First Single‐Center Experience of Minimally Invasive Pediatric Living Donor Liver Transplantation in China

ABSTRACT

Background

The use of laparoscopic procedures for liver transplantation (LT) remains controversial. This study aimed to present our preliminary experience with a minimally invasive pediatric living donor liver transplantation (LDLT).

Methods

The medical records of pediatric patients who underwent laparoscopy‐assisted LDLT, namely laparoscopic mobilization of the diseased liver followed by open explant hepatectomy and graft implantation using an upper midline incision at Beijing Friendship Hospital between November 2019 and March 2023, were retrospectively reviewed, focusing on demographics and pre‐, intra‐, and postoperative outcomes.

Results

Laparoscopy‐assisted LDLT was successfully performed in all 13 pediatric patients. The mean total operative time was 478 min (range, 315–615 min), the median portal vein clamping time was 47 min (range, 33–107 min), the average time required to remove the liver was 229 min (range, 115–357 min), and the median cold ischemia time was 85 min (range, 29–214 min). The intraoperative course for all the recipients was uneventful. All patients recovered well without any significant acute postoperative problems, with only one patient presenting with hepatic artery thrombosis on postoperative day 1 who made a good recovery after immediate thrombectomy and re‐anastomosis. During a median follow‐up of 41.8 (range, 24.3–64.3 months), all recipients survived with 100% graft survival.

Conclusion

This is the world's largest single‐center cohort study of pediatric laparoscopy‐assisted LDLT using an upper midline incision. Our results provide preliminary evidence for the safety and feasibility of minimally invasive LDLT in selected pediatric patients, which may be a reasonably compromised strategy before attempting pure laparoscopic LT.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2400086319

This is the world's largest single‐center cohort study of pediatric laparoscopy‐assisted LDLT using an upper midline incision. Our results provide preliminary evidence for the safety and feasibility of minimally invasive LDLT in selected pediatric patients, which may be a reasonably compromised strategy before attempting pure laparoscopic LT.

Abbreviations

ALT

alanine aminotransferase

AST

aspartate aminotransferase

GRWR

graft‐to‐recipient weight ratio

HA

hepatic artery

HV

hepatic vein

ICU

intensive care unit

INR

international normalized ratio

IVC

inferior vena cava

LDLT

living donor liver transplantation

LT

liver transplantation

MELD

model for end‐stage liver disease

PELD

pediatric end‐stage liver disease

POD

postoperative day

PV

portal vein

T‐Bil

total bilirubin

1. Introduction

Since the first successful clinical liver transplantation (LT) performed in a 3‐year‐old child with biliary atresia in 1963, LT has been established as the only curative treatment for acute liver failure, end‐stage liver disease, and certain inherited metabolic liver diseases [1, 2, 3]. With improvements in surgical techniques, pre‐ and post‐operative management, and immunosuppressive drugs, an increasing number of patients could benefit from LT, and short‐ and long‐term patient and graft survival has dramatically improved [4, 5, 6]. To address the shortage of donor organs and improve recipients' quality of life, transplant surgeons have been seeking innovative surgical solutions, including split LT, reduced‐size LT, living donor LT, domino LT, auxiliary LT, and cross‐auxiliary LT [7, 8, 9, 10].

Owing to its minimally invasive nature, laparoscopic surgery is widely accepted as the first choice for surgical procedures worldwide. Liver transplant surgeons have also begun exploring the application of laparoscopic techniques in the field of transplant surgery, mainly living‐donor hepatectomy. Based on the accumulated experience of laparoscopic liver donor hepatectomy, several recently published papers reported the successful application of laparoscopic techniques in liver transplant recipients [11, 12, 13, 14, 15, 16, 17]. Although these cases have demonstrated the feasibility and safety of laparoscopic procedures for LT, concerns and controversies remain [18, 19]. Thus, additional experience is warranted to weigh the clinical benefits and risks of this approach properly. In this article, we aimed to facilitate future practice of laparoscopic LT by analyzing our single‐center preliminary experience with laparoscopy‐assisted living donor liver transplantation (LDLT) using an upper midline incision.

