Standardized Hybrid Living Donor
Hemihepatectomy in Adult-to-Adult
Living Donor Liver Transplantation
Susumu Eguchi, Akihiko Soyama, Takanobu Hara, Koji Natsuda, Satomi Okada,
Takashi Hamada, Taiichiro Kosaka, Shinichiro Ono, Tomohiko Adachi,
Masaaki Hidaka, and Mitsuhisa Takatsuki
Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
The aim of this study was to analyze the outcomes of the most updated version and largest group of our standardized
hybrid (laparoscopic mobilization and hepatectomy through midline incision) living donor (LD) hemihepatectomy com-
pared with those from a conventional laparotomy in adult-to-adult living donor liver transplantation (LDLT). Of 237
adult-to-adult LDLTs from August 1997 to March 2017, 110 LDs underwent the hybrid procedure. Preoperative and
operative factors were analyzed and compared with conventional laparotomy (n 5 126). The median duration of laparo-
scopic usage was 26 minutes in the hybrid group. Although there was improvement in applying this procedure over time
from the beginning of the series of cases studied, blood loss and operative duration were still smaller and shorter in the
hybrid group. There was no signiﬁcant difference between the groups in the incidence of postoperative complications
greater than or equal to Clavien-Dindo class III. There was no difference in recipient outcome between the groups. Our
standardized procedure of hybrid LD hepatectomy is applicable and safe for all types of LD hepatectomies, and it enables
the beneﬁt of both the laparoscopic and the open approach in a transplant center without a laparoscopic expert.
Liver Transplantation 24 363–368 2018 AASLD.
Received August 27, 2017; accepted November 26, 2017.
Since the ﬁrst complete pure laparoscopic left lateral
segmentectomy for hepatocellular carcinoma was per-
formed in 1995,
we have expanded the adaptation of
laparoscopic liver resection.
Except for cases requir-
ing an anterior approach or patients with a history of
upper abdominal surgery, all other procedures were
able to be performed through midline abdominal inci-
This method has also been adopted for living
donor (LD) hemihepatectomy and even for recipi-
For LD, a certain size of incisional wound is
needed in any case in order to take the graft liver out
without any damage.
For LD hemihepatectomy, initially we attempted
hepatectomy with a right rib costal incision, but with
this approach, we found poor visual ﬁeld access to the
root of the hepatic vein and the ribs did not make a
sufﬁcient retraction. Conversely, with this incision
method, we were able to recognize when the inferior
vena cava (IVC) is located almost in the midline.
Therefore, ﬁrst we made a midline incision, and under
the pneumoperitoneum, the right hepatic ligaments
and bare area were dissected under laparoscope, and
then we extended the median incision of the upper
abdomen. Around the IVC, the right hepatic vein and
the adrenal gland were sufﬁciently accessible by the
subsequent midline extension laparotomy. This
approach is similar to the method reported by Koffron
et al. in 2006,
and it makes use of the laparoscopic
advantages. This is the same reason why splenectomy
through a large laparotomy is decreasing.
Abbreviations: IVC, inferior vena cava; LD, living donor; LDLT,
living donor liver transplantation; n.s., not signiﬁcant; YS, year
Address reprint requests to Susumu Eguchi, M.D., Ph.D., Department
of Surgery, Nagasaki University Graduate School of Sciences, 1-7-1
Sakamoto, Nagasaki, 852-8501 Japan. Telephone: 1 81958197316,
FAX: 1 81958197319, E-mail: email@example.com
2017 by the American Association for the Study of Liver
View this article online at wileyonlinelibrary.com.
Potential conflict of interest: Nothing to report.
EGUCHI ET AL.