A team of surgeons at NewYork-Presbyterian/Columbia University Medical Center is the first in the country to report a fully laparoscopic hepatectomy - the removal of a portion of the liver - from a living adult donor for adult and teenage recipients. The procedure advances transplant surgery and offers hope for addressing the significant shortage of liver donors.
In the September issue of the American Journal of Transplantation, the team, led by Dr. Benjamin Samstein, surgical director of the Living Donor Liver Transplant Program at NewYork-Presbyterian/Columbia and assistant professor of surgery at Columbia University Medical Center, reports on two of the center's five successful fully laparoscopic hepatectomies from living adult donors for adult and teenage recipients. The group is one of three teams in the world, and the only in the United States, reporting the successful procedure.
"This is a small step, but I think a useful one," says Dr. Samstein. "We're at the forefront of perhaps a new era for living-donor liver transplants."
Despite public awareness campaigns and other efforts aimed at raising the availability of donor organs, there is a nationwide shortage of deceased organ donations. Thus, living donors are an important source of organs to aid patients living with end-stage organ disease, particularly of the liver and kidneys.
The ﬁrst successful living-donor liver transplant was performed in children in 1989 and subsequently extended to adults. Yet only about four percent of liver transplants are done with a living donor, compared with nearly 50 percent of kidney transplants, Dr. Samstein says. "Even though there is a tremendous need, we're not seeing the same use of living-donor livers as we are of living-donor kidneys," he says.
More than 90 percent of living-donor kidney transplants are done laparoscopically, explains Dr. Samstein, which results in reduced morbidity, scarring, and pain, as well as a quicker return to normal activities. Laparoscopic living-donor kidney removal has replaced the open approach in many centers around the world. Most liver donor surgeries, however, are still done through complex open surgery, leaving the donor with a greater risk of postoperative mortality, morbidity, and pain, as well as a recovery period that lasts, on average, eight to 12 weeks - two to three times longer than the recovery period for a laparoscopic kidney donor. Dr. Samstein says these factors may contribute to potential donors' hesitation or ineligibility.
While open hepatectomy remains the standard procedure for adult living-donor liver transplantation at most centers, a few strategies over the past several years have made the surgery less invasive. Researchers have succeeded in reducing the incision needed to remove a portion of the liver; they have also developed a hybrid technique that uses both open surgery and laparoscopy. This model has reduced postoperative pain for the donor.
In 2009, NewYork-Presbyterian/Columbia surgeons began doing fully laparoscopic hepatectomies on adult donors for transplantation into children. Pediatric recipients require only about 15 to 20 percent of a healthy adult liver for transplant. The liver has the unique ability to regenerate in both the donor and the recipient, growing and remodeling to form a complete, functioning organ. But adult recipients require a much larger portion of liver for successful transplant - about 30 to 35 percent - necessitating a more central cut through the donor liver. With three years of experience with hybrid and full laparoscopic techniques with more than 50 minimally invasive donor hepatectomies, the team was ready to expand laparoscopy to full left hepatectomies for adult recipients.
The current publication presents the details of two living adult donors who donated, through laparoscopic surgery, portions of their livers to others - the first, a 47-year-old man who donated to his young teenage daughter and the second a 28-year-old woman who donated to her mother-in-law.
While the recipient operation still requires an open procedure, the surgeons found the donor recovery in these cases to be half that of traditional open-surgery donation - from eight to four weeks - and substantially reduced even from the hybrid technique, with no additional postoperative donor complications. The donors also appeared to have less pain and lower risk of postsurgical hernia.
The authors caution that this procedure should be performed only in select cases and only by teams with signiﬁcant experience in both living-donor procedures and laparoscopic liver surgery, as laparoscopic hepatectomies require speciﬁc training. "While donor comfort and recovery are extremely important issues, donor safety continues to be paramount and the adoption of new surgical techniques ultimately needs to demonstrate that it meets the standard of safety of old techniques before adopted," they write.
NewYork-Presbyterian/Columbia remains the only center in the country currently performing fully laparoscopic living-donor hepatectomies for transplant into both pediatric and adult recipients.
"Clinical innovation and scientific progress constitute the core of the Center for Liver Disease and Transplantation's mission," says Dr. Jean C. Emond, chief of transplantation at NewYork-Presbyterian/Columbia and the Thomas S. Zimmer Professor of Reconstructive Surgery (in Pediatrics) at Columbia University Medical Center. "While this fully laparoscopic approach is still new and in its infancy, this is an important step in furthering the goal of successful liver transplantation from generous living donors." Dr. Emond was a member of the team that pioneered living donor liver transplantation, which is now considered one of the most important advances in the treatment of severe liver disease.
About the Living Donor Liver Transplant Program at the Center for Liver Disease and Transplantation
The Living Donor Liver Transplant Program at NewYork-Presbyterian/Columbia University Medical Center is one of the largest living-donor liver programs in North America. The program has performed more than 220 living-donor liver transplants since its inception. The team has also performed more left lobe donations than any other living-donor liver program in North America and introduced fully laparoscopic donation for all pediatric living-donor liver transplants in 2009.