2. Methods

2.1. Patients

A total of 188 pediatric patients underwent LDLT at the Beijing Friendship Hospital, Capital Medical University, between November 2019 and March 2023, during which laparoscopy‐assisted LT was performed in 13 patients. The inpatient and outpatient medical records were reviewed for patient data, including demographic data (sex, height, weight, and underlying liver disease), transplantation details [age at LT, donor type, graft type, graft cold ischemic time, graft warm ischemic time, time to remove the liver, total operative time, estimated blood loss, duration of intensive care unit (ICU) and hospital stay, and postoperative complications], and laboratory measures [albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (T‐Bil), albumin, and international normalized ratio (INR)].

This retrospective cohort study was approved by the Institutional Review Board of the hospital, and the study protocol conformed to the ethical guidelines of the Helsinki Declaration revised in 2013 and the Declaration of Istanbul. Written informed consent was obtained from all the patients. This work was reported in line with the “Preferred Reporting of Case Series in Surgery” (PROCESS) 2023 guidelines [20]. It has been registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/) with the unique identifying number “ChiCTR2400086319”.

2.2. Surgical Procedure

The patient was placed supine in the reversed Trendelenburg position (Figure 1A–C). The pneumoperitoneum was maintained at 13 mmHg, and 5 trocars were used. The falciform ligament was divided into the anterior aspect of the suprahepatic inferior vena cava (IVC) (Figure 2A), and the left triangular ligament was divided (Figure 2B). The diseased liver was turned to the left and upward, and the short hepatic veins were dissected in sequence along the anterior wall of the IVC until the hepatic vein joined the IVC (Figure 2C–F). The common hepatic artery and right and left branches of the hepatic artery were dissected and controlled. The common bile duct was dissected until bifurcation of the right and left hepatic ducts was controlled. Finally, portal veins were dissected and controlled.

FIGURE 1.

(A) Position of the patient, surgeons, and monitors. (B) Surgical incision marks. (C) Position of the ports. (D, E, F) The abdominal wound of the pediatric recipient (Patient 2) intra‐operatively, immediately after abdominal closure and 18 months post‐operatively.

FIGURE 2.

Operative view of laparoscopy‐assisted living donor liver transplantation from Patient 1. (A) The falciform ligament was divided. (B) The left triangular ligament was divided. (C) The third porta of the liver was dissected. (D) The short hepatic veins were controlled with clips and LigaSure. (E) The right liver was mobilized to the inferior vena cava as near as possible. (F) Left lateral view of the inferior vena cava after dissection. (G) Operative view showing the diseased liver through an upper middle incision. (H) The recipient's portal vein and hepatic artery were clamped and ligated. (I) After positioning the liver graft, the common opening between the graft's left hepatic vein and the middle hepatic vein was anastomosed to the recipient's hepatic vein opening. (J) The recipient's portal vein trunk was anastomosed to the graft's left portal vein. (K) After reperfusion, the recipient's right hepatic artery was anastomosed to the graft's left hepatic artery. (L) End‐to‐end bile duct anastomosis. (M) Laparoscopic view of the hepatic vein after anastomosis. (N) Laparoscopic view of the portal vein anastomosis, hepatic artery anastomosis, and bile duct anastomosis. (O) The implanted liver graft before the abdominal closure.

An upper midline incision was made (Figures 1D, 2G), and vascular forceps were placed via the trocar hole in the left upper abdomen for subsequent clamping of the suprahepatic IVC. The recipient's portal vein and hepatic artery were clamped and ligated (Figure 2H), and the diseased liver was removed. After positioning the liver graft, the common opening between the graft's left and middle hepatic veins was anastomosed to the recipient's hepatic vein opening (Figure 2I). The recipient's portal vein trunk was anastomosed to the left portal vein of the graft (Figure 2J). After reperfusion, the recipient's right hepatic artery was anastomosed to the left hepatic artery of the graft (Figure 2K), and end‐to‐end bile duct anastomosis was performed in patients with inherited metabolic liver disease (Figure 2L), and choledochojejunostomy for children with biliary atresia. Before closing the abdomen, re‐examine the hepatic vein anastomosis (Figure 2M), portal vein anastomosis, hepatic artery anastomosis and bile duct anastomosis (Figure 2O) using laparoscopy. The patency of the vessels was confirmed by intraoperative Doppler ultrasound examination. Finally, the midline incision and port sites were closed after meticulous hemostasis and drain insertion (Figure 1E).

