Donor body mass index over 30 is no barrier for pure laparoscopic donor right hepatectomy.

Backgrounds/Aims: Challenges arise when translating pure laparoscopic donor right hepatectomy (PLDRH) results from Asian to Western donors, due to differences in body mass index (BMI). This study compares the outcomes of PLDRH and conventional open donor right hepatectomy (CDRH) in donors with BMI over 30. Methods: Medical records of live liver donors (BMI > 30) undergoing right hepatectomy (2010-2021) were compared: 25 PLDRH cases vs. 19 CDRH cases. Donor and recipient demographics, operative details, and outcomes were analyzed. Results: PLDRH and CDRH had similar donor and recipient characteristics. PLDRH had longer liver removal and warm ischemic times, but a shorter post-liver removal duration than CDRH. Donor complication rates were comparable, with the highest complication being grade IIIa in PLDRH, necessitating needle aspiration for biloma on postoperative day 11. Fortunately, this donor fully recovered without additional treatment. No complications exceeding Clavien-Dindo grade IIIa occurred in either group. Recipient outcomes between the groups were similar. Conclusions: This study supports PLDRH as a viable option for donors with BMI over 30, challenging the notion that high BMI should deter considering PLDRH. The findings provide valuable insights into the safety and feasibility of PLDRH, encouraging further exploration of this technique in diverse donor populations.

Criteria for selecting living liver donors to optimize recipient outcomes in pure laparoscopic donor right hepatectomy: a cohort study.

BACKGROUND: Although the adoption of pure laparoscopic donor hepatectomy has expanded driven by considerations of donor cosmesis and function, the criteria for selecting candidates for pure laparoscopic donor right hepatectomy (PLDRH) continue to be debated. This study aimed to delineate the distinctive characteristics of donors and recipients who underwent conventional open-donor right hepatectomy (CDRH) during the era of PLDRH. MATERIALS AND METHODS: The authors conducted a retrospective review of a prospectively collected single-centre database encompassing all right hepatectomies at Seoul National University Hospital from April 2016 to December 2021, a period during which there were no absolute contraindications for PLDRH. RESULTS: During the exclusive PLDRH period, there were still 63 cases of CDRH alongside 362 cases of PLDRH. The CDRH donors were older, had a lower estimated remnant liver volume, and a higher incidence of expected multiple openings in the portal vein and bile duct based on preoperative imaging compared with PLDRH donors. In the subgroup analysis, including only donors meeting two or more criteria (age ≥40 years, estimated remnant liver volume ≥35%, or multiple anticipated vessel openings), recipients in the PLDRH group exhibited significantly more early major complications ( P =0.029) compared with those in the CDRH group. CONCLUSION: As PLDRH gains traction in practice, it is essential to acknowledge that specific donor conditions, such as advanced age, limited remnant liver volume, and anticipation of multiple portal or bile duct openings, may merit contemplating CDRH as a means of optimizing recipient outcomes.

Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital.

Pure laparoscopic donor hepatectomy (PLDH) has become a routine procedure at Seoul National University Hospital, and the pure laparoscopic method is now being applied to liver recipients as well. This study aimed to review the procedure and outcomes of PLDH to identify any areas that required improvement. Data from 556 donors who underwent PLDH between November 2015 and December 2021 and their recipients were retrospectively reviewed. Among these, 541 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). The mean hospital stay of the donor was 7.2 days, and the rate of grade I, II, IIIa, and IIIb complications was 2.2%, 2.7%, 1.3%, and 0.9%, respectively, without any irreversible disabilities or mortalities. The most common early and late major complications in the recipient were intraabdominal bleeding (n = 47, 8.5%) and biliary problems (n = 198, 35.6%), respectively. Analysis of the PLDRH procedure showed that operative time, liver removal time, warm ischemic time, Δhemoglobin%, Δtotal bilirubin%, and postoperative hospital stay decreased significantly as the number of cases accumulated. In conclusion, the operative outcomes of PLDRH improved as the number of cases increased. However, continuous caution is needed because major complications still occur in donors and recipients even after hundreds of cases.

Evaluation of the efficacy and safety of conversion from the tacrolimus capsule to tablet in stable liver transplant recipients with maintenance therapy: a 24-week, open-label, single-center, phase IV exploratory clinical study.

