Pure laparoscopic living donor hepatectomy: learning curve, technical pearls and pitfalls
Review Article

Pure laparoscopic living donor hepatectomy: learning curve, technical pearls and pitfalls

Dagny von Ahrens, Benjamin Samstein

Department of Surgery, Weill Cornell Medicine, New York, NY, USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Benjamin Samstein, MD. Payson 707, 525 East 68th Street, New York, NY 11201, USA. Email: samstei@med.cornell.edu.

Abstract: Living donor liver transplant (LDLT) has markedly reduced waiting list mortality and expanded access to life-saving therapy for thousands across the globe. Application of minimally invasive surgery to donor hepatectomy has been markedly slower than in many other aspects of surgery. For donors undergoing hepatectomy, many long-lasting issues related to donation appears to involve the large incision typically used for donor hepatectomy. This has provided significant motivation for a minimally invasive approach to donor hepatectomy. Pure laparoscopic donor hepatectomy was initially reported in 2002 but adoption has been slowed by concerns about hemostasis, donor safety and recipient outcomes. Highly select centers have successfully developed minimally invasive living donor programs and have been reporting outcomes and techniques utilized. We review the technical approaches have been learned by early adopters. We discuss some of the pitfalls and challenges associated with laparoscopic donor hepatectomy. We discuss the reported experiences with the learning curve for this complex operation. We discuss the future of minimally invasive surgery for donor hepatectomy.

Keywords: Living donor; hepatectomy; laparoscopy; liver transplantation

Received: 27 November 2019; Accepted: 05 December 2019; Published: 15 April 2020.

doi: 10.21037/ls.2019.12.03


Living donor liver transplant (LDLT) was successfully developed after experience with reduced sized grafts and high pediatric waitlist mortality in the 1980s (1). First performed in 1989 using left lateral sections (LLS), LDLT eventually included hemi-hepatectomies for adult recipients (2-4). Use of living donors for transplantation has required careful balance with consideration of donor risk (5).

Donor hepatectomy has been associated with excellent short-term outcomes (6). However, significant donor morbidity can occur with the large incision used for most open donor hepatectomies. At least 30% to 50% of the complications of LDLT appear to be related to abdominal wall trauma, including hernia, bowel obstruction, and chronic abdominal discomfort (7). Furthermore, many of the chronic or longer issues that liver donor face may be related to abdominal wall trauma rather than liver mass or function. This has provided significant motivation for a minimally invasive approach to donor hepatectomy.

Laparoscopic procurement of the LLS for LDLT was first reported in 2002 (8). The adoption of minimally invasive techniques in liver donor surgery has been markedly slower than in kidney. Concerns about hemostasis and safety limited application of minimally invasive surgical (MIS) techniques to donor hepatectomy. Within 10 years of the first laparoscopic donor nephrectomy, minimally invasive techniques were routinely applied for donor nephrectomy (9). However, laparoscopic donor hepatectomy remained isolated to a handful of liver transplant centers despite multiple reports indicating that pure laparoscopic approach to LLS donor hepatectomy was equivalent to open approach (10-14). Although MIS was extended to hemi-hepatectomies in 2006 (15) purely laparoscopic approach to hemi-hepatectomies would take more than 10 years from Cherqui et al.’s report and nearly 20 years from Ratner et al.’s report on laparoscopic donor nephrectomy (16,17). Several series in 2013 described hemi-hepatectomies performed via pure laparoscopic approach (18-20). A reduction in post-operative analgesia, ileus, length of stay, improved patient satisfaction, and earlier return to work has been demonstrated in some MIS series (21-23). In 2014, Morioka consensus conference in 2014 acknowledged laparoscopic LLS as the standard of care but cautioned that hemi-hepatectomy should be reserved for expert centers (24).

Since then, laparoscopic living donor hepatectomy has continued to steadily expand but remains utilized at a minority of LDLT centers throughout the world. The number of publications has increased with 7 publications between 2002 and 2007 to 66 in the past 5 years. We aim to review the cumulative published experience related to the learning curve as well as technical pearls and pitfalls that have been identified by groups with significant experience in performing PLDH.

Technical pearls

The complexity of PLDH requires an experienced team, advanced laparoscopic equipment and a significant surgical skillset. The development of technology has facilitated the growth of MIS liver surgery and PLDH. Enhanced laparoscopy is widely considered to facilitate laparoscopic liver surgery either in the 4K platform or 3D. The 3D flexible scope improves visualization, knot tying and dissection speed in PLDH. A significant reduction in operative time with the 3D technology in laparoscopic liver resection when compared with retrospective 2D controls has been described (25). Several Korean and an American group performing PLDH employ this technology and report its benefit in their experience (19,26,27).