2.3. Posttransplant Immunosuppression

All the patients received standard immunosuppressive therapy according to our established protocol [21]. Intraoperative and postoperative induction therapy consisted of administration of various dosages of methylprednisolone at different stages. It commenced with intravenous administration of 10 mg/k/day before hepatic revascularization, followed by 2–3 mg/kg/day, and then the dosage was tapered down and eventually to 0.2 mg/kg/day for adults or 1.0 mg/kg/day for children over 7 days. Basilisimab was intravenously administered intraoperatively and on postoperative day 4 at a dose of 10 or 20 mg, depending on the patient's weight (> 30 or ≤ 30 kg, respectively). Tacrolimus administration was initiated 24 h postoperatively at a dosage of 0.05 mg/kg twice daily. The tacrolimus dosage was dynamically adjusted according to the target whole‐blood trough level, and a trough level of 8–12 ng/mL was achieved during the first month. Subsequently, the patients received standard long‐term immunosuppression therapy consisting of tacrolimus, mycophenolate mofetil (≥ 2 years of age), and low‐dose steroids. The dosage of steroids was gradually tapered and eventually withdrawn within the first six months after LT.

2.4. Posttransplant Management and Long‐Term Follow‐Up

The patients were managed and followed up by hepatologists and transplant surgeons at our institution. Standardized procedures for peri‐ and post‐operative management and long‐term follow‐up were performed as previously described [22]. In brief, to monitor graft function and coagulation function, biochemical parameters, including ALT, AST, and T‐Bil, and coagulation indices, including INR, prothrombin time, activated partial thromboplastin time, fibrinogen, and platelets, were measured once or twice daily for the first 7 postoperative days. Subsequently, measurements were taken every two days for 14 days, two to three times weekly for 1 month, weekly for 2 months, every other week for 3 months, monthly until 6 months, and once every 2–3 months thereafter.

To prevent vascular thrombosis, prophylactic anticoagulant therapy, consisting of intravenous heparin sodium and sequential oral warfarin, was administered according to our standard protocol [23]. In brief, if no active bleeding was detected, continuous intravenous administration of heparin sodium (10 IU/kg/h) was started on the second postoperative day and continued for 1 week. Anticoagulant therapy with warfarin was then added to maintain a prothrombin time of 15–20 s and an INR of 1.5–2.0 until 3 months after LT.

Color Doppler ultrasonography was performed to monitor graft arterial and portal vein flow once daily within 1 week after LT. Subsequently, measurements were taken every two or three days within 2 weeks, once or twice weekly for 1 month, weekly for 2 months, every other week for 3 months, monthly until 6 months, and once every 2–3 months thereafter. Ultrasonography was performed whenever vascular thrombosis was suspected, and computed tomography scans were performed if ultrasound revealed abnormalities.

2.5. Statistical Analysis

Statistical analysis was performed using the GraphPad Prism 9.2.0 software (GraphPad Software). The Shapiro–Wilk test was initially conducted to assess the normality of the continuous variables. The results are presented as the mean (range) for normally distributed data and as the median (range) for non‐normally distributed data.

3. Results

3.1. Patient Characteristics

Between November 2019 and March 2023, 188 pediatric patients underwent LDLT at our center, of which 13 recipients received laparoscopy‐assisted LDLT. Patient characteristics are summarized in Table 1. Nine of the 13 patients had inherited metabolic liver disease, including three of ornithine transcarbamylase deficiency, one of Primary hyperoxaluria type 1, one of argininemia, one of Tyrosinemia, one of Wilson's disease, one of progressive familial intrahepatic cholestasis type 3, one of hyperhomocysteinemia, and the other four patients had biliary atresia. The mean age at transplant was 7.2 years (range, 1.7–12.3 years). Patient 3, who received ABO‐incompatible LT, underwent preoperative desensitization with rituximab 2 weeks prior to LDLT to reduce anti‐donor ABO antibody titers.

TABLE 1.

Pretransplant, intratransplant, and posttransplant patient characteristics.

