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Sioutas et al. Hepatoma Res 2021;7:26 https://dx.doi.org/10.20517/2394-5079.2020.111 Page 3 of 9

According to the authors, LLR is a logical option even for recurrent HCC, with better short-term
[26]
postoperative outcomes than the open approach . Hybrid hepatectomy for HCC has also been associated
with shorter length of hospital stay, same survival rates, and longer operation time when compared with
[27]
open hepatectomy .

A study by Chen et al. showed that RLR for HCC is a feasible option for challenging major hepatectomies
[28]
in cirrhotic patients. When compared to the open procedure, it resulted in shorter hospital stay, less
postoperative pain, and similar survival outcomes, but longer operation time . When compared with the
[28]
open or the laparoscopic approach, it was found to be comparable in terms of margin-free resection
rates . Overall, LLR and RLR are considered to be equivalent in terms of safety and effectiveness for the
[29]
[30]
management of liver neoplasms .

ROLE OF MINIMALLY INVASIVE LIVING DONOR HEPATECTOMY FOR LIVER
TRANSPLANTATION
Technical details and learning curve of laparoscopic living donor hepatectomy
Living donor LT was first reported in 1990 [31,32] . The first laparoscopic donor hepatectomy in 2002 was a left
lateral donor segmentectomy (LLDS) for a pediatric recipient . Further minimal invasive surgical
[33]
approaches have since been described .
[34]

During laparoscopic donor hepatectomy, the Pringle maneuver is typically utilized to allow less blood loss
[35]
in donors without affecting liver function . For parenchymal transection, the high-pressure waterjet
system or the ultrasonic surgical aspirator are used . For hepatic and portal vein occlusion and division,
[36]
surgical staplers are used. For the hepatic artery and the bile duct, Hem-o-lok clips are used to avoid
shortening of vessel length . Because precise bile duct transection is important, intraoperative
[37]
cholangiography or indocyanine-green fluorescence cholangiography is often used . After resection, the
[38]
graft is retrieved through a Pfannenstiel incision in an endo-bag. The retrieval should be careful to avoid
graft injury . Furthermore, several innovations have been implemented for minimally invasive donor
[39]
hepatectomy, either preoperatively (i.e., 3D imaging and 3D printing ) or intraoperatively (i.e., surgical
[40]
[41]
robot ).
[42]
Donor hepatectomy is technically demanding. In particular, the learning curve for pure laparoscopic LLDS
[43]
is 25 cases , while the more difficult right donor hepatectomy requires approximately 60 cases [44,45] .
However, these numbers depend on other factors, such as prior experience on both open donor
hepatectomy and minimally invasive surgery in general.

Types and benefits of minimally invasive living donor hepatectomy
According to a recent systematic review, open donor hepatectomy is superior to the laparoscopic approach
in terms of hilar and parenchymal dissection and ischemic time. However, the laparoscopic approach has a
superior cosmetic effect .
[39]
Pure laparoscopic left and right hepatectomy for adult recipients
To choose between left or right donor hepatectomy, the surgeon has to consider the size of the recipient to
avoid small-for-size syndrome . Pure laparoscopic donor left and right hepatectomies for adult recipients
[46]
were first reported in 2013 [47-50] . These procedures are complex and require a high level of surgical expertise.
Despite this, some experienced teams have published successful reports with laparoscopic living donor
hepatectomy [51-55] . Some experts support the use of right donor hepatectomy without specific selection
[38]
criteria , while others have developed such criteria incorporating vascular anatomy and graft weight [56,57] .