Midline Incision Living Donor Liver Transplantation as a Step Toward Minimally Invasive Liver Transplantation: A Propensity Score Matched Analysis.

Abstract

Performing the living donor liver transplant (LDLT) recipient operation via a midline incision (MILT) may reduce perioperative morbidity and postoperative wound related issues. Also, it is likely to bear significance in the current era of minimally invasive recipient surgery (MIRS) as competence in performing an MILT is likely to be the stepping-stone toward and importantly, the safety net in performing a safe MIRS. We present our series of MILT, highlighting the evolution and its technical modifications. Propensity score matched analysis (based on MELD, GRWR, and etiology) of MILT versus standard LDLT (reverse L incision) (SILT) with a 1:2 ratio was performed from a prospectively collected database. All perioperative recipient data including postoperative morbidity and mortality were compared. Among 75 MILT and 150 SILT patients, there were no significant differences between the groups with regards to operative time (520 ± 73 vs. 522 ± 120 min, p = 0.89) and cold ischemia time (110 ± 45 vs. 118 ± 60 min, p = 0.31). The warm ischemia time was significantly longer in the MILT group (52 ± 24 min vs. 46 ± 14 min, p = 0.02). While the mean blood loss was comparable between the groups (1675 ± 850 vs. 1550 ± 1150 mL, p = 0.41), blood transfusion requirements including packed red cells (5 (IQR:3-7) vs. 3 (IQR:1-6), p = 0.03) and fresh frozen plasma (3 (IQR:2-4) vs. 2 (IQR:0-3), p = 0.02) were significantly higher in MILT patients. There was no difference between the groups with regards to major 90-day morbidity (18.6% vs. 15.3%, p = 0.53), duration of hospital stay (15 (IQR:10-18) vs. 14 (IQR: 12-18) days, p = 0.06), and 1-year (92% vs. 95.3%) and 3-year mortality (92% vs. 91.4%) (p = 0.89). We present the feasibility and safety of MILT in LDLT. In the current milieu of MIRS, competence in performing a safe MILT may become an essential component of the recipient surgeon's armamentarium.