Robotic Donor Hepatectomy: Technique, Recovery and Safety

Robotic donor hepatectomy removes part of a living donor's liver through small ports using a surgical robot, with the graft extracted through a low incision hidden below the belt line. In the programme of Dr. Dheeraj Manchanda, Associate Consultant - HPB Surgery and Liver Transplantation, BLK-Max Super Speciality Hospital, New Delhi, India, donors go home within five to seven days and return to office work within four to six weeks.

Dr. Manchanda explains how donors are selected, how the graft is planned and how recovery unfolds, with donor safety as the one principle that governs every step.

Why donor safety comes first

In living donor liver transplantation two people undergo surgery, but only one of them needs it. The patient is operated on because of liver disease; the donor is operated on because the patient needs a liver. As Dr. Manchanda frames it, the donor does not need surgery at all. Everything in the programme therefore hinges on a single aim: keeping donor morbidity and mortality to a minimum.

He names mortality deliberately. An untoward event during surgery can sometimes be beyond anyone's control. Morbidity, by contrast, is largely controlled before the operation through a detailed, staged evaluation. Its logic is unusual. As he puts it, the idea is not to select a donor; the idea is to disqualify any donor who is unsuitable in any respect, whether in the anatomy or physiology of the liver or through a disease of the donor's own.

For the wider context of indications, timing and outcomes, see the pillar guide, recent advances in liver transplant.

Donor criteria before robotic donor hepatectomy

The criteria his team applies are:

• Relationship: the donor must be a family member.
• Age: 18 to 50 years, extendable to 55 as an upper limit.
• Blood group: O, the universal donor, or the same group as the patient. With an ABO-incompatible protocol, a relative of a non-matching group can also donate (see ABO-incompatible liver transplant and complex cases).
• Fitness: medically fit and psychologically sound enough to give consent.
• No diabetes and no alcohol use: both cause fatty change (steatosis) in the donor's liver.
• A healthy liver: no steatosis and no underlying liver disease.
• No transmissible disease: including hepatitis B, hepatitis C, HIV and syphilis.
• Favourable anatomy and adequate volume: the donor must be able to give enough liver for the patient to benefit, while keeping enough to sustain his or her own life.
• Voluntary consent: donation must be freely chosen.

The legal framework sets the outer boundary of who may donate. Living organ donation in India is governed by the Transplantation of Human Organs and Tissues Act and its 2014 Rules. Donors are expected to be relatives: near relatives can donate, and wider family members such as cousins also qualify with the approval of an Authorisation Committee, which is required whenever the donor is not a near relative and for any donation involving a foreign national.

At Dr. Manchanda's centre, about 35% of prospective donors are turned down. The usual reasons are excess weight, unsuitable anatomy, or a disease diagnosed during the evaluation itself.

The staged donor evaluation

Evaluation proceeds in three stages, each of which can end the process.

1. Medical evaluation. Blood tests establish the donor's metabolic status, starting with the blood group.
2. Surgical and radiological evaluation. Imaging addresses two questions. The first is anatomy: the arrangement of the bile ducts and blood vessels in the donor's liver. The second is volume: how much liver would go to the patient, and how much would remain with the donor.
3. Psychological and multidisciplinary evaluation. Hepatology, psychology, psychiatry, critical care and anaesthesia teams assess both donor and patient for fitness for surgery.

Planning the graft

Grossly, the liver divides into a right and a left lobe. The right lobe has an anterior and a posterior sector. The potential grafts follow that anatomy:

• Right lobe graft: the anterior and posterior sectors, the standard adult graft.
• Left lobe graft: the left lateral sector plus segment 4.
• Right posterior sector graft: an option in some adult cases.
• Left lateral segment graft: used for very small children.

The choice depends chiefly on the donor's anatomy, and on two numerical limits. The first protects the recipient: the graft-to-recipient weight ratio (GRWR), the graft's weight in grams divided by the recipient's weight in kilograms, should be at least 0.8. Below that, the surgeon must modulate the blood flow entering the graft through the portal vein. The second protects the donor: the remnant, the part of the liver that stays with the donor, must be at least 30%. That remnant has to sustain the donor until the liver regenerates, or, more precisely, grows in size, to full capacity.