Purpose: The tablet form of tacrolimus is more convenient for drug ingestion than the capsule form. We examined the efficacy and safety of tacrolimus tablets and a satisfaction survey after formula conversion in liver transplant (LT) recipients. Methods: This study was an open-label, prospective clinical trial for tacrolimus formula 1:1 conversion from capsule to tablet in 41 adult LT recipients with tacrolimus maintenance therapy of more than 1 month. The primary endpoint was incidence of biopsy-proven acute rejection (BPAR) within 24 weeks. Surveys 1 week before and 4 weeks after formula conversion were conducted for total daily dose of medication, number, scale of discomfort and satisfaction. Results: The overall incidence of BPAR was 0% and there was no graft loss or patient death. The incidence of adverse effects was 34.1% (n = 14) after formula conversion. The most common severe adverse effect was abnormal liver function test (n = 5): biliary complications (n = 4) and alcoholic recidivism (n = 1). Total daily dose and number of tacrolimus doses were significantly lower after formula conversion (P < 0.05) without changes in trough level. According to survey analysis, there was no significant difference in discomfort and satisfaction scales from capsule to tablet conversion (P < 0.05). Conclusion: The present study suggests that the new tablet formula can be a useful treatment option to maintain a consistent level of tacrolimus with a lower total daily dose and number in adult LT recipients.

Soluble suppression of tumorigenicity 2 is a potential predictor of post-liver transplant renal outcomes.

Acute kidney injury is considered an independent prognostic factor for mortality in patients with liver cirrhosis. Non-treated acute kidney injury can progress to hepatorenal syndrome with a poor prognosis. As suppression of tumorigenicity 2 (ST2) is a member of the interleukin-1 receptor family that aggravates inflammation and fibrotic changes in multiple organs, we measured soluble ST2 (sST2) level in the serum and urine of liver-transplant recipients at the time of transplantation. The serum sST2 level significantly increased in liver-transplant recipients with suppressed kidney function compared with that in recipients with normal function. In recipients with severely decreased liver function (model for end-stage liver disease score ≥ 30), the serum sST2 level was higher than that in recipients with preserved liver function (model for end-stage liver disease score ≤ 20, P = 0.028). The serum sST2 level in recipients with hepatorenal syndrome was higher than that in liver-transplant recipients without hepatorenal syndrome (P = 0.003). The serum sST2 level in patients with hepatorenal syndrome was higher than that in recipients without a history of acute kidney injury (P = 0.004). Recipients with hepatorenal syndrome and recovered kidney function showed higher sST2 levels than those who did not recover (P = 0.034). Collectively, an increase in the serum sST2 level reflects a decrease in both kidney and liver functions. Thus, measuring sST2 level at the time of liver transplantation can help predict renal outcomes.

Pure laparoscopic donor right hepatectomy in patients over 50 years old: Why age should not be a barrier.

INTRODUCTION: Given the global aging population, the average age of liver donors is increasing. This study aimed to evaluate the surgical outcomes of grafts from pure laparoscopic donor right hepatectomy (PLDRH) in liver donors aged > 50 years. METHODS: The medical records of liver donors were retrospectively reviewed. The donors underwent conventional donor right hepatectomy (CDRH) from January 2011 to May 2019 or PLDRH from March 2016 to May 2019. We divided the donors into three groups: PLDRH donors aged ≥50 (n = 26; Group 1) and aged < 50 (n = 257; Group 2), and CDRH donors aged ≥50 years (n = 66; Group 3). RESULTS: Operation time (p < .01) and hospital stay (p < .01) were significantly lower in Group 1 than in Group 3. Other postoperative outcomes of donors including graft anatomical variation, graft weight, graft-to-recipient weight ratio, and hepatic steatosis were similar among the three groups. Although no postoperative complications occurred in Groups 1 and 3, they were detected in 17 cases (6.6%) in Group 2. No postoperative complications were detected among the recipients. CONCLUSIONS: PLDRH was feasible and safe in donors aged over 50 years, with outcomes similar to those for donors aged <50 years. PLDRH should not be avoided solely based on the donor's age ≥50 years.

Recurrence in patients with totally necrotic nodules of hepatocellular carcinoma after liver transplantation: "totally" an inaccurate description.

