Giacomo Concone

Current status and perspectives in split liver transplantation

Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation (SLT) for adult and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.

Evolution of robotic nephrectomy for living donation: From hand-assisted to totally robotic technique

The application of robotic‐assisted surgery offers EndoWrist instruments and 3‐D visualization of the operative field, which are improvements over traditional laparoscopy. The results of the few studies published so far have shown that living donor nephrectomy using the robot‐assisted technique is safe, feasible, and offers advantages to patients.

Split-Liver Full-Left Full-Right: Proposal for an Operative Protocol

INTRODUCTION Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor. OBJECTIVE The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure. MATERIALS AND METHODS A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined. RESULTS The donor characteristics should be consistent with the following: age≤55 years; weight≥70 kg; body mass index<28 kg/m2; intensive care unit stay<7 days; sodium level<160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis<20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs. CONCLUSIONS The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria.

Initial Experience with Robot-Assisted Nephrectomy for Living-Donor Kidney Transplantation: Feasibility and Technical Notes

BACKGROUND Robot-assisted surgery provide endowrist instruments and 3-dimensional visualization of the operative field that are improvements over traditional laparoscopy. The few research studies published so far have demonstrated that living-donor nephrectomy using the robot-assisted technique is safe and feasible, providing advantages for patients. METHODS Since November 2009, we performed 20 robot-assisted living-donor nephrectomies. Eight patients underwent hand-assisted robotic nephrectomy, whereas 20, totally robotic nephrectomy. RESULTS Median intraoperative bleeding was 174 mL (range, 10-750) but no patient needed intraoperative transfusion with blood cells. The median warm ischemia time was 3.16 minutes (range, 0.30-6.5). there was no case of conversion to an open procedure. The median operative time was 311 minutes (range, 85-530); the median console time was 160 minutes (range, 135-220). CONCLUSION Robot-assisted living-donor kidney recovery was a safe and effective procedure. The totally robotic recovery is an evolving technique. The prospect of robotic staplers, endowrist ligature, and robotic single port may further increase these advantages.

Living-Donor Liver Transplantation: Donor Selection Criteria and Postoperative Outcomes. A Single-Center Experience With a 10-Year Follow-up

BACKGROUND Donor safety must be considered to be a priority in live-donor liver transplantation (LDLT). The aim of this study was to evaluate these outcomes with special attention to surgical complications and their treatment. METHODS From March 2001 to March 2012, 80 live donors underwent right hepatectomy (5-8 segments). The middle hepatic vein was always left in the donor. Our retrospective study analyzed surgical outcomes and complications according to the Clavien classification modified for live donors. RESULTS With a median follow up of 63.2 ± 12.6 months, the mortality was 0%. Two donors experienced intraoperative complications, but all of them had complete recovery there after. Among the 22 complications in 17 donors (21.2%), 7 (8.7%) were major complications (Clavien grade 2b) but only 2 donors required surgical treatment. CONCLUSIONS LDLT is a safe and feasible modality to alleviate the cadaveric donor shortage. The efficacy of this procedure is similar to that with deceased donors.

Detailed Abdominal Organ Inspection and Early Surgical Steps for Abdominal Organ Procurement

Sternotomy is a mandatory surgical step for carefully inspecting the thorax and mediastinum.Accurately inspect all abdominal organs.Perform liver biopsy whenever liver steatosis is evident to have a better evaluation of macroscopic and microscopic steatotic components.Try to recognize an accessory or replaced right hepatic artery from the superior mesenteric artery and consider that it is present in approximately18 % of cases.Preserve a left accessory or replaced left hepatic artery from the left gastric artery running throughout the lesser sac.Polar renal arteries arising from the iliac arteries should be carefully checked. If present, care should be taken to preserve polar renal arteries; iliaccannulation before the origin of the polar artery must be performed.When the supraceliac abdominal aorta is difficult to control, consider cross-clamping the thoracic aorta as an alternative to supraceliac aortic crossclamping.In case of rapid donor destabilization during the procedure, consider quick cannulation of the inferior abdominal aorta above the iliac vessels anda blind cross-clamping of the descending thoracic aorta.Before perfusion, remember to flush the gallbladder and clear the common bile duct of retained bile.

Laparoscopic and Robot-Assisted Nephrectomy

In this chapter the main technical steps of laparoscopic and robot-assisted nephrectomy are discussed. Laparoscopic nephrectomy: examine carefully the position of the donor preoperatively, to avoid discomfort for the patient and for the surgeons. Communicate with all the members of the surgical team, including anaesthesiologists and nurses, to clarify the main phases of the operation. Get ready for a rapid open conversion, drawing on the body of the donor the midline incision. Remind that hand-assisted technique can become useful to manage unexpected difficulties. Avoid the use of non-tissue affixing ligation technique for renal vessels. Plan a strategy to maximize the length of renal vessels, using Endoscopic GIA or TA stapling device, keeping away from early bifurcations. Note the advantages of using a LigasureTM vessel sealing for dissection, to shorten operative time and to avoid clips interfering with the stapling suture line. Pay a lot of attention to haemostasis of the Pfannenstiel incision, since the heparin bolus effect may result in subcutaneous hematoma. Robot assited nephrectomy: do not put metallic clips where you will need to use staplers. Place the patient in order to avoid collisions among robotic arms and between robotic arms and the patient itself. For donor safety concerning renal artery: It’s better to use TA instead of GIA stapler to avoid the risk of stapler malfunctioning. The section should be done with robotic scissors after placement of an hem-o-lock on the arterial stump. Always administer one bolus of curare together with heparin to facilitate the kidney extraction. Left Nephrectomy: extend the dissection of the splenopancreatic block up to the left diaphragmatic crura. Renal vein should be encircled with an elastic tape after the section of gonadic and adrenal veins in order to: Easily recognize it during posterior isolation of the kidney. Modulate robotic arm’s strength with adequate traction during dissection manoeuvres and staplering.