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

目的：建立腹腔镜辅助供体肝切除术的程序，在微创和安全的way.Methods：我们选择了一个29岁/O的一个8个月/O的男孩与胆道闭锁的母亲作为活体供体，以提供通过最小的访问要切除的侧段移植。我们通过在气腹下将柔性腹腔镜通过12 mm套管针放置在上脐切口上来开始供体手术。在双侧肋下区域放置2个12 mm和2个5 mm穿刺器。通过分离肝脏附件充分游离肝外段，然后在腹腔镜视野下尽可能精确地准备肝左静脉根部、胆囊管、肝左动脉、门静脉左支和肝左管。在将导管置入胆囊管进行术中胆管造影后，切除胆囊。在开始肝切除术前，为了避免可能的CO2栓塞， ...更多信息 肝脏的切面。在剑突下作7 cm正中小切口，采用升壁法进行腹腔镜观察。在进行术中超声检查以确定所有主要血管和胆管后，我们开始通过微剖腹术用双极钳和超声剥离器通过使血液流入移植物来进行肝切除。采用小切口直接结扎并分离肝脏切面上出现的所有血管和胆尘。我们完成了准备的肝左静脉，肝左动脉，左门静脉，左肝管通过小切口下直接在沿着腹腔镜视图。术中胆道造影后，我们将左肝管根部分离，并通过小切口将切断的一端缝合。然后，完全分离仅与肝左静脉、肝左动脉和左门静脉连接的外侧段移植物。在放置血管夹并通过小剖腹术分离所有这些血管后，我们取出外侧段移植物并开始异位灌注移植物。灌注后将移植物植入受体体内。所有血管的根部均通过小切口直接闭合。在确认无出血和胆漏后，我们通过沿肝脏切面放置引流管沿着完成了腹腔镜辅助供体肝切除术。结果：1995年4月至2004年3月，我所共行29例开放式供肝肝侧叶切除术，手术过程顺利，无并发症发生。手术时间为510分钟（开放手术平均：368分钟，范围为266 - 459分钟）。失血量为70 ml（开放手术平均：252 ml，范围从不可数到790 ml）。供体在手术的第二天开始口服摄入，并在术后第八天回家，没有任何并发症。开放手术后平均住院时间为15天，范围为9 - 45天。移植物的大小为248 g，移植物在受体中的功能良好。受体没有并发症相关的移植手术，包括原发性移植物非功能，肝动脉血栓形成，并从切割表面的肝胆汁泄漏。结论：我们已经建立了安全和微创供体肝切除术，以尽量减少对活体供体的负担。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