Title: Minimally Invasive Approach to Recipient Surgery in Living Donor Liver Transplantation
Abstract: Potential conflict of interest: Nothing to report. Akihiko Soyama is the first author and wrote the initial draft of the manuscript under the supervision of Susumu Eguchi. Takanobu Hara, Hajime Matsushima, Takashi Hamada, Hajime Imamura, Takayuki Tanaka, Tomohiko Adachi, and Masaaki Hidaka revised and refined the manuscript. Akihiko Soyama, Takanobu Hara, Hajime Matsushima, Takashi Hamada, Hajime Imamura, Takayuki Tanaka, Tomohiko Adachi, Masaaki Hidaka, and Susumu Eguchi read and approved the final manuscript for submission. TO THE EDITOR: We read with great interest the article by Suh et al. concerning the application of minimally invasive surgery in living donor liver transplantation (LDLT); the procedure included pure laparoscopic explant hepatectomy and graft implantation using an upper midline incision.(1) In terms of minimally invasive surgery with the application of a laparoscopic procedure in LDLT, we previously reported a case series with hand‐assisted laparoscopic surgery (HALS) for mobilization of the liver that enables subsequent total hepatectomy and implantation of the partial graft through the upper midline.(2) As Suh et al. mentioned, the implantation through an upper midline incision is considered a merit of this procedure. Jain et al. investigated the incidence of abdominal wall numbness in patients following liver transplantation.(3) Although liver transplantation is a life‐saving procedure, wound‐related complications that may affect the mid‐term and long‐term quality of life should be minimized. Regarding indications for LDLT with a minimally invasive approach, we agree with the discussion by Suh et al. that patients with small livers because of atrophy or shrinkage would be better candidates for this procedure than those with larger livers because small livers provide adequate space that allows easier manipulation of instruments and cameras. When considering the application of laparoscopic surgery, in addition to the low invasiveness, it is important to consider its usefulness as a surgical technique per se. In our previous report, among the 9 patients who underwent LDLT with hand‐assisted laparoscopic mobilization of the liver, splenectomy was also performed in 7 of the patients. Because splenectomy in patients with severe cirrhosis by HALS is an already widely established procedure,(4) it is considered a reasonable approach to use HALS for spleen mobilization, even in liver transplant recipients. Regarding how the benefits of pneumoperitoneum can be achieved in liver transplantation, we should investigate whether the reduction in bleeding due to pneumoperitoneum that has been recognized in other hepatectomy procedures is also present in total hepatectomy of liver transplantation without parenchymal resection. Minimally invasive surgery has been established in several types of liver surgery and is becoming widely adopted in living donor surgery.(5) When considering the application of the concept of minimal invasive surgery for liver transplantation recipients whose characteristics differ markedly from those of patients undergoing other types of liver surgery, the merits and utility of the procedure in addition to the feasibility should be extensively discussed.