Choon Hyuck David Kwon, MD, PhD, Director of Laparoscopic Liver Surgery, Cleveland Clinic talks about how laparoscopic living liver donor transplant surgery is a less invasive option for transplant candidates.
Tell me about laparoscopic liver transplant?
Dr. Kwon: It’s laparoscopic liver resection for the living donor of a liver transplant. We are not doing laparoscopic on the recipient, but on the living donors. It’s a procedure that previously we always used to do by making a big incision or laparotomy around 15 inches. It’s a big commitment from a donor. That incision is known to be quite difficult to bear for the patient. It is a very high rate of hernia as well. Many patients suffer after because of the incision. It’s a big commitment and probably a long recovery. Usually it takes around three months to be able to go back to work. Some patients take longer, some patients its quicker.
That’s probably be a big deterrent on why people won’t do it.
Dr. Kwon: It is not only a deterrent, but it’s also a very big stress factor, especially for the group that are very self-conscious about their body figure like the younger age group. If you want to become a living donor that means no more bikini wearing. Of course, some patients are proud of their scars and I fully appreciate that. And it’s a scar from 15 inches to around four inches right below the navel. The incisions that we make look like they have a C-SEC. It’s a similar incision but slightly smaller than that. This is the fantasy, it’s called the Pfannenstiel incision. That incision is known to have the least pain. It’s almost close to 0%. It’s a lot easier for the patient to recover after surgery and it’s also cosmetically very solid and you can wear bikinis after that.
So how soon would that person be able to get back to work?
Dr. Kwon: The recovery takes half of what it takes for open surgery. I would say from one to two months. Those who recover well, they are back to work by one month. Those who recover slower it takes about two months. It’s still a big operation because what’s going on inside the abdominal is still the same thing. So, the recovery of the removed liver is still there. That burden is still there, but at least you have less trauma of the abdominal wall and that makes it a lot easier for the patient to recover. If you look at the amount of pain medication that donors usually require, the patients with laparoscopic usually require half to a third of the pain medications that patients with open surgery receive.
Tell me about the first surgery you did?
Dr. Kwon: The first surgery was a very nice situation. It was a young gentleman who was very giving, and he stepped forward to donate to his girlfriend’s father. They had been dating for quite some time and he heard that his girlfriend’s father was getting sick and there was no one in the family that was a match to give the liver to the recipient. He was like, okay, why don’t I step up? We looked at his anatomy and everything, and we did quite a bit of preparation before embarking on this endeavor because from my experience having done this kind of system back in my home country it takes a lot of preparation to do it. It’s a very complex operation. We decided after about nine months of preparation we were ready for that. So, I think it was nice that I could offer this kind of procedure to someone who was so giving.
When this happens, do both surgeries happen on the same day?
Dr. Kwon: We usually take the donors about an hour earlier than they receive it. That is traditionally done in open surgery as well. The time that it takes for laparoscopic used to take a lot longer. Now the time that it takes for open surgery is almost the same as it takes for laparoscopic.
What is that timeframe?
Dr. Kwon: It’s usually between five to seven hours. The last case we took less than five hours. I hope that in the future everybody knows what they’re supposed to do, and everything is well structured and protocolized. I think most patients can now receive it within six hours.
Can you explain how the laparoscopic surgery works?
Dr. Kwon: Traditionally we would make a big incision, we would retract, we would expose the field and deliver under our direct vision. With laparoscopic we put out half inch holes, about five to six. And through that we put a camera and some instruments through the holes, and we do the whole procedure and the liver resection itself through the camera and through the holes. Once the process is finished, there’s an incision where we take and deliver intact. That’s where the incision for the fantasies comes to place. The incision is made just the right size for the graph to be taken out of the body without being traumatized and in the location where it hurts least. So, the whole process is done the same as an open surgery, but under scope and with laparoscopic instruments.
How long does the laparoscopic operation take?
Dr. Kwon: It takes a similar time to open surgery because a lot of things are not well set, and we don’t have a lot of delay. I would say performing laparoscopic surgery is sort of like wearing a straight jacket while you do the surgery. You don’t have the flexibility of movement. You don’t have the flexibility of doing a lot of things that you can do in open surgery. I explain to the patients of a laparoscopic, most of the time I’m able to do an operation laparoscopically, but if something happens during complex surgery those incidents cannot be corrected laparoscopically and it’s going to be too dangerous for you to proceed laparoscopically. We don’t hesitate to open because the safety of the donor is more important than anything else. You always tell the donors the percentage that it can be converted to open, but most of them just ended up doing laparoscopically.
If nothing goes wrong and everything goes to plan, is there more risk to laparoscopic?
Dr. Kwon: Currently there is not a lot of data or otherwise. In the U.S. we are the second institution having started this program and worldwide, there is less than 1,000 cases reported whereas there are probably more than 20,000 open living donors. So, laparoscopy is still very small, so we don’t know. The preliminary data says that once you have gained that experience and once you have the things set up properly the complication rate is lower compared to open because you are void of the complication related with making a big abdominal incision. The way the laparoscopic works is you put some carbon dioxide inside the abdominal wall, you do the surgery and that acts like a gas tampon on the vessels. Most of the reports about laparoscopic liver resection is shown to have less bleeding. So, less bleeding and less complication results in less overall surgical trauma to the donors.
How big of a piece of the liver do you take out in that surgery?
Dr. Kwon: It’s around the size of two fists. Depending on the left to right, the left is usually about one third of your liver, the right is about two thirds of your liver. But when you take the left, it’s a little bit bigger than one fist. When you take the right, these may be a little bit larger than two fists around.
How long does it take for that donor liver to grow back?
Dr. Kwon: It’s very interesting how the liver reacts. The liver has a system in which it can detect how much liver tissue is necessary for you to maintain your life, detoxify all the toxins that are produced or manage all the metabolism that is necessary for the liver cells. When you first take it out and you have, let’s say 50% remnant, the first month it grows fast and it reaches around 80% of its original size, within four to six weeks. And then from there we have enough liver mass to be safe. Then it starts to grow slower. So, it’s very interesting. It’s known that the liver grows faster in recipients because usually the recipients are sicker. So, the liver understands that it needs to function more. It grows back faster than in the donor because the recipient usually has more metabolic demands than the donor.
How’s the liver donor doing and when do the donors usually go home?
Dr. Kwon: He’s doing great. Not in much pain and back to his normal life. The girls from the father is doing great too. He’s rejuvenated because he’s a lot younger. It’s like he’s had some young, fresh tissue in his body that rejuvenates him and he’s so much stronger and so much healthier than he used to be. Some people ask what the outcome of the recipient is when I do this procedure. In the initial stage when there is not enough data, we’re not sure whether the outcome was similar, or better or worse. Now from the data that we have it is well known that the outcome is the same as an open, and there’s some recent data that says the outcome may be even better in laparoscopic because it traumatizes the graft less than open surgery. But that’s a small piece.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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