Characteristics	Recipient 1	Recipient 2	Recipient 3	Recipient 4	Recipient 5	Recipient 6	Recipient 7	Recipient 8	Recipient 9	Recipient 10	Recipient 11	Recipient 12	Recipient 13
Gender	Male	Female	Male	Male	Female	Female	Female	Male	Male	Female	Female	Female	Female
Age at LT, years	12.2	5.2	8.2	7.8	4.2	2.1	11.3	12.3	7.8	6.6	4.2	1.7	10.5
Height, cm	150	103	125	136	105	87	148	142	129	126	103	90	145
Weight, kg	56.0	19.0	22.0	30.0	15.2	12.0	33.0	32.0	26.5	23.0	16.0	11.5	32.0
BMI, kg/m2	24.89	17.91	14.08	16.22	13.79	15.85	15.07	15.87	15.92	14.49	15.08	14.20	15.22
Underlying liver disease	Primary hyperoxaluria type 1	Argininemia	Biliary atresia	Biliary atresia	Tyrosinemia	Ornithine transcarbamylase deficiency	Wilson's disease	Progressive familial intrahepatic cholestasis type 3	Ornithine transcarbamylase deficiency	Hyperhomocysteinemia	Biliary atresia	Ornithine transcarbamylase deficiency	Biliary atresia
Laboratory findings
Platelet, ×103/μL	206	274	138	75	56	436	36	50	291	218	122	341	62
ALT, U/L	21	118	37	165	21	354	31	127	10	104	184	97	157
AST, U/L	25.0	99.5	58.8	242.6	33.1	306.9	39.4	229.9	25.8	61.5	258	150.2	167.5
T‐bil, mg/dL	0.55	0.69	0.68	2.67	0.73	0.68	1.17	8.06	0.49	0.32	19.60	0.58	1.71
Albumin, g/dL	4.36	4.18	4.01	4.02	4.07	3.93	3.52	3.01	4.22	4.18	4.14	3.91	3.72
INR	1.04	2.13	1.24	1.09	1.41	1.50	1.62	1.58	1.32	1.24	1.47	1.46	1.04
Child‐turcotte‐pugh score	A5	A6	B7	B7	A6	A6	A6	C10	A6	A5	B8	A6	B7
ABO	ABO‐compatible	ABO‐compatible	ABO‐incompatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible	ABO‐compatible
Graft type	Left lobe with middle hepatic vein	Left lateral segment	Left lobe with middle hepatic vein	Left lobe with middle hepatic vein	Left lobe with middle hepatic vein	Left lateral segment	Left lobe with middle hepatic vein	Left lobe with middle hepatic vein	Left lateral segment	Left lobe with middle hepatic vein	Left lateral segment	Left lateral segment	Left lobe with middle hepatic vein
Actual graft weight, g	395	241	308	356	257	317	390	401	261	304	366	261	504
Actual GRWR, %	0.71	1.27	1.40	1.19	1.69	2.64	1.18	1.25	0.98	1.32	2.29	2.27	1.58
Open conversion	No	No	No	No	No	No	No	No	No	No	No	No	No
Portal vein clamping, min	40	65	44	38	56	57	47	107	50	33	46	40	55
Anhepatic phase, min	35	60	34	36	40	49	39	91	49	32	46	39	42
Graft cold ischemic time, min	29	85	88	31	49	114	106	214	96	64	66	59	97
Graft warm ischemic time, min	35	60	34	36	40	49	39	91	49	32	46	39	42
Time to remove the liver, min	241	293	357	159	163	115	219	183	231	207	339	142	323
Total operative time, min	505	610	481	445	462	315	415	421	522	405	586	428	615
Estimated blood loss, mL	200	300	180	100	100	230	300	800	250	110	190	200	190
Transfusion, mL
RBC	0	0	0	0	0	160	400	600	0	0	150	150	260
FFP	0	100	0	0	0	0	0	400	0	0	100	0	400
INR on POD 1	2.03	2.88	2.77	2.16	3.26	2.20	2.32	3.55	3.12	2.00	2.62	1.82	1.86
INR on POD 7	2.45	1.45	2.50	2.26	1.70	1.24	1.32	1.19	1.51	1.21	1.91	1.70	1.21
T‐Bil on POD 1, mg/dL	1.96	1.14	3.02	3.55	2.08	3.45	2.22	9.01	1.60	1.31	12.28	0.83	4.52
T‐Bil on POD 7, mg/dL	1.11	0.47	1.96	1.87	1.24	2.17	0.72	5.61	0.88	0.78	5.70	0.51	1.10
ALT on POD 1, U/L	1052	1188	1455	236	710	4772	355	817	912	497	968	1435	1299
ALT on POD 7, U/L	192	133	395	136	93	44	88	252	212	287	149	358	300
AST on POD 1, U/L	1621.8	1842.4	957.9	230.6	685.3	7086.3	299.6	1026.2	1098.6	682.8	1417.2	1623.5	2413.0
AST on POD 7, U/L	55.6	47.6	268.5	60.8	35.1	80.7	32.8	71.3	81	129.3	50.7	91.7	41.2
ICU stays, days	2	2	2	3	4	16	3	3	3	2	4	2	2
Hospital stays, days	25	38	36	30	21	31	15	22	14	14	14	15	14
Surgical complications	Bile leakage (POD 21), biliary anastomotic strictures (POM 8)	Biliary anastomotic strictures (POM 6)	None	None	None	Hepatic artery thrombosis (POD 1)	Biliary anastomotic strictures (POM 1.5)	None	None	None	None	None	None
Medical complications	Epstein–Barr virus viremia	Epstein–Barr virus viremia	None	Epstein–Barr virus viremia	None	Pneumonia, acute kidney injury, Epstein–Barr virus viremia	Epstein–Barr virus viremia	ACR	None	None	Epstein–Barr virus viremia	None	None
Follow‐up, months	64.3	58.4	57.9	54.0	53.4	50.0	41.8	28.8	28.5	25.8	25.2	24.6	24.3
Age at last follow‐up, years	17.5	10.0	12.9	12.2	8.6	6.2	14.7	14.7	10.1	8.7	6.3	3.7	12.5
Outcome	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function	Alive with good graft function