Port placement is critical to a safe and efficient PLDH. Optimizing reach and angle can avoid damage to the graft itself and streamline surgeon ergonomics. One group described their experience and evolution port placement, as well as the challenges encountered with misplacement of each, such as difficult access to vital structures, suboptimal axis of control for inflow, or fighting between instruments (28).

Laparoscopy is dependent on a hemostatic field. Blood in the operative field absorbs light and diminishes visualization. Suction devices cannot be used continuously as they lessen pneumoperitoneum and reduce the operative field. Thus, bleeding has a dramatic impact on progression and makes the operation more difficult. Intermittent hepatic inflow occlusion is associated with lower blood loss in the donors and no difference in liver function (29). Many centers performing laparoscopic donor hemi-hepatectomy use intermittent Pringle maneuver to facilitate parenchymal transection and every laparoscopic liver surgeon should have a quick technique to gain inflow control. In our program, we utilize a Satinsky clamp inserted into the LLQ to gain inflow control. Other techniques that can be used for inflow occlusion include bulldog clamps, umbilical tape through a chest tube (30), straight vascular clamp in the LUQ.

The most common instrument for parenchymal transection is laparoscopic Cavitron Surgical Aspirator (CUSA Excel; Valleylab, Boulder, Colorado, USA). The ultrasound waves generate energy to fragment and aspirate parenchymal tissue. It is usually used in conjunction with an energy device such as bipolar cautery. This allows for a controlled laparoscopic transection and helps in minimizing blood loss. As mentioned above, blood within the field hinders visualization in a laparoscopic case as it absorbs light requiring meticulous hemostasis throughout the case (31). Our group prefers an articulating bipolar device such as the Caiman (Aesculap, Tuttlingen, Germany) to facilitate liver mobilization and hemostasis.

Our group and others have used modifications of the hanging maneuver performed with umbilical tape, plastic tubing or Goldfinger retractor (Ethicon Endosurgery, Cincinnati, OH, USA) depending upon the group’s preference (30). This maneuver also assists in accuracy in defining the transection plane.

Biliary imaging both pre-operatively and intra-operatively is critical to minimize biliary complications of both donor and recipient. It is important to have intra-operative cholangiography to ensure the optimal transection plane (32,33). Whether indocyanine-green fluorescence cholangiography (ICG) or traditional contrast cholangiography is used, currently is a matter of surgeon preference (19,23,32,33).

Patient selection is also paramount to a successful PLDH program. Early in the PLDH experience at one center, complications were more likely in donors with vascular and biliary anomalies (34). This is not uniform and the highest experienced center has reported good outcomes with patients with anatomic variants rate (34-36). It is reasonable that donors with variant anatomy not be selected until adequate experience has been achieved in PLDH (37).


The liver’s lack of external landmarks and the nonlinear plane of transection in a donor hepatectomy increase the risk of technical errors. Additionally, the ideal liver retractor is more similar to a human hand than a laparoscopic grasper. Large livers can be difficult to retract and vulnerable to capsular injury. Thus some centers advocate restricting laparoscopic donor hepatectomy to smaller livers (38).

The precision required in defining the transection plane in donor surgery to optimize graft anatomy and avoid remnant bile leak is a key component of both open and laparoscopic donor hepatectomy. Laparoscopic magnification may enhance visualization and identification of bile leak but testing for bile leaks is more challenging laparoscopically. Bile leaks with laparoscopic suturing have been reported (34) and many laparoscopic donor programs feel that clipping provides the most watertight occlusion of the remnant duct stump. Biliary stricture can also occur in the donor and has been reported (34). Donor vascular complications have occurred and are often due to variant anatomy and as discussed above donors with variants anatomy are most appropriate for centers with the most experience of laparoscopic donor hepatectomy (10-12,34,39).

Recipient complications must also be considered and use of staplers particularly bilateral staplers have raised concerns about vessel length. Graft quality in PLDH has been shown to be similar to open though in some early experiences multiple bile ducts were encountered (23). Utilization of staplers for vascular transection does shorten the graft vasculature and requires expertise for reconstruction (36). Recipient artery complications have been rare and thought to potentially be due traction injury due to manipulation laparoscopically with lack of tactile feedback or thermal injury due to CUSA or energy (27). Vein length can be addressed using extension grafts (40).