Purpose: Total necrosis of hepatocellular carcinoma (HCC) achieved via locoregional treatment (LRT) is considered to indicate a lack of tumor viability. Nonetheless, there is insufficient evidence of recurrence after liver transplantation (LT) in patients with such a status. The aim of this study was to investigate the prognosis of patients diagnosed with totally necrotic nodules upon explant hepatectomy after LT. Methods: We conducted a retrospective study of patients diagnosed with totally necrotic nodules after LT for HCC. A total of 165 patients with HCC who underwent living- or deceased-donor LT from 2000 to 2020 in our hospital were included. Results: A total of 5 patients (3.0%) exhibited HCC recurrence during a median follow-up of 84 months (range, 4-243 months) after LT. The 5-year overall and recurrence-free survival rates of these patients were 92.8% and 92.2%, respectively. Four patients in the HCC-recurrence group (80.0%) died even after further treatment, including transarterial chemoembolization, surgery, and systemic treatment. Both univariate and multivariate analyses of clinicopathological factors identified a maximum diameter of the totally necrotic nodules of >5 cm as the only factor associated with tumor recurrence following LT (P = 0.005 and P = 0.009, respectively). Conclusion: Total necrosis of HCC via LRT yielded excellent survival outcomes for patients undergoing LT. Nevertheless, patients with large tumors should be considered at high risk of recurrence after LT, suggesting the need for their active surveillance during the follow-up period.

Modified Charlson comorbidity index as a survival prediction tool for older patients after liver transplantation.

Purpose: An increasing number of older patients now undergo liver transplantation (LT). Although the overall outcomes in older patients are not different from those of younger patients, there is no tool to predict LT prognosis in older patients. We hypothesized that a modified Charlson comorbidity index (mCCI) and 5-factor modified frailty index (mFI-5) can predict outcomes in older patients after LT. Methods: This retrospective study included 155 patients (aged >65 years) who underwent LT at Seoul National University Hospital. The recipients were subcategorized into 2 groups based on the mCCI score and mFI-5: the low (0-1) and high (2-5) mCCI groups, and low (≤0.4) and high (>0.4) mFI-5 groups. The independent effect of each variable on post-LT survival was determined using the mCCI subgroup, age at transplantation, sex, Child-Turcotte-Pugh score, model for end-stage liver disease (MELD) score, and mFI-5 subgroup. Results: The high-mCCI group (41 patients) showed significantly lower 1- and 3-month and 1-, 3-, and 5-year survival than the low-mCCI group. Using the Cox regression model, the mCCI, sex, and MELD score remained significant. The mFI-5 was not a significant factor to predict patients' survival. Conclusion: The mCCI and MELD scores could be used to predict post-LT survival in older patients.

Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations.

Hepatic artery thrombosis (HAT) after liver transplantation is associated with a marked increase in morbidity, leading to graft and patient loss. We evaluated the outcomes of adult living donor liver transplantation patients with HAT under an aggressive surgical intervention. A total of 1355 recipients underwent adult living donor liver transplantation at the Seoul National University Hospital. Surgical redo reconstruction for HAT was performed in all cases except in those with graft hepatic artery injury and late detection of HAT. Postoperative HAT developed in 33 cases (2.4%) at a median time of 3.5 days. Thirty patients (90.9%) underwent redo-arterial reconstruction. The survival rates in patients with HAT were similar to the rates in those without HAT (72.7% vs. 83.8%, p = 0.115). Although graft survival rates were lower in patients with HAT (84.8%) than in those without HAT (98.0%) ( p < 0.001), the graft survival rate was comparable (92.0% vs. 98.0%, p = 0.124) in the 25 patients with successful revascularization. Biliary complication rates were higher in patients with HAT (54.5%) than in those without HAT (32.0%) ( p = 0.008). In conclusion, the successful redo reconstruction under careful selection criteria saved the graft without retransplantation in 96.0% of the cases. Surgical revascularization should be preferentially considered for the management of HAT in adult living donor liver transplantation.

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report.

Attenuated portal vein (PV) flow is challenging in pediatric liver transplantation (LT) because it is unsuitable for classic end-to-end jump graft reconstruction from a small superior mesenteric vein (SMV). We thus introduce a novel technique of an end-to-side jump graft from SMV during pediatric LT using an adult partial liver graft. We successfully performed two cases of end-to-side retropancreatic jump graft using an iliac vein graft for PV reconstruction. One patient was a 2-year-old boy with hepatoblastoma and a Yerdel grade 3 PV thrombosis who underwent split LT. Another patient was an 8-month-old girl who had biliary atresia and PV hypoplasia with stenosis on the confluence level of the SMV; she underwent retransplantation because of graft failure related to PV thrombosis. After native PV was resected at the SMV confluence level, an end-to-side reconstruction was done from the proximal SMV to an interposition iliac vein. The interposition vein graft through posterior to the pancreas was obliquely anastomosed to the graft PV. There was no PV related complication during the follow-up period. Using a jump vascular graft in an end-to-side manner to connect the small native SMV and the large graft PV is a feasible treatment option in pediatric recipients with inadequate portal flow due to thrombosis or hypoplasia of the PV.