Abbreviations: ACR, acute cellular rejection; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; FFP, fresh frozen plasma; GRWR, graft‐to‐recipient weight ratio; GRWR, graft‐to‐recipient weight ratio; ICU, intensive care unit; INR, international normalized ratio; LT, liver transplantation; MELD, model for End‐Stage Liver Disease; PELD, pediatric End‐Stage Liver Disease; POD, postoperative day; POM, postoperative month; T‐Bil, total bilirubin.

3.2. Liver Transplantation Course

Laparoscopy‐assisted LDLT was successfully completed in all the patients, and none of the recipients required open conversion (Figure 1F). The detailed operative data are summarized in Table 1. Six patients received the left lobes with middle hepatic veins, and the other seven patients received the left lateral segments. The mean graft‐to‐recipient weight ratio (GRWR) was 1.52% (range, 0.71%–2.64%). The median time for portal vein clamping was 47 min (range, 33–107 min), and the average time required to remove the liver was 229 min (range, 115–357 min). The median graft cold ischemic time (defined as “the interval from initiation of the donor in vivo cold organ preservation to removal of the graft from 4°C cold storage”) was 85 min (range, 29–214 min) and the median graft warm ischemic times (defined as “the interval from removal from cold storage to establishment of reperfusion of the liver graft”) were 40 min (range, 32–91 min). The mean total operative time was 478 min (range, 315–615 min) and the median intraoperative blood loss was 200 mL (range, 100–800 mL). The median stay in the intensive care unit (ICU) was 3 days (range, 2–16 days). The median length of hospital stay was 21 days (range, 14–38 days).

