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

Table 1 Biliary duct and portal vein variations

Biliary duct variations
A	Normal bifurcation (57%)
B	Trifurcation of 3 ducts (12%)
C	Right anterior (C1, 16%) or right posterior (C2, 4%) duct draining into common hepatic duct
D	Right posterior (D1, 5%) or right anterior (D2, 1%) duct draining into left hepatic duct
E	Absence of hepatic duct confluence (3%)
F	Drainage of right posterior duct into cystic duct (2%)
Portal vein variations
I	Classical anatomy
II	Trifurcation
III	Right posterior vein as first branch of main portal vein
IV	Segment VII branch separate branch of right portal vein
V	Segment VI branch separate branch of right portal vein

Table 2 Clavien-Dindo classification for donor and recipient complications[55]

Grade	Definition
I	Non-life threatening. Requires only bedside interventions, postoperative bleeding requiring three units of packed red blood cells, no prolongation of hospital or ICU stay longer than twice the population median
II	No residual disability. Any complication that is potentially life threatening, or requires use of four units of packed red blood cells, or prolongation of hospital stay for > 4 wk or ICU stay for > 5 d
III	Residual disability. Any complication with residual or lasting functional disability or development of malignant disease
IV	Liver failure or death. Requires liver transplantation (grade IVA) or results in death (grade IVB)

ICU: Intensive care unit.

Table 3 Reported complications of minimally invasive living donor hepatectomy

Grade	Complication
I	Fever, gastroenteritis, gastric ulcer, occipital alopecia, pneumothorax without drainage, wound infection, suprapubic hematoma, ileus, arm neuropraxia, atelectasis, transient neuropenia
II	Gastroparesis, pulmonary infection, segment IV infarction, bile duct stenosis, pancreatitis, cystitis, incisional port-size hernia
IIIa	Biliary leakage, fluid collection, bladder injury, portal vein thrombosis or stenosis
IIIb	Abdominal abscess, intra-abdominal bleeding

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.