Learning curve

Laparoscopic donor hepatectomy requires experience in donor hepatectomy as well as laparoscopic liver surgery. Laparoscopic hepatectomy has been shown to have a long learning curve of 45–60 cases (41). All of the groups that have developed PLDH had accumulated extensive experience with hundreds of procedures in open donor liver surgery and laparoscopic liver surgery prior to embarking on laparoscopic donor program development. With this experience still, the published learning curves for PLDH ranged from at least 15–20 for LLS (11,42) to 60 procedures for major LDH emphasizing the complexity of this operation (37). The most recent report using a CUSUM analysis determined the learning curve for right-sided PLDH to be 70 cases, with an extensive experience in living donor hepatectomy and laparoscopic hepatectomy up front suggesting an even more substantial curve (43).

In each of the published series, operative time, warm ischemic time and blood loss generally decrease over time and the largest series generally report fewer major complications including vascular and biliary complications later in their experience (26,27,34,44). In many of these, the authors report an alteration in technique after encountering complications, for instance, remnant bile duct closure with suture, metal clip or Hem-o-Lock clip, or the use of ICG cholangiogram after biliary complications. This evolution in technique inherent to development of novel procedures warrants caution in interpreting complication rates and operative times.

It is unclear whether learning curve data from early adopters who are primarily self-taught will be generalizable to other groups. As the technique become more standardized, it may be that learning curves will be shortened. However, living donor and laparoscopic liver surgery requires coordination of a large team that may include junior surgeons, surgical trainees, circulating nurses, scrub nurses and OR technicians. The experience of each team member can impact operative time and perhaps even outcomes.

Future directions

Minimally invasive application to living donor hepatectomy appears to be growing significantly. In addition to conventional laparoscopy, the robotic platform has been increasingly utilized for hepatectomy as surgeons gain experience. The first donor robotic hepatectomy was reported in 2011 in a hybrid fashion (45). A series of thirteen pure robotic donor hepatectomies was reported in 2016 with excellent outcomes (46) including acceptable warm ischemic time and comparably low rates of vascular and biliary complications in the recipients. ICG is built-in to the system making its use easier and more dynamic throughout the robotic case. Wider adoption of robotic living donor hepatectomy has been limited by the lack of tools for parenchymal transection primarily the ultrasonic aspiration.

Proctoring and mentoring have been integral the dissemination of experience in MIS living donor hepatectomy amongst centers throughout the world; yet, there are so few first generation PLDH surgeons that the creation of formalized training programs is not possible. Continuing the trend of proctoring and mentoring will be necessary to ensure quality and diffusion of best practices as more centers develop laparoscopic living donor programs.

Experience in pure laparoscopic donor hepatectomy is increasing at select centers. The technical difficulty, steep learning curve and requirement for donor safety and excellent recipient outcomes should encourage the exchange of lessons learned at these highly specialized institutions throughout the development of a PLDH program. Challenges for diffusion of this technique are significant but surmountable.




Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


  1. Broelsch CE, Emond JC, Whitington PF, et al. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg 1990;212:368-75; discussion 375-7. [Crossref] [PubMed]
  2. Strong RW, Lynch SV, Ong TH, et al. Successful liver transplantation from a living donor to her son. N Engl J Med 1990;322:1505-7. [Crossref] [PubMed]
  3. Lo CM, Fan ST, Chan JK, et al. Minimum graft volume for successful adult-to-adult living donor liver transplantation for fulminant hepatic failure. Transplantation 1996;62:696-8. [Crossref] [PubMed]
  4. Kawasaki S, Makuuchi M, Matsunami H, et al. Living related liver transplantation in adults. Ann Surg 1998;227:269-74. [Crossref] [PubMed]
  5. Singer PA, Siegler M, Lantos JD, et al. The ethical assessment of innovative therapies: liver transplantation using living donors. Theor Med 1990;11:87-94. [Crossref] [PubMed]
  6. Muzaale AD, Dagher NN, Montgomery RA, et al. Estimates of early death, acute liver failure, and long-term mortality among live liver donors. Gastroenterology 2012;142:273-80. [Crossref] [PubMed]
  7. Abecassis MM, Fisher RA, Olthoff KM, et al. Complications of living donor hepatic lobectomy--a comprehensive report. Am J Transplant 2012;12:1208-17. [Crossref] [PubMed]
  8. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet 2002;359:392-6. [Crossref] [PubMed]
  9. Wright AD, Will TA, Holt DR, et al. Laparoscopic living donor nephrectomy: a look at current trends and practice patterns at major transplant centers across the United States. J Urol 2008;179:1488-92. [Crossref] [PubMed]
  10. Soubrane O, Cherqui D, Scatton O, et al. Laparoscopic left lateral sectionectomy in living donors: safety and reproducibility of the technique in a single center. Ann Surg 2006;244:815-20. [Crossref] [PubMed]
  11. Soubrane O, de Rougemont O, Kim KH, et al. Laparoscopic Living Donor Left Lateral Sectionectomy: A New Standard Practice for Donor Hepatectomy. Ann Surg 2015;262:757-61; discussion 761-3. [Crossref] [PubMed]
  12. Scatton O, Katsanos G, Boillot O, et al. Pure laparoscopic left lateral sectionectomy in living donors: from innovation to development in France. Ann Surg 2015;261:506-12. [Crossref] [PubMed]
  13. Macacari RL, Coelho FF, Bernardo WM, et al. Laparoscopic vs. open left lateral sectionectomy: An update meta-analysis of randomized and non-randomized controlled trials. Int J Surg 2019;61:1-10. [Crossref] [PubMed]
  14. Broering DC, Elsheikh Y, Shagrani M, et al. Pure Laparoscopic Living Donor Left Lateral Sectionectomy in Pediatric Transplantation: A Propensity Score Analysis on 220 Consecutive Patients. Liver Transpl 2018;24:1019-30. [Crossref] [PubMed]
  15. Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522-5. [Crossref] [PubMed]
  16. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995;60:1047-9. [PubMed]
  17. Ratner LE, Kavoussi LR, Sroka M, et al. Laparoscopic assisted live donor nephrectomy--a comparison with the open approach. Transplantation 1997;63:229-33. [Crossref] [PubMed]
  18. Soubrane O, Perdigao Cotta F, Scatton O. Pure laparoscopic right hepatectomy in a living donor. Am J Transplant 2013;13:2467-71. [Crossref] [PubMed]
  19. Samstein B, Cherqui D, Rotellar F, et al. Totally laparoscopic full left hepatectomy for living donor liver transplantation in adolescents and adults. Am J Transplant 2013;13:2462-6. [Crossref] [PubMed]
  20. Troisi RI, Wojcicki M, Tomassini F, et al. Pure laparoscopic full-left living donor hepatectomy for calculated small-for-size LDLT in adults: proof of concept. Am J Transplant 2013;13:2472-8. [Crossref] [PubMed]
  21. Lee KW, Hong SK, Suh KS, et al. One Hundred Fifteen Cases of Pure Laparoscopic Living Donor Right Hepatectomy at a Single Center. Transplantation 2018;102:1878-84. [Crossref] [PubMed]
  22. Samstein B, Griesemer A, Cherqui D, et al. Fully laparoscopic left-sided donor hepatectomy is safe and associated with shorter hospital stay and earlier return to work: A comparative study. Liver Transpl 2015;21:768-73. [Crossref] [PubMed]
  23. Suh SW, Lee KW, Lee JM, et al. Clinical outcomes of and patient satisfaction with different incision methods for donor hepatectomy in living donor liver transplantation. Liver Transpl 2015;21:72-8. [Crossref] [PubMed]
  24. Wakabayashi G, Cherqui D, Geller DA, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015;261:619-29. [PubMed]