3.3. Posttransplant Outcome

We observed 100% graft and patient survival at a median follow‐up of 41.8 (range, 24.3–64.3 months). The average age at the last follow‐up was 10.6 years (range, 12.5–17.5 years). Patient 1 was diagnosed with biliary leak on postoperative day (POD) 21 and was managed with ultrasound‐guided percutaneous transhepatic biliary drainage. Moreover, this patient also suffered from a biliary anastomotic stricture in the eighth postoperative month and recovered well after choledochojejunostomy. Patient 2 developed a biliary anastomotic stricture and was treated with endoscopic retrograde cholangiopancreatography and biliary stenting 6 months postoperatively, which eventually resolved 1 year later. Patient 6 developed hepatic artery thrombosis (HAT) on POD 1 and recovered well after immediate thrombectomy and re‐anastomosis. Patient 7 experienced a biliary anastomotic stricture in the first and half postoperative months, which was treated with end‐to‐end biliary reconstruction. Meanwhile, all living donors recovered well with no procedure‐related postoperative complications. Acute cellular rejection (ACR) occurred in one patient, who was treated with high‐dose intravenous steroids. Patient 6 developed pneumonia and acute kidney injury during the perioperative period and recovered after medical treatment with antibiotics and renal replacement therapy. Epstein–Barr virus viremia occurred in 6, all of whom were treated with intravenous ganciclovir, and none of the patients developed post‐transplant lymphoproliferative disorder.

4. Discussion

To our knowledge, this is the first report of laparoscopy‐assisted LDLT in which the diseased liver was mobilized laparoscopically, followed by explantation of the native liver and implantation of a partial liver graft through an upper midline incision, as well as the first large‐scale attempt in pediatric liver transplant recipients worldwide. Our preliminary results from 13 consecutive patients demonstrated the safety and feasibility of laparoscopy‐assisted LT using an upper midline incision in selected patients.

Given its potential advantages over the open approach, such as the reduced size of the abdominal incision, facilitated rehabilitation, and shorter hospital stay, the laparoscopic technique has been increasingly used for living‐donor hepatectomy. The advantages of laparoscopy have also attracted transplant surgeons to make initial attempts at surgical procedures performed on liver transplant recipients [24, 25]. Several liver transplant teams worldwide have developed laparoscopic approaches for explant hepatectomy and liver graft implantation in liver transplant recipients. In 2011, Eguchi et al. reported a less invasive liver transplant recipient procedure in which total hepatectomy and liver graft implantation were performed through a short upper midline incision after mobilization of the diseased liver using hand‐assisted laparoscopic surgery [26]. Before this study, we accumulated sufficient experience and made several technological innovations in pure laparoscopic living‐donor hepatectomy [27]. Based on previous work and our experience, we set out to explore the potential of using laparoscopic techniques in liver transplant recipient surgery. We presume that it is theoretically feasible to complete mobilization of the recipient's diseased liver with laparoscopy, similar to laparoscopic living‐donor hepatectomy. However, considering the initial attempt of this innovative procedure and the safety of the recipient as a priority, we planned to perform explantation of the native liver and subsequent implantation of the partial graft liver using an upper midline incision after mobilization. After careful evaluation and preparation, we completed the first laparoscopy‐assisted LDLT procedure by using an upper midline incision in November 2019. Subsequently, the procedure was performed successfully in the remaining 12 cases. Transplant teams from France and Korea, in the meantime, have successively reported successful cases of minimally invasive LT by purely laparoscopic explant hepatectomy and graft implantation through upper midline incision (Table 2) [11, 12, 15]. Successful experiences with pure laparoscopic explant hepatectomy and graft implantation using upper midline incisions have allowed the extension of the minimally invasive LT to purely laparoscopic explant hepatectomy and hybrid laparoscopic/robotic graft implantation using suprapubic incisions (Table 2) [13, 28]. Until recently, Suh et al. described the first successful pure laparoscopic LDLT, which included both pure laparoscopic explant hepatectomy and graft implantation (Table 2) [14].

TABLE 2.

Summary and literature review of the recipients.

