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Page 4 of 9 Sioutas et al. Hepatoma Res 2021;7:26 https://dx.doi.org/10.20517/2394-5079.2020.111

Several studies have described successful pure laparoscopic right hepatectomy for donors with variations in
bile ducts [53,58,59] , while anatomical reasons have been associated with high complication rates [45,60] .
Laparoscopic right donor hepatectomy has been associated with a similar complication rate and shorter
[38]
length of hospital stay compared to the open approach [45,60] . Suh et al. showed that complication rates,
hospital stay, and re-hospitalization were similar between donors undergoing either pure laparoscopic or
open right donor hepatectomy.

Right donor hepatectomy may be preferred for yielding a larger graft, yet studies have shown that
[61]
[49]
laparoscopic left donor hepatectomy is also feasible . Samstein et al. compared laparoscopic to open or
hybrid left donor hepatectomy. While the laparoscopic group required a longer time for graft procurement,
it was associated with decreased blood loss, shorter hospital stay, and fewer days away from work. The one-
[61]
year survival rates were similar between the two groups .
Pure laparoscopic left lateral donor sectionectomy for pediatric recipients
Laparoscopic LLDS is considered to be a safe alternative to the open approach. This method has been
advocated to become the new standard of care for LLDS for pediatric recipients . It has the benefit of
[57]
acceptable recipient outcomes, less intraoperative bleeding, a shorter length of hospital stay, no wound
complications, and similar biliary and vascular complications with the open approach, again with the
[67]
potential drawback of long operative time [61-66] . Soubrane et al. compared laparoscopic liver with kidney
donors and found that, while liver donors had longer hospital stay and operation times, LLDS resulted in
fewer minor complications .
[67]

Hand-assisted and hybrid donor hepatectomy
Hand-assisted or hybrid donor hepatectomy has the same principles as pure laparoscopic donor
hepatectomy, but the hepatic hilum is dissected and the liver is transected through a small open upper
midline or transverse incision [34,68] . Similarly, the muscle layer is not interrupted, and, as a result, patients
feel less abdominal wall pain than with the open hepatectomy . However, the small incision of these
[69]
techniques has drawbacks for obese patients with deep body cavities, such as longer operative duration,
postoperative complications, and longer hospital stay, as it is difficult for surgeons to manage vascular
injuries in these deeper areas [68,70,71] . Recent meta-analyses associated laparoscopic-assisted hepatectomy with
fewer complications, less blood loss and pain, no mortality, faster recovery, better cosmetic result, and
longer operation time [70,72] . In other words, laparoscopic-assisted hepatectomy is a safe and feasible
alternative to open hepatectomy for well-selected donors when performed by experienced teams and can
[73]
be gradually adopted by less-experienced groups [74,75] . In fact, hand-assisted or hybrid donor hepatectomy
can be used by surgeons when transitioning from open to pure laparoscopic donor hepatectomy, because of
[76]
the steep learning curve of the latter .

Robotic donor hepatectomy
[40]
The first robotic donor hepatectomy was a right hepatectomy reported by Giulianotti et al. in 2012, and
since then it has been implemented by several centers [40,77-79] . This technique offers the benefits of 3D vision,
a stable and magnified field, and improved instrument precision compared to the laparoscopic technique.
This helps the biliary and vascular dissection, and the decision of the point of transection, while the
improved ability for suture ligation of venous bleeders can be helpful in minimizing blood loss . The first
[40]
[77]
series of 13 robotic right donor hepatectomies was published by Chen et al. in 2016. The robotic group
required no open conversion, the postoperative recovery was quicker, and the need for analgesics was
decreased. Compared to the open group, the robotic one showed comparable results for complication rates,
blood loss, and recovery of donor liver function. However, the robotic group had longer operation time, and