaging has corrected this loss of a 3-dimensional view. Three-dimensional visualization is known to reduce the operating time compared to high-definition 2-dimensional visualization. (1) Three-dimensional laparoscopy, using a flexible scope, was especially useful during liver mobilization because there was only a small space for manipulation. The depth perception and hand-eye coordination were excellent, leading to accurate and swift dissection that was crucial when dissecting the hilum and resecting the parenchyma. It was also helpful in bleeding control and during intracorporeal knotting to achieve biliary suture. For identifying a safe bile duct division point, we used preoperative MRCP and carefully dissected around the bile duct. Since 2009, intraoperative cholangiography has not been routinely performed and is replaced by MRCP in our center. (2) First, intraoperative cholangiography is quite cumbersome and X-ray exposure is unavoidable. Injecting dye through the bile duct can be quite difficult in a laparoscopic surgery. Second, recent MRCP is able to provide precise and accurate results in place of intraoperative cholangiography. Lastly, precise perception of adequate dissection line for the bile duct is possible with careful dissection around the bile duct. Occasionally, when preoperative MRCP shows a short division point, we can check the patency of the left bile duct and common hepatic duct by carefully probing through the divided bile duct opening or cystic duct opening. Recently, we employed a new strategy, ie, fluorescence cholangiography, which uses intravenous injected indocyanine green and nearinfrared camera. This precise cholangiography can provide real-time imaging, which makes deciding the appropriate division point much easier. In this article, we presented our initial experience in pure 3-dimensional laparoscopic extended right hepatectomy for LDLT. Pure 3-dimensional laparoscopic extended right hepatectomy was feasible in selected adult donors. Since November 2015, most of the living donor hepatectomies in our center have been done using pure 3-dimensional laparoscopy. Pure 3-dimensional laparoscopy is applicable if there are no anomalies of the bile duct or portal vein. However, further experience would be needed to conclusively standardize a safe and feasible procedure. In summary, our 2 cases offer evidence that the extended right graft can be procured through pure 3- dimensional laparoscopy. It is a consistent attempt to LETTERS FROM THE FRONTLINE 1435

6 SUH ET AL. LIVER TRANSPLANTATION, October 2016 reduce donor morbidity as well as to increase the graft function of the recipient. This procedure will be a new option for adult LDLT, which caters to the demand of both the donors and the recipients. Kyung-Suk Suh, M.D.* Suk Kyun Hong, M.D.* Nam-Joon Yi, M.D., Ph.D. Kwang-Woong Lee, M.D., Ph.D. Hyo-Sin Kim, M.D. Kyung Chul Yoon, M.D., Ph.D. Hyeyoung Kim, Ph.D. Department of Surgery College of Medicine Seoul National University Seoul, South Korea REFERENCES 1) Velayutham V, Fuks D, Nomi T, Kawaguchi Y, Gayet B. 3D visualization reduces operating time when compared to highdefinition 2D in laparoscopic liver resection: a case-matched study. Surg Endosc 2016;30: ) Suh KS, Suh SW, Lee JM, Choi Y, Yi NJ, Lee KW. Recent advancements in and views on the donor operation in living donor liver transplantation: a single-center study of 886 patients over 13 years. Liver Transpl 2015;21: ) Kiuchi T, Kasahara M, Uryuhara K, Inomata Y, Uemoto S, Asonuma K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors. Transplantation 1999;67: ) Mirnezami R, Mirnezami AH, Chandrakumaran K, Abu Hilal M, Pearce NW, Primrose JN, Sutcliffe RP. Short- and long-term outcomes after laparoscopic and open hepatic resection: Systematic review and meta-analysis. HPB (Oxford) 2011;13: ) Soubrane O, Cherqui D, Scatton O, Stenard F, Bernard D, Branchereau S, et al. Laparoscopic left lateral sectionectomy in living donors. Ann Surg 2006;244: LETTERS FROM THE FRONTLINE