	Dokmak et al. 2020 [11] and Dokmak et al. 2022 [15]						Suh et al. 2021 [12]					Suh et al. 2022 [13]	Suh et al. 2022 [14]
	Recipient 1	Recipient 2	Recipient 3	Recipient 4	Recipient 5	Recipient 6	Recipient 7	Recipient 8	Recipient 9	Recipient 10	Recipient 11	Recipient 12	Recipient 13
Age at LT, years	52	54	29	53	41	41	48	69	58	52	75	51	60
Gender	Female	Male	Male	Female	Female	Female	Male	Male	Female	Male	Male	Male	Male
Underlying liver disease	Unresectable liver metastases of neuroendocrine tumors						HBV	Alcoholic liver disease	NASH	Alcoholic liver disease	HBV	Autoimmune hepatitis	Alcoholic liver cirrhosis and hepatocellular carcinoma
Height, cm	161.0	N/A	N/A	N/A	N/A	N/A	160.0	173.0	152.0	160.6	166.0	171.0	168.5
Weight, kg	48	N/A	N/A	N/A	N/A	N/A	62.7	79.0	56.5	65.5	75.4	68.7	75.8
BMI, kg/m2	18.5	24	26	23	24	35	24.5	26.4	24.5	25.4	27.4	23.5	26.7
Child‐turcotte‐pugh score	N/A	N/A	N/A	N/A	N/A	N/A	A5	C11	A5	B9	B9	C11	A5
MELD score	N/A	N/A	N/A	N/A	N/A	N/A	6.4	17.5	8.8	15.5	10.4	14.8	8.3
Type of LT	DDLT	DDLT	DDLT	DDLT	DDLT	DDLT	LDLT	LDLT	LDLT	LDLT	LDLT	LDLT	LDLT
Conversion	No	No	No	No	No	No	Yes	Yes	No	No	No	No	No
Type of graft	Reduced	Reduced	Whole liver	Splitting right liver lobe	Whole liver	Reduced	Right lobe					Right lobe	Right lobe
Laparoscopic procedure in LT	Pure laparoscopic hepatectomy and graft implantation using an upper midline incision						Failed	Failed	Pure laparoscopic hepatectomy and graft implantation using an upper midline incision			Pure laparoscopic hepatectomy and robotic graft implantation using a suprapubic incision	Pure laparoscopic hepatectomy and graft implantation using a suprapubic incision
Explant liver weight, g	1023	1260	1616	1177	1600	2377	1539	672	1224.5	752	863	1020	N/A
Liver graft weight, g	629	710	920	1180	1069	1556	614	813	580	752	773	843	703.5
GRWR, %	1.31	N/A	N/A	N/A	N/A	N/A	0.98	1.03	1.03	1.15	1.03	1.23	0.93
Portal vein clamping, minutes	50	N/A	N/A	N/A	N/A	N/A	74	59	161	188	160	N/A	212
Anhepatic phase, minutes	43	42	59	67	40	60	68	201	25	126	135	N/A	185
Cold ischemic time, minutes	466	418	431	575	360	530	141	72	132	109	50	N/A	N/A
Warm ischemic time, minutes	38	36	30	32	35	40	47	56	31	27	37	N/A	84
Time to remove liver, minutes	225	N/A	N/A	N/A	N/A	N/A	253	173	285	180	166	260	369
Total operative time, minutes	405	450	405	420	390	323	558	570	640	575	499	1065	960
Estimated blood loss, mL	400	600	400	450	250	600	3400	7800	1750	5250	4350	11 500	3300
Transfusion of RBC, pack	0	0	0	1	0	0	4	22	2	13	10	20	5
Transfusion of FFP, pack	0	0	0	0	0	0	0	18	1	6	6	16	0
Length of the midline incision, cm	15	13	18	14	13	20	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Hospital stays, days	14	11	10	10	14	14	25	16	30	26	15	13	11
Postoperative complications	No	No	No	No	Pulmonary	Pulmonary	Bile leakage	Wound seroma	Prolonged liver function test elevation	Bile leakage	No	No major complications	No
Follow‐up duration, months	29	16	7	7	5	5	5.2	5.2	3.5	3.3	3.1	2.2	0.4

Abbreviations: BMI, body mass index; DDLT, deceased donor liver transplantation; FFP, fresh frozen plasma; GRWR, graft‐to‐recipient weight ratio; HBV, hepatitis B virus; LDLT, living donor liver transplantation; LT, liver transplantation; MELD, model for end‐stage liver disease; N/A, not available; RBC, red blood cell NASH, nonalcoholic steatohepatitis.

