Development of laparoscopic donor hepatectomy to minimize the burden imposed on a living donor

目的：建立微创、安全的腹腔镜辅助供肝切除术方法。方法：我们选择一名29岁的母亲，其8岁的男孩患有胆道闭锁，作为活体供体，通过最小通道提供外侧段移植物切除。我们通过在气腹下的肚脐上切口放置一个12mm套管针的柔性腹腔镜开始供体手术。双侧肋下放置两个12mm和两个5mm套管针。通过分割肝附着物，充分调动肝外侧段，尽可能在腹腔镜下精确准备左肝静脉根、囊管根、左肝动脉根、左门静脉根、左肝管根。将导管置入胆囊管进行术下胆管造影后取出胆囊。在开始肝切除术之前，停止气腹，以避免可能的二氧化碳栓塞通过肝脏切面。采用提壁法在剑突下方行7cm正中小剖腹切开术。在进行手术前超声检查以确定所有主要血管和胆管后，我们开始通过微型剖腹手术，使用双极凝固钳和超声解剖，使血液流入移植物。所有出现在肝脏切面的血管及胆尘均通过小剖腹直接结扎分离。我们在腹腔镜直视下通过迷你剖腹术完成左肝静脉根、左肝动脉根、左门静脉根、左肝管根的预备。术中胆管造影后，我们切开左肝管根部，并通过小剖腹缝合切口末端。然后将外侧段移植物完全分离，仅与左肝静脉、左肝动脉和左门静脉连接。在放置血管夹并通过小型剖腹手术分离所有血管后，我们取出外侧段移植物并开始原位灌注移植物。灌注后将移植物植入受体体内。通过小剖腹手术直接关闭所有血管的根部。经确认无出血、无胆漏，沿肝脏切口放置引流管，完成腹腔镜辅助供肝切除术。我们将此腹腔镜辅助供体外侧节段切除术的手术结果与我院1995年4月至2004年3月进行的29例开放式供体外侧节段切除术的手术结果进行比较。结果：腹腔镜辅助供肝切除术手术过程顺利、顺利。手术时间510分钟（开放手术平均368分钟，266 ~ 459分钟）。出血量70 ml（平均开腹手术：252 ml，从数不清到790 ml不等）。捐赠者在手术的第二天开始口服，并在术后第八天返回家中，没有任何并发症。开腹手术后平均住院时间15天，9 ~ 45天不等。移植体大小248 g，移植功能良好。受者无移植手术相关并发症，包括原发性移植物无功能、肝动脉血栓形成、肝切面胆漏。结论：我们建立了安全、微创的供肝切除术，以减轻活体供体的负担。少

Aims : To establish the procedure for laparoscopy-assisted donor hepatectomy both in minimally invasive and safe way.Methods : We selected a 29 y/o mother of an 8 m/o boy with biliary atresia as a living donor to provide the lateral segment graft to be resected through the minimum access. We started the donor surgery by placing a flexible laparoscope through a 12mm trocar on the upper navel incision under pneumoperitoneum. Two 12mm and two 5mm trocars were placed in the sub costal area bilaterally. The lateral segment was fully mobilized by dividing attachments of the liver, then preparation of the roots of the left hepatic vein, the cystic duct, the left hepatic artery, the left portal vein, and the left hepatic duct was precisely done under laparoscopic view as much as possible. The gall bladder was removed after placing a catheter into the cystic duct for infra-operative cholangiogram. Before starting liver resection, pneumoperitoneum was quitted to avoid possible CO2 embolism throu … More gh the cut surface of the liver. A 7cm of median mini-laparotomy was made beneath the xiphoid process by introducing the wall lifting method for laparoscopic view. After performing infra-operative ultrasonogram to identify all the major vessels and bile ducts, we started liver resection through the mini-laparotomy with a bipolar coagulating forceps and an ultrasonic dissector by having blood inflow into the graft. All the vessels and bile dusts appeared on the cut surface of the liver were ligated and divided directly through the mini-laparotomy. We completed preparation of the roots of the left hepatic vein, the left hepatic artery, the left portal vein, and the left hepatic duct through the mini-laparotomy under direct vision along with laparoscopic view. After having infra-operative cholangiogram, we divided the root of the left hepatic duct and sutured the cut end through the mini-laparotomy. Then, the lateral segment graft was fully separated in connection only with the left hepatic vein, the left hepatic artery, and the left portal vein. After placing vessel clamps and dividing all these vessels through the mini-laparotomy, we retrieved the lateral segment graft and started perfusion of the graft ex situ. The graft was implanted into the recipient after perfusion. The roots of the all vessels were closed directly through the mini-laparotomy. We completed laparoscopy-assisted donor hepatectomy by placing a drainage tube along the cut surface of the liver after confirming no bleeding and no bile leakage. We compared the operative result of this laparoscopy-assisted donor lateral segmentectomy with that of twenty-nine open donor lateral segmentectomy done from April 1995 to March 2004 at our institute.Results : The procedure of the laparoscopy-assisted donor hepatectomy was smooth and uneventful. The operative time was 510 minutes (mean of open surgery : 368 minutes, ranging from 266 to 459 minutes). The blood loss was 70 ml (mean of open surgery : 252 ml, ranging from uncountable to 790 ml). The donor started oral intake on the next day of the surgery and went back home on the eighth post-operative day without having any complication. The mean hospital stay after open surgery was 15 days, ranging from 9 to 45 days. The size of the graft was 248 g and the graft function was well in the recipient. The recipient had no complication related to the graft surgery including primary graft non-function, hepatic artery thrombosis, and bile leakage from the cut surface of the liver.Conclusions : We have established safe and minimally invasive donor hepatectomy to minimize the burden imposed on a living donor. Less