Laparoscopic Left Lateral Sectionectomy in Living Donors
Laparoscopic Left Lateral Sectionectomy in Living Donors
Of the 70 donors, 66 (94.3%) were operated upon using pure laparoscopy, whereas 4 (5.7%) required conversion to an open technique. Neither hybrid nor hand-assisted techniques were used. No donor received an intraoperative allogeneic transfusion. The Lyon team used a cell saver system for an autotransfusion in 6 donors. The median operative time was 275 (range: 175–520) minutes, and mean blood loss was 82 ± 79 mL (range: 10–770). The mean graft warm ischemia was 9.0 ± 4.1 minutes. Operative data are presented in Table 3.
Four conversions (5.7%) were necessary, 3 during left lateral section procurement and 1 during a left liver procurement. The first conversion was undertaken after a left portal branch injury while cutting the left bile duct. The vein was easily repaired, but a systematic conversion was performed to make sure that there was no stenosis of the left portal vein. This injury occurred at the beginning of our experience (case 4 in 2003). Two of the conversions were undertaken because of a poor exposure and slow progression during transection. The last conversion was performed because of doubts regarding the biliary anatomy. This last conversion was performed to check the anatomy of the biliary tree because of a putative biliary duct variation. None of the conversions were associated with acute or uncontrolled bleeding or with the need for perioperative transfusion. All converted donors had an uneventful recovery.
No donor died. The median hospital stay was 6 days, ranging from 3 to 18 (Table 4). Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (15.7%) had grade 1 complications; 5 donors (7.1%) had grade 2 complications; and 1 donor had a grade 3 complication.
Overall, 4 donors required reoperation: 2 for biliary leakage, 1 for suprapubic hematoma, and 1 for cystoscopy. One donor had a hematoma of the suprapubic incision that required surgical drainage and transfusion of 2 units of packed red blood cells. One donor had a macroscopic hematuria and pelvic pain due to urinary bladder trauma. Cystoscopy revealed a transfixion suture through the urinary bladder wall. After the endoscopic removal of this suture and urinary catheter placement, the donor fully recovered.
Two donors (2.8%) developed a massive bile leakage and underwent reoperations. The primary clinical manifestation of the choleperitoneum due to bile leakage was confusion and abdominal pain. Both reoperations were performed by redo-laparoscopy. In 1 case, the source of the biliary leak was due to titanium clip dislodgement on the left bile duct stump. In the other case, the bile leak originated from the segment I duct. In both cases, Prolene sutures were used to close the biliary leak. After these 2 events, we decided to replace standard titanium clips by the hem-o-lock type or stitches, and no similar events have occurred.
One donor presented a grade 3 complication. On follow-up, this donor presented with cholestasis. Magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography studies showed a stenosis of the right anterior bile duct. An endoscopic prosthesis was left in place upon the resolution of the cholestasis. However, because this biliary stenosis, the donor required an exhaustive follow-up by MRI. Later, neither cholestatic nor infectious complications occurred, and there was no dilation of the intrahepatic bile ducts at the time of the last follow-up. Finally, 1 donor presented a gastric stress ulcer diagnosed by a gastroscopy under sedation that was treated medically.
The median graft weight was 252 (range: 118–390] g (Table 2). The correlation between CT volumetric assessment and graft weight is given in Figure 1.
(Enlarge Image)
Figure 1.
Correlation between CT volumetric assessment and graft weight.
Eleven grafts had 2 left bile ducts. Two grafts had 2 left arteries. There was no variation in the anatomy of the left portal branch. The hepatic vein anatomy was modal in all cases.
One recipient experienced a massive esophageal variceal bleeding during surgery and died before graft implantation. Of the 64 LLS transplanted children, 5 recipients (7.8%) had hepatic artery thrombosis (HAT), 3 (4.6%) had portal vein thrombosis, 3 (4.6%) presented acute rejection, and 10 (15.6%) had biliary complications. Three children (4.6%) died in the perioperative period. The reoperation rate for those complications was 12.5% (8 cases). Six children (9.3%) required a retransplantation during the follow up for cholangitis and arterial thrombosis. There was no case of primary graft nonfunction. Overall, patient and graft survival rates for LLLS pediatric transplantation were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively (Fig. 2).
(Enlarge Image)
Figure 2.
Overall patient and graft survival rates for LLLS pediatric transplantation (64 patients).