Notably, despite this procedure's tremendous innovation and preliminarily proven feasibility, concerns about its potential negative impact on recipients' outcomes have been raised [29, 30, 31, 32]. The significantly extended ischemia time and operative time may diminish the theoretical benefit (rapid rehabilitation, early recovery, and better wound satisfaction) of the laparoscopic approach in sick liver transplant recipients. More importantly, the complexity of the procedure and the potential intraoperative catastrophic events may only allow this procedure to be performed by a highly experienced transplantation team. The evolution of surgery has shown that surgeons should weigh the risk/benefit ratio of innovative surgical techniques before applying them to their patients. Gradually accumulating experience, including stepwise incrementation in difficulty, namely, the learning curve, should also be emphasized. Given that the current theoretical risks of pure laparoscopic LT are greater than its benefits, more experience is required to evaluate the safety and feasibility of this innovative approach. Furthermore, the technical difficulty and learning curve required for laparoscopic LT in various transplant centers at different levels make it challenging to perform widely. In the present study, we used laparoscopy‐assisted surgery to mobilize the native liver, and an upper midline incision was made to explant the native liver and implant a partial liver graft. On the one hand, laparoscopy can overcome the problem of unsatisfactory exposure due to upper midline incision. In contrast, compared to the inverted “L” or Mercedes incision, the midline incision avoids transverse incision with muscular division, which may facilitate rapid rehabilitation, reduce abdominal pain, and help prevent postoperative lung complications, wound hematoma, infection, and incisional hernia. Moreover, liver transplant recipients only had a small midline wound and several port site wounds, which were barely visible. The resulting self‐confidence in wound satisfaction may be clinically significant, especially for pediatric and adolescent recipients. More importantly, the accumulation of experience with techniques such as laparoscopy‐assisted LT with a median incision may help overcome the learning curve [33].

Nevertheless, for transplant centers attempting to perform laparoscopy‐assisted LDLT using an upper midline incision, recipient selection is critical to the success of the procedure before overcoming the learning curve. First, we recommend choosing pediatric (age > 1 year old, weight > 10 kg) or relatively thin adult patients whose anteroposterior dimensions of the abdomen are not too long, so that the exposure to the operating field of view is not compromised under an upper midline incision. Secondly, the vascular and biliary anatomy of the liver graft should not be too complicated (preferably as a single branch). Thirdly, the patient has no history of complex abdominal surgeries, which indicates that the intra‐abdominal adhesions will not be severe. Collectively, careful preoperative evaluation of the donor and recipient and comprehensive surgical planning are essential. Patient safety and successful LT performance are paramount. If the compromised operating field of view attributed to laparoscopy or upper midline incision has affected the surgical operation or even endangered the recipient's safety, open conversion or conventional surgical incision should be performed promptly.

In summary, this study provides preliminary evidence of the feasibility of laparoscopy‐assisted LT using an upper midline incision in selected pediatric and adult recipients. Pure laparoscopic LT may be the future of surgical procedures performed in liver transplant recipients, but its clinical value is still highly controversial. We believe that laparoscopy‐assisted LT with an upper midline incision may be a reasonably compromised strategy before attempting a pure laparoscopic liver transplant.

Author Contributions

Zhi‐Jun Zhu: Conceptualization, Methodology, Project administration, Funding acquisition, Investigation, writing – review and editing. Lin Wei: Conceptualization, Methodology, Project administration, Funding acquisition, Investigation, writing – review and editing. Guang‐Peng Zhou: Conceptualization, Methodology, Project administration, Data Curation, Formal analysis, writing – original draft. Zhi‐Gui Zeng: Methodology, Project administration, Investigation, writing – review and editing. Hong‐Yu Li: Methodology, Project administration, Investigation, writing – review and editing. Wei Qu: Supervision, Project administration, writing – review and editing. Li‐Ying Sun, Yu‐Le Tan, and Jun Wang: Data Curation, Supervision, Project administration, writing – review and editing. All authors approved the final version of this manuscript for publication.

Funding

This work was supported by grants from the Capital's Funds for Health Improvement and Research (Number. 2024‐4‐1111; Number. 2024‐1‐2022), Young Elite Scientists Sponsorship Program of the Beijing High Innovation Plan (Number. 20250872), and Talent Development Plan for the Future in Medical‐Engineering Integration by BRA‐CDCHE and ZTA (MBRC0012025057). The funders had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation.

Ethics Statement

This study was conducted in accordance with the World Medical Association Declaration of Helsinki and approved by the Ethics Committee Review Board of Beijing Friendship Hospital, Capital Medical University (2024‐P2‐139‐01).

Consent

Written informed consent was obtained from all the participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.