Feb 22, 2023, 16:26 PM by Anna Shults

The altruistic nature of live organ donation demands that we continue to seek better, safer, and less traumatic modalities for our donors. This has been achieved nationwide with living donor kidney transplant, through the adoption of laparoscopic and robotic donor nephrectomies at almost every level.

Written by Amar Gupta, MD, FRCSC
Director of the Abdominal Transplant Surgery Fellowship, Baylor University Medical Center

While each of us got involved in the field of organ transplantation for our own reasons, one common thread must be a deep desire to help others. It is why we spend time away from our families flying to procure organs, why we advocate for our patients in local and national forums, and why the outcomes of our care are so emotional.

But what happens when the service we offer our patients is going to hurt them, no matter what? This is the case with our living kidney and liver donors. There is no question that living donation is beneficial to society, our recipients, and even to our donors. The vast majority of donors report they would donate again if they could. They report an immense, immeasurable emotional and spiritual benefit from knowing they are saving the life of a loved one. Despite this, it is impossible to overlook the surgical trauma, cosmetic scars, and surgical risks to which these otherwise healthy donors are exposed.

The altruistic nature of live organ donation demands that we continue to seek better, safer, and less traumatic modalities for our donors. This has been achieved nationwide with living donor kidney transplant, through the adoption of laparoscopic and robotic donor nephrectomies at almost every level. Unfortunately living donor hepatectomies still lag far behind.

The slow adoption of minimally invasive donor hepatectomy in North America is likely due to many factors, including the steep learning curve seen in laparoscopic major hepatectomy, lack of liver-specific robotic tools, inexperience with minimally invasive liver surgery amongst donor surgeons, and the highly sensitive nature of the donor operation. Although these challenges are real, they should not prevent us from evolving and offering the best outcomes possible for our liver donors.

The robotic platform has proven especially attractive to our group due to the high resolution, static optics and the fine dexterous controls allowing for fine suturing and dissection of the portal structures and vena cava. Using a dual console setup and video recordings also allows an ideal and safe setting for training in real time for such a high-risk operation and as a debriefing tool. Perhaps this can lead to wider dissemination of safe minimally invasive donor hepatectomy for our donors.

The adoption of any new technique or modality will always have naysayers. This is a healthy part of change. Opponents will point out that there has never been a randomized controlled trial demonstrating superiority, and most retrospective studies show similar blood loss, length of stay, and operative morbidity (or perhaps a slight advantage for minimally invasive approaches). Maybe we are measuring the wrong things? If we can get donors through their hepatectomy with less pain, less days off work, less self-conscious thoughts about their scars – and do it as safely as with open surgery – then maybe that is all the significance we need.

If we put our donors first and think about what we can do to further lessen the blow of donation, then everyone wins. This may require us to learn new techniques, adopt new technology, and throw old dogma out. Transplantation has always been on the cutting edge of improving outcomes, and we should certainly not stop with donor hepatectomies. Our donors deserve it.