  25. Velayutham V, Fuks D, Nomi T, et al. 3D visualization reduces operating time when compared to high-definition 2D in laparoscopic liver resection: a case-matched study. Surg Endosc 2016;30:147-53. [Crossref] [PubMed]
  26. Hong SK, Shin E, Lee KW, et al. Pure laparoscopic donor right hepatectomy: perspectives in manipulating a flexible scope. Surg Endosc 2019;33:1667-73. [Crossref] [PubMed]
  27. Suh KS, Hong SK, Lee KW, et al. Pure laparoscopic living donor hepatectomy: Focus on 55 donors undergoing right hepatectomy. Am J Transplant 2018;18:434-43. [Crossref] [PubMed]
  28. Lee JM, Shehta A, Suh KS, et al. Guidance for Optimal Port Placement in Pure 3-Dimensional Laparoscopic Donor Right Hepatectomy. Liver Transpl 2019;25:1714-22. [Crossref] [PubMed]
  29. Park JB, Joh JW, Kim SJ, et al. Effect of intermittent hepatic inflow occlusion with the Pringle maneuver during donor hepatectomy in adult living donor liver transplantation with right hemiliver grafts: a prospective, randomized controlled study. Liver Transpl 2012;18:129-37. [Crossref] [PubMed]
  30. Rotellar F, Pardo F, Benito A, et al. Totally laparoscopic right-lobe hepatectomy for adult living donor liver transplantation: useful strategies to enhance safety. Am J Transplant 2013;13:3269-73. [Crossref] [PubMed]
  31. Swanstrom L, Soper N. Mastery of Endoscopic and Laparoscopic Surgery. 4 ed. Philadelphia, PA: Lippincott Williams and Wilkins, 2013.
  32. Rotellar F, Pardo F, Benito A, et al. Totally Laparoscopic Right Hepatectomy for Living Donor Liver Transplantation: Analysis of a Preliminary Experience on 5 Consecutive Cases. Transplantation 2017;101:548-54. [Crossref] [PubMed]
  33. Kim YS, Choi SH. Pure Laparoscopic Living Donor Right Hepatectomy Using Real-Time Indocyanine Green Fluorescence Imaging. J Gastrointest Surg 2019;23:1711-2. [Crossref] [PubMed]
  34. Kwon CHD, Choi GS, Kim JM, et al. Laparoscopic Donor Hepatectomy for Adult Living Donor Liver Transplantation Recipients. Liver Transpl 2018;24:1545-53. [Crossref] [PubMed]
  35. Lee B, Choi Y, Han HS, et al. Comparison of pure laparoscopic and open living donor right hepatectomy after a learning curve. Clin Transplant 2019;33:e13683. [Crossref] [PubMed]
  36. Shehta A, Lee JM, Lee KW, et al. Pure Laparoscopic Living Donor Hepatectomy for Donors With Right Portal Vein Anatomical Variations. Liver Transpl 2019;25:1445-54. [Crossref] [PubMed]
  37. Samstein B, Griesemer A, Halazun K, et al. Pure Laparoscopic Donor Hepatectomies: Ready for Widespread Adoption? Ann Surg 2018;268:602-9. [Crossref] [PubMed]
  38. Kim KH, Kang SH, Jung DH, et al. Initial Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy in an Experienced Adult Living Donor Liver Transplant Center. Transplantation 2017;101:1106-10. [Crossref] [PubMed]
  39. Hong SK, Lee KW, Choi Y, et al. Initial experience with purely laparoscopic living-donor right hepatectomy. Br J Surg 2018;105:751-9. [Crossref] [PubMed]
  40. Hwang S, Lee SG, Park KM, et al. Quilt venoplasty using recipient saphenous vein graft for reconstruction of multiple short hepatic veins in right liver grafts. Liver Transpl 2005;11:104-7. [Crossref] [PubMed]
  41. Brown KM, Geller DA. What is the Learning Curve for Laparoscopic Major Hepatectomy? J Gastrointest Surg 2016;20:1065-71. [Crossref] [PubMed]
  42. Broering DC, Berardi G, El Sheikh Y, et al. Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation. Ann Surg 2018. [Epub ahead of print]. [PubMed]
  43. Hong SK, Suh KS, Yoon KC, et al. The learning curve in pure laparoscopic donor right hepatectomy: a cumulative sum analysis. Surg Endosc 2019;33:3741-8. [Crossref] [PubMed]
  44. Takahara T, Wakabayashi G, Nitta H, et al. The First Comparative Study of the Perioperative Outcomes Between Pure Laparoscopic Donor Hepatectomy and Laparoscopy-Assisted Donor Hepatectomy in a Single Institution. Transplantation 2017;101:1628-36. [Crossref] [PubMed]
  45. Giulianotti PC, Tzvetanov I, Jeon H, et al. Robot-assisted right lobe donor hepatectomy. Transpl Int 2012;25:e5-9. [Crossref] [PubMed]
  46. Chen PD, Wu CY, Hu RH, et al. Robotic liver donor right hepatectomy: A pure, minimally invasive approach. Liver Transpl 2016;22:1509-18. [Crossref] [PubMed]
doi: 10.21037/ls.2019.12.03
Cite this article as: von Ahrens D, Samstein B. Pure laparoscopic living donor hepatectomy: learning curve, technical pearls and pitfalls. Laparosc Surg 2020;4:14.