Results of the Donors
Of the 70 donors, 66 (94.3%) were operated upon using pure laparoscopy, whereas 4 (5.7%) required conversion to an open technique. Neither hybrid nor hand-assisted techniques were used. No donor received an intraoperative allogeneic transfusion. The Lyon team used a cell saver system for an autotransfusion in 6 donors. The median operative time was 275 (range: 175–520) minutes, and mean blood loss was 82 ± 79 mL (range: 10–770). The mean graft warm ischemia was 9.0 ± 4.1 minutes. Operative data are presented in Table 3.
Conversion
Four conversions (5.7%) were necessary, 3 during left lateral section procurement and 1 during a left liver procurement. The first conversion was undertaken after a left portal branch injury while cutting the left bile duct. The vein was easily repaired, but a systematic conversion was performed to make sure that there was no stenosis of the left portal vein. This injury occurred at the beginning of our experience (case 4 in 2003). Two of the conversions were undertaken because of a poor exposure and slow progression during transection. The last conversion was performed because of doubts regarding the biliary anatomy. This last conversion was performed to check the anatomy of the biliary tree because of a putative biliary duct variation. None of the conversions were associated with acute or uncontrolled bleeding or with the need for perioperative transfusion. All converted donors had an uneventful recovery.
Postoperative Outcome and Morbidity
No donor died. The median hospital stay was 6 days, ranging from 3 to 18 (Table 4). Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (15.7%) had grade 1 complications; 5 donors (7.1%) had grade 2 complications; and 1 donor had a grade 3 complication.
Overall, 4 donors required reoperation: 2 for biliary leakage, 1 for suprapubic hematoma, and 1 for cystoscopy. One donor had a hematoma of the suprapubic incision that required surgical drainage and transfusion of 2 units of packed red blood cells. One donor had a macroscopic hematuria and pelvic pain due to urinary bladder trauma. Cystoscopy revealed a transfixion suture through the urinary bladder wall. After the endoscopic removal of this suture and urinary catheter placement, the donor fully recovered.
Two donors (2.8%) developed a massive bile leakage and underwent reoperations. The primary clinical manifestation of the choleperitoneum due to bile leakage was confusion and abdominal pain. Both reoperations were performed by redo-laparoscopy. In 1 case, the source of the biliary leak was due to titanium clip dislodgement on the left bile duct stump. In the other case, the bile leak originated from the segment I duct. In both cases, Prolene sutures were used to close the biliary leak. After these 2 events, we decided to replace standard titanium clips by the hem-o-lock type or stitches, and no similar events have occurred.
One donor presented a grade 3 complication. On follow-up, this donor presented with cholestasis. Magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography studies showed a stenosis of the right anterior bile duct. An endoscopic prosthesis was left in place upon the resolution of the cholestasis. However, because this biliary stenosis, the donor required an exhaustive follow-up by MRI. Later, neither cholestatic nor infectious complications occurred, and there was no dilation of the intrahepatic bile ducts at the time of the last follow-up. Finally, 1 donor presented a gastric stress ulcer diagnosed by a gastroscopy under sedation that was treated medically.
Graft Characteristics
The median graft weight was 252 (range: 118–390] g (Table 2). The correlation between CT volumetric assessment and graft weight is given in Figure 1.
(Enlarge Image)
Figure 1.
Correlation between CT volumetric assessment and graft weight.
Eleven grafts had 2 left bile ducts. Two grafts had 2 left arteries. There was no variation in the anatomy of the left portal branch. The hepatic vein anatomy was modal in all cases.
Recipient Outcomes
One recipient experienced a massive esophageal variceal bleeding during surgery and died before graft implantation. Of the 64 LLS transplanted children, 5 recipients (7.8%) had hepatic artery thrombosis (HAT), 3 (4.6%) had portal vein thrombosis, 3 (4.6%) presented acute rejection, and 10 (15.6%) had biliary complications. Three children (4.6%) died in the perioperative period. The reoperation rate for those complications was 12.5% (8 cases). Six children (9.3%) required a retransplantation during the follow up for cholangitis and arterial thrombosis. There was no case of primary graft nonfunction. Overall, patient and graft survival rates for LLLS pediatric transplantation were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively (Fig. 2).
(Enlarge Image)
Figure 2.
Overall patient and graft survival rates for LLLS pediatric transplantation (64 patients).
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