Letter to the Editor: Minimally invasive donor hepatectomy—Would the robotic approach ameliorate recipient bile leak rates compared to pure laparoscopic technique?

摘要

To the editor, We read with interest the article by Jang et al1 on outcomes in recipients that underwent external biliary drainage (EBD) to reduce postoperative biliary complications following living donor liver transplantation. Some points in the manuscript are noteworthy, and the authors are to be complimented for their forthright reporting. The authors have adopted the EBD technique in grafts with small ducts, compromised ducts, and multiple bile duct openings. However, 2 or more bile ducts were more common among grafts in the non-EBD group, probably because the EBD technique was adopted later in the program. This may have influenced the final conclusion as both arms of the study appear to be similar. Perhaps propensity score matching may have resulted in a better comparison between the 2 groups. The warm ischemia time has been calculated from the time the right hepatic artery was clamped till the graft was extracted from the peritoneal cavity. The average time of almost 30 minutes in this study is intriguing. Other studies on minimally invasive donor hepatectomy have reported significantly shorter time periods.2 As rightly mentioned, the markedly longer warm ischemia could be one of the reasons for the increased biliary complications among recipients. Out of 190 recipients that received grafts from pure laparoscopic donors (PLDH) during the study period, 90(47.36%) of them went on to develop significant biliary complications (grade 3). In addition, 3 other recipients developed bile leaks due to EBD-related issues. Furthermore, the occurrence of grade 1&2 adverse biliary outcomes is not clear in this study. Considering the unparalleled experience of the authors, the high incidence of biliary complications in recipients following PLDH is not only unsettling but thought-provoking as well. Multiple bile duct openings on the graft where a single bile duct is expected remain a major drawback of PLDH. This is because bile duct division and precise suturing of the remnant bile duct using fine sutures during PLDH is difficult. Surgeons commonly apply clips during donor bile duct division, which will lead to a reduction in length and result in multiple bile duct openings on the graft. We have previously reported that the robotic platform would probably be the better modality as bile duct division exactly mimics open surgery, and outcomes are comparable to open donor hepatectomy even when complicated grafts are harvested.3,4 As randomized trials comparing both modalities are unlikely to happen, data from studies like this is crucial in streamlining guidelines and helping centers new to minimally invasive donor hepatectomy in taking informed decisions.