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Sioutas et al. Hepatoma Res 2021;7:26 https://dx.doi.org/10.20517/2394-5079.2020.111 Page 5 of 9

[77]
one donor had bile leakage after discharge . While some studies have shown the safety of robotic donor
hepatectomy, they have not yet reported superiority in efficacy when compared to open and laparoscopic
approaches [80,81] . A recent systematic review supports that the robotic approach is more beneficial regarding
hilar dissection, while the laparoscopic is more beneficial for parenchymal dissection with no major
difference in terms of ischemic time or cosmesis . In 2018, the international consensus statement on RLR
[39]
recommended that robotic donor hepatectomy can be an alternative option when performed by
experienced surgeons .
[82]

Laparoscopic living donor hepatectomy for recipients with hepatocellular carcinoma
Lee et al. compared pure laparoscopic vs. open donor right hepatectomy for living donor LT. The authors
[45]
reported data from 115 donors and recipients, with HCC being the indication for LT in 67.8% of the
patients. The study concluded that pure laparoscopic donor right hepatectomy is safe when performed by
[83]
[45]
an experienced team . A year later, Lee et al. conducted a similar study of 33 donors and recipients, with
HCC being the indication for LT in 21.2% of the patients. The incidence of postoperative complications
among donors was similar between the open and laparoscopic groups, while the two approaches yielded
[83]
similar results for most perioperative outcomes . Further details about these two studies are shown in
Table 1 [45,83] .

LAPAROSCOPIC-ASSISTED LIVER TRANSPLANTATION
Nine cases of living donor LT with hand-assisted laparoscopic surgery were first reported in 2011 by
Eguchi et al. . The hand-assisted laparoscopic total hepatectomy was performed with an upper midline
[84]
incision. Explantation and liver graft implantation were performed with an open approach after extending
[84]
the incision . In 2015, 29 selected cases of hybrid procedure for living donor LT were reported . Liver
[85]
recipients treated with the hybrid approach had no significant differences in blood loss, duration of surgery,
[85]
vascular anastomosis, and survival, compared to those treated with the conventional open procedure .
Dokmak et al. in 2020 published a hybrid LT case for neuroendocrine liver metastases with laparoscopic
[86]
total hepatectomy and liver graft implantation through a preexisting incision. They showed that the
[86]
laparoscopic approach for LT recipients may be safe and reasonable . Details from these studies are
summarized in Table 2 [84-86] . That growing body of evidence, even in patients with cancer, suggests that the
use of laparoscopy either for the donor or the recipient in LT for HCC will pave the way for further
advancements in the field of minimally invasive surgery and its introduction in the field of LT.

CONCLUSION
The use of minimally invasive surgical approaches for LT appears to be feasible. Such approaches may be
beneficial even for patients with recurrent HCC after resection requiring salvage LT. Regarding LLDS,
laparoscopy is advocated to become the gold standard. Regarding living donor hepatectomy or LT itself,
minimally invasive or hybrid laparoscopic approaches have been described. However, laparoscopic or even
robotic donor hepatectomy is still rarely performed and only by experienced teams, and thus the need for
an international registry or multicenter studies is apparent. In the future, the ongoing improvements in
technology will probably further expand this rising surgical field.