This past September, three medical centers across the world simultaneously reported the first fully laparoscopic living donor hepatectomies on adults donating to other adults. One of these centers was in Belgium, another in France, and the third was here in New York City, at New York-Presbyterian/Columbia University Medical Center.
A living donor hepatectomy is a procedure in which a portion of a healthy person’s liver is removed so it may be transplanted to a patient suffering from end-stage liver disease. Due to the liver’s unique ability to regenerate inside the body of both the donor and the recipient, only a portion of the liver is needed for a successful operation. While living donor hepatectomy has become quite common throughout the United States, New York-Presbyterian/Columbia remains the only center performing this operation using minimally invasive laparoscopic techniques rather than standard open surgery.
In order to learn more about living donor liver transplants we talked with Dr. Benjamin Samstein, the lead surgeon on the operating team that performed this groundbreaking procedure.
When did surgeons begin performing living donor liver transplantation?
Dr. Samstein – The first living donor transplantation of any kind was a kidney transplant performed in 1954. The application of living donor hepatectomy to liver transplantation didn’t occur until 1989. This was due to the fact that liver transplants in general weren’t performed until 1963. So, compared to kidney transplantation, live donor liver transplantation was about 35 years behind.
When live donor liver transplantation did begin it was performed on parents donating to children, and it was done in only a few centers throughout the world. One of the leading centers at the time was at the University of Chicago, where Dr. Jean C. Emond played a critical role in the development of this technique. In 1990 his team presented the first large published series outlining their experiences with live donor liver transplantation. From there the procedure expanded to adults in the mid-1990s.
When did surgeons begin using laparoscopic techniques for live donor liver transplantation?
Laparoscopic techniques in live donor liver transplantation are a relatively new development, and it is important to note that New York-Presbyterian/Columbia is currently the only center in the United States performing fully laparoscopic living donor hepatectomies. This includes both adults donating to children and adults donating to other adults.
In fact, the majority of people who undergo living donor hepatectomies still require the removal of around 60% of their livers, and therefore require open surgery. For most donors this means a recovery time of about 8-12 weeks, and the risk of death is estimated to be about 1 in 500. In addition, the surgical scar from this procedure is anywhere from 20-50cm in length (8-20 inches).
For these reasons we have embarked on a programmatic effort to lower the risk for donors and shorten recovery time.
How have you been able to improve risk and recovery time for living donors?
The first step began in 2008, when we began doing left-lobe hepatectomies on patients whenever possible. This operation requires only about 40% of the liver to be successful, and we now do more than half of our operations in this manner. This operation is specific to adult-to-adult liver donations; for adult-to-children donations the standard is to remove what is called the left-lateral segment, which is about 15% of an adult liver.
While we were performing these 40% living donor hepatectomies we began building our experience with laparoscopic donation in general, and by 2012 we had performed more than a dozen laparoscopic donations on parents donating to children.
Building on these two experiences, the 40% liver donation for adult-to-adult transplants and the laparoscopic operations for adult-to-children transplants, we began to combine the two, so we now do 40% liver donations laparoscopically in adult-to-adult cases. We did our first case in August of 2012 and our second case that November.
What are the benefits of a laparoscopic operation for the donor?
One of the main benefits of this procedure is that instead of an 8-20 inch scar that remains after open surgery, patients generally have a scar of about 3 inches. This scar is usually located in the lower abdomen, which tends to be an area that is less painful and less noticeable. In addition, we have observed reduced pain and shorter recovery times after surgery (less than 6 weeks, as opposed to 8-12 weeks for open surgery).
What advice would you give to somebody interested in living donor organ donation?
If somebody is interested in becoming a living donor, there are a few standards that must be met:
- The donor must be in general good health
- They must be between the ages of 20 and 60
- They have to be blood type compatible with the recipient
- The donor must have an altruistic reason for donating – Meaning they can’t be financially motivated
What is the next step for the field of liver transplantation?
I think the next step will be performing 60% hepatectomies through laparoscopic means. Some adult recipients need 60% of the donor’s liver due to their size and severity of their disease. So our hope is that over the next 5-10 years all liver donors will donate via a laparoscopic technique. This would enable an average recovery time of less than 6 weeks, while also reducing postoperative complications and enabling more people to benefit from liver transplantation.
In addition, the greatest risk for patients with end-stage liver disease is dying before they get a transplant. Approximately 30-50% of the people on the liver transplant list will die before their transplant. Our hope is that the advent of laparoscopic techniques for living donor hepatectomies will encourage more people to become living donors, and that this will ultimately lead to more patients receiving the transplants they so desperately need.