From open incision to robotic donor hepatectomy

The conventional donor operation used a large Makuuchi incision, a J-shaped or reverse-L cut across the upper abdomen. Dr. Manchanda's team has moved to minimally invasive donor hepatectomy using the da Vinci Xi robotic system. On the recipient side, the team has moved to a midline incision. The rationale is that the incision itself adds to post-operative morbidity; the overriding goal remains doing the surgery safely.

What makes robotic donor surgery work

Doctors attending the session asked the natural question: if the operation is minimally invasive, how does a large piece of liver come out? Dr. Manchanda's answer is that operating is not the main challenge. The robotic console gives about ten-times magnified vision. The real challenge is extracting the graft from the donor safely, without damaging it.

For extraction, the team uses a Pfannenstiel incision, a low horizontal incision above the pubic bone. The incision is kept liberally long so the graft can be removed safely. It sits below the belt line and is hardly visible, and it is closed with absorbable monofilament subcuticular sutures, so the cosmetic result is not a concern.

Warm ischaemia time

The critical interval is the first warm ischaemia time: the period from clamping the graft's portal vein inside the donor to removing the graft. At his centre it is now about 5 to 6 minutes. When the team began, it took about 7 minutes; it now takes about 5. Dr. Manchanda acknowledges this may look like a marginal improvement, but minimising warm ischaemia and extracting the graft safely remains a priority.

Two operations, one sequence

The donor and recipient operations run simultaneously, but which starts first is a matter of protocol.

In patients without cancer, the donor operation starts first. Imaging before surgery does not always match what the surgeon finds: discrepancies in liver quality and volume have been reported. So the team inspects the donor's liver directly. If it looks fatty or the surface is irregular, a biopsy goes for frozen section, a rapid pathology reading made while the operation is under way. Only if the pathologist reports no fibrosis and no significant steatosis does the recipient operation begin.

In patients with liver cancer, the recipient operation starts first. The team performs an inspection laparotomy on the patient, an exploratory opening of the abdomen to look for spread. Only once it is clear there is no peritoneal metastasis and no deposits on the diaphragm, the spleen or the surface of the bowel does the donor operation begin. The sequence is designed so that a donor does not undergo surgery for a transplant that cannot go ahead.

Recovery after robotic donor hepatectomy

The question every donor asks is how donation will change his or her life. India's first living donor liver transplant was performed in 1998, so the country now has nearly three decades of experience. In Dr. Manchanda's experience, donors have shown no long-term morbidity. Donor deaths have occurred at various centres, at a rate below 1%.

Recovery at his centre follows a consistent pattern:

• Discharge: within five to seven days.
• Normal activity: within two to three weeks.
• Office work: within four to six weeks (heavy manual work takes longer).
• Heavy physical activity and gym training: no earlier than six months, the minimum his team allows.

One of his slides shows a son who donated part of his liver to his father and started gym training at six months; a photograph a year into his training shows how well he has fared.

Donors often become carers. Many patients who travel from outside the city come with few family members, sometimes for reasons of logistics or expense, and occasionally the donor is the only relative with them. His team regularly sees the donor take over the patient's care during recovery. In another case from his slides, the donor who looked like the patient's daughter was in fact his wife.

Does the donor's liver grow back?

The remnant left in the donor grows in size until it can fully sustain the donor. Dr. Manchanda's team has begun documenting this. As part of a study, his centre now performs a non-contrast CT scan of the abdomen on the sixth day after surgery as a protocol in every donor. The scan serves two purposes. It checks for any fluid collection, which has proved rare. And it measures the liver's dimensions. The team has documented liver growth on CT as early as day 6, and the data is under review for publication.

How safe is living liver donation overall?

Living donation is never risk-free, and Dr. Manchanda does not present it as such. What makes it acceptable is the combination described here: strict criteria that turn away about a third of volunteers, a staged evaluation designed to disqualify, a remnant of at least 30%, smaller incisions through robotic surgery, and a sequence designed not to put a donor at risk for a transplant that cannot proceed.

For a related perspective, Dr. Sandeep Jha's masterclass covers living liver donor evaluation and right lobe surgery, and Dr. Ashish George's covers who can donate a liver. Dr. Manchanda's answers to attending doctors on regeneration and theatre sequencing are on the Live Discussion page, and his background is on his doctor profile. Indicative figures for the transplant itself are on the liver transplant cost page.