Improving Safety in Living Liver Donation: Lessons From Intraoperative Adverse Events in 438 Donors Undergoing a Left Liver Resection

Abstract

Background: Donor safety is paramount in living organ donation. Left liver resections are considered safer than right lobe hepatectomies. However, unexpected intraoperative adverse events (iAEs), defined as any deviation from the ideal intraoperative course, can also occur during left liver resections and may be life threatening or lead to postoperative complication or permanent harm to the donor and recipient.

Methods: Records of 438 liver living donors (LDs) who underwent 393 left lateral sectionectomies (LLSs) and 45 left hepatectomies (LHs) between July 1993 and December 2018 in a pediatric living-donor liver transplantation center were reviewed for the appearance of iAEs that could have influenced the donor morbidity and mortality and that could have contributed to the improvement of the LD surgical protocol.

Results: Clinical characteristics of LLS and LH groups were comparable. Nine iAEs were identified, an incidence of 2%, all of them occurring in the LLS group. Seven of them were related to a surgical maneuver (5 associated with vascular management and 2 with the biliary tree approach). One iAE was associated with an incomplete donor workup and the last with drug administration. Each iAE resulted in subsequent changes in the surgical protocol. Donor outcome was at risk by 5 iAEs classed as type a, recipient outcome by 2 iAEs (type b) and both by 2 iAEs (type c). Postoperative complications occurred in 87 LDs (19.9%), with no differences between the LLS and LH groups (P = 0.227). No Clavien-Dindo class IVa or b complications or donor mortality (Clavien-Dindo class V) were observed.

Conclusions: iAEs debriefings induced changes in our LD protocol and may have contributed to reduced morbidity and zero mortality. iAEs analysis can be used as a quality and safety improvement tool in the context of LD procedures, which may include right liver donation, laparoscopic, and robotic living liver graft procurement.

Graphical abstract

FIGURE 1.

Biochemistry and hematologic postoperative evolution in living liver donors undergoing the left lateral liver segmentectomy including the segment II and III and the left hepatectomy, which comprises the segment II, III, and IV with the middle hepatic vein. A, Postoperative donor AST levels, (B) postoperative donor ALT levels, (C) postoperative donor Bil levels, (D) postoperative donor INR levels, (E) postoperative donor Hb levels, and (F) postoperative donor Plt levels. ALT, alanine transaminase; AST, aspartate aminotransferase; Bil, total bilirubin; Hb, hemoglobin; INR, international normalized ratio; Plt, platelet; POD, postoperative day.