Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Table 4 Barriers to global dissemination of minimally invasive donor hepatectomy

Barriers
Institutional barriers	Donor safety: concerns for compromised donor safety when using MIS approaches (e.g., control of bleeding, parenchymal transection). High-risk: donor morbidity and mortality can compromise institutional reputation and even suspension of living donor transplantation program. Limited evidence: existing studies selecting for most ideal patients
Surgeon-related barriers	Learning curve: high surgical experience in both minimally invasive liver surgery and living donor hepatectomy. Limited MIS experience by liver surgeons. Transplant surgeons in some countries do not frequently practice HPB surgery
Accessibility	Localization of expertise in very few centers worldwide. Need for proctoring by surgical experts to start MIDH program (e.g., fly in experts from specialist centers to proctor first cases, local surgeons fly to specialist centers to observe). Resources: need for specialized technology (e.g., CUSA)

CUSA: Cavitron ultrasonic surgical aspirator; HPB: Hepato-pancreato-biliary; MIDH: Minimally invasive donor hepatectomy; MIS: Minimally invasive surgery.