Living Donor Liver Transplant: Send in the Robots

摘要

See Article on Page 1455 Potential conflict of interest: Nothing to report. Although living donor liver transplantation (LDLT) has expanded the organ donor supply, concerns about short‐term and longterm donor morbidity have limited a wider adoption. Minimally invasive surgical (MIS) techniques for donor hepatectomy were initially described in 2002.(1) However, more than a decade went by before techniques for left lateral sectionectomy gained traction, spreading to full hemihepatectomies.(2‐4) Although MIS techniques rapidly disseminated to most centers in donor nephrectomy, this change has not been reproduced in MIS donor hepatectomy, which has remained concentrated at a few high‐volume LDLT programs. The result is that most living donors undergo traditional open hepatectomy with a possible recovery of several months. In the current issue, Broering et al. report a series of robotic right donor hepatectomies performed with initial proctoring.(5) Using propensity score matching, they describe 35 patients who underwent transplantation with this technique compared with 70 patients who underwent open surgery. The donation procedures performed using the robotic technique required less patient‐controlled analgesia and shorter length of stay. Initially, the operative time was substantially longer than for the open donor hepatectomy, but the authors had a reduction in operative time as their experience increased. Fewer complications occurred in the robotic donor hepatectomies compared with the open donor hepatectomies. No conversions to open hepatectomy were required. The robotically procured grafts did not differ anatomically, and recipient outcomes were equivalent. This experience is notable for a number of reasons: the use of proctoring, the decision to perform consecutive cases rather than selective cases, and the use of the robotic platform. The use of proctoring to expand the center experience outside of formal training programs could enable exponential growth in the application of MIS techniques. The availability of dual robotic consoles greatly facilitates proctoring. However, although Broering et al. imply the importance of proctoring, they leave many unanswered questions, such as who should do the proctoring and how many cases are required? The robotic platform may allow for complex anatomical issues to be addressed safely. Some programs have selected donors with smaller allografts or simpler biliary anatomy.(6,7) Three‐dimensional visualization, fully articulating instruments, and arms that never tire undoubtedly replicate open surgery in ways that classic laparoscopy does not. Indocyanine green cholangiography may be a useful adjunct in cases with more complex biliary anatomy. Hand‐assisted platforms have facilitated the expansion of laparoscopy in donor nephrectomy. Although hand assistance has been used in donor hepatectomy,(8) it has not been routinely adopted. The similarity of performing hepatectomies on the robotic platform to performing open surgery, albeit with vastly improved visualization, may aid its broader application. However, cost limitations as well as a limited access to the robot for training surgeons in hepatopancreatobiliary and liver transplant may limit widespread adoption of this practice. As technology continues to evolve and there are improvements in energy devices, camera equipment, and the overall platform itself, robotic liver surgery may ultimately outperform and replace other MIS techniques. Reducing donor morbidity while preserving recipient outcomes is the goal of the application of MIS to LDLT. Although many questions remain, the experience described by Broering et al. makes a case for the use of the robotic platform in donor hepatectomy.