Experience With Establishing a Robotic Donor Hepatectomy Program for Pediatric Liver Transplantation

Abstract

Background: The benefits of minimal invasive donor hepatectomy, especially for left lateral sectionectomy (LLS) have been unequivocally demonstrated. Moreover, donors in pediatric liver transplantation (LT) are usually parents who need to recover quickly to take care of the child. There are inherent limitations to conventional laparoscopic surgery including surgeon's experience with advanced laparoscopic surgery and steep learning curve which limits the wide application of minimal invasive donor hepatectomy. We share our experience of establishing a program of robotic donor hepatectomy (RDH) and achieving proficiency in performing RDH for pediatric LT.

Methods: Data were prospectively collected of consecutive LLS RDH based on a structured learning algorithm. Donor and recipient outcomes were analyzed.

Results: Seventy-five consecutive cases of LLS RDH were performed. The median primary warm ischemia time was 6 min (interquartile range [IQR]: 5-7 min). No major complications (grade ≥IIIb Clavien-Dindo) were noted in the cohort. There were no emergency conversion to open surgery and neither were there postoperative explorations through a laparotomy. Seven grafts were hyper-reduced and 5 required venoplasty. Two recipients died because of severe sepsis and multiorgan failure. Major complications occurred in 15 children (20%), none of which were attributable to RDH. Median hospital stay of the donors and recipients was 5 d (IQR: 5-6) and 12 d (IQR: 10-18) respectively.

Conclusions: We share our experience of starting a RDH program for pediatric LT. We highlight the challenges and our learning algorithm to spur teams on the cusp of starting robotic transplant programs.

FIGURE 1.

Operating room setup with the docked robot. CUSA, Cavitron Ultrasonic Suction Aspirator.

FIGURE 2.

Port placement for RDH. A1–A2, assistance ports; Pf, Pfannensteil incision; R1–R4, ports for the robotic arms; RDH, robotic donor hepatectomy.

FIGURE 3.

CUSUM analysis of cases. A, CUSUM analysis for operative time in minutes. B, CUSUM analysis for complication rates. CUSUM, cumulative sum control chart.