Posttransplant sequential adrenal and spine metastasis of hepatocellular carcinoma responsive to combined regorafenib and radiotherapy: a case report.

Adrenal and spinal metastases of hepatocellular carcinoma (HCC) are rare entities with significant morbidity and mortality, particularly after liver transplantation (LT). We report a case of a 49-year-old man who underwent LT for hepatitis B-related end-stage liver disease and HCC (single 4.5 cm lesion [T1N0], without vascular invasion) in 2016. Eighteen months later, adrenal metastasis and hepatitis B seropositive conversion were developed with normal serum tumor. Adrenal metastasis was treated with radiation therapy (RT) and hepatitis B showed spontaneous seronegative conversion. However, 35 months later, spinal metastasis occurred with elevation of the protein induced by vitamin K absence or antagonist-II (PIVKA-II) level (197 mAU/mL), along with hepatitis B seropositive conversion. After sorafenib, sequential regorafenib with RT led to partial response of the spinal lesions, along with hepatitis B seronegative conversion and normal PIVKA-II levels. After 9 months of regorafenib combined with RT, two recurrent lesions were found, as well as hepatitis B seropositive conversion and lesions were treated with transarterial chemoembolization. The patient survived for more than 71 months after LT and 53 months after recurrence under various combinations of therapy. Combined systemic and locoregional therapies can be a treatment option for HCC recurrence, even in LT patients.

Long-term outcomes of liver transplantation using grafts from donors with active hepatitis B virus replication: a multicenter cohort study.

Purpose: Liver grafts from donors with HBV infection contributed to expanding the donor pool under the hepatitis B immunoglobulin and antiviral agents (nucleos(t)ide analogues) in the HBV-endemic area. We report long-term outcomes of liver transplantations (LTs) using grafts from donors with active or chronic HBV infection. Methods: Overall, 2,260 LTs performed in 3 major hospitals in Seoul from January 2000 to April 2019 were assessed for inclusion. Twenty-six grafts (1.2%) were obtained from HBsAg (+), HBeAb (+), or HBcAb (+) donors, and recipient outcomes were retrospectively reviewed. Donor and recipient demographics and transplantation outcomes were analyzed. Results: Sixteen deceased donor LTs were performed using active HBsAg (+) grafts. Ten other LTs were sourced from 10 living donors. There was no significant difference in survival in patients who received deceased donor LTs compared with that in those who underwent LT with non-hepatitis virus-infected grafts. Fourteen patients who were followed up for >5 years were stable, and no difference in hepatocellular carcinoma recurrence rate was observed 5 years after transplantation between transplants from donors with and those without HBV. Conclusion: Considering long-term outcomes, liver grafts from donors with active HBV replication can be safely used for LT.

Total robot-assisted recipient's surgery in living donor liver transplantation: First step towards the future.

Lee and colleagues describe a groundbreaking total robot-assisted explant hepatectomy followed by robotic engraftment for a patient requiring a living donor liver transplant. This report represents a crucial step towards implementing robot-assisted liver transplantation, a cutting-edge surgical technique that could change the surgical trend in recipient surgery for liver transplantation.

Initial outcome of external biliary drainage in living donor liver transplantation with pure laparoscopic donor hepatectomy.

Biliary complications after living donor liver transplantation (LDLT) are the most common and intractable complications due to both surgical and nonsurgical factors. External biliary drainage (EBD), a surgical option to prevent biliary complications, has recently been adopted in the era of pure laparoscopic donor right hepatectomy, which may result in increased bile duct problems in the recipients. This study retrospectively reviewed the patients who underwent LDLT with duct-to-duct anastomosis between July 2017 and October 2020 to analyze the initial outcomes of EBD and to compare the incidence of biliary complications in adult LDLT recipients who underwent duct-to-duct anastomosis with or without EBD. Only patients who underwent pure laparoscopic donor hepatectomy were included in this study. The patients were divided into 2 groups according to the application of EBD. The median follow-up period was 28.5 months. The overall incidence of Clavien-Dindo grade IIIa biliary complications was 35.0% (n=14) in the EBD group and 50.7% (n=76) in the non-EBD group ( p = 0.08). The incidence of biliary leakage was 0% in the EBD group and 15.3% in the non-EBD group ( p = 0.01). The EBD-related complication rate, that is, involving retraction, accidental removal, and dislocation, was 40.0%. EBD implementation is effective in preventing biliary leakage after LDLT with a graft procured using the pure laparoscopic donor right hepatectomy method with duct-to-duct biliary anastomosis. However, efforts should be made to prevent EBD-related complications. Further studies are needed to establish appropriate selection criteria for EBD.

Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation.

In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.

Pure laparoscopic vs open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis.

BACKGROUND/PURPOSE: Since minimally invasive surgery has been incorporated in overall surgery, pure laparoscopic technology is involved in most hepatectomies, including right hepatectomy, in patients with hepatocellular carcinoma (HCC). However, its feasibility and safety in right hepatectomy are still controversial owing to the limited literature. This study aimed to compare the short- and long-term outcomes of pure laparoscopic right hepatectomy (PLRH) with those of open right hepatectomy (ORH) in patients with HCC. METHODS: The prospectively collected medical records of 327 patients with HCC who underwent right hepatectomy between January 2010 and April 2020 at Seoul National University Hospital were retrospectively reviewed. We performed 1:1 propensity score matching between the PLRH and ORH groups. The primary end point was short-term outcomes, including hospital stay, blood loss, and morbidity; the secondary end point was long-term outcomes, including overall and recurrence-free survival. RESULTS: Forty-nine patients were included in each group. Patients who underwent PLRH had a shorter postoperative hospital stay than those who underwent ORH (12.2 vs 8.9 days; P < .001). The requirement for blood transfusion was significantly lower in the PLRH group than in the ORH group (10.2% vs 2.0%; P = .010). The operative time (P = .479) and proportion of major complications (P = .487) were comparable between the groups. There were no significant differences in overall survival (P = .524) and the recurrence-free survival rate (P = .576) between the groups. CONCLUSIONS: Postoperative outcomes, including oncological outcomes, were comparable between PLRH and ORH, showing that PLRH can be a safe and feasible option to replace ORH in patients with HCC.

Pure Laparoscopic Versus Open Right Hepatectomy in Living Liver Donors: Graft Weight Discrepancy.

BACKGROUND Accurate volumetric evaluation of donors' livers before surgery is crucial for successful living-donor liver transplantation. However, there are few studies on the volumetric evaluation in the recently popularized pure laparoscopic donor hepatectomy method, in contrast to the number of studies for conventional donor hepatectomy. We aimed to analyze the difference between estimated graft weight and actual graft weight in pure laparoscopic donor right hepatectomy (PLDRH) and conventional donor right hepatectomy (CDRH) procedures. MATERIAL AND METHODS The medical records of 612 donors who underwent right hepatectomy in living-donor liver transplantation between January 2014 and December 2020 were retrospectively reviewed. The CDRH group targeted patients from January 2014 to October 2015, and the PLDRH group targeted patients from March 2016 to December 2020. RESULTS There were 119 and 376 donors who underwent CDRH and PLDRH, respectively. Although there was no significant difference in the estimated graft weights (P=0.994) and actual graft weights (P=0.489) between the groups, the estimated graft weights were significantly higher than the actual graft weights in both groups. However, the estimated graft weight and actual graft weight showed linear correlations in both the CDRH (r=0.81, P<0.001) and PLDRH (r=0.76, P<0.001) groups, with the CDRH group having greater linearity. CONCLUSIONS The estimates of graft weight were similar between the 2 groups. However, since the actual graft weight tended to be smaller in the PLDRH group, this should be considered before surgery.

Progression of a persisting mesenchymal hamartoma to intrahepatic cholangiocarcinoma 24 years after the initial diagnosis: A case report.

Mesenchymal hamartoma of the liver (MHL) is a rare benign tumor that often presents in early childhood, and it rarely occurs in adulthood. Aberrant development of the portal tract is a known cause of MHL. Although limited information is available on the natural course of MHL, malignant transformation has been reported in a few cases. Here, we report a case of a 26-year-old female with intrahepatic cholangiocarcinoma secondary to unresected MHL. The patient underwent resection of the hepatic mass, which was diagnosed as MHL at 2 years of age, due to an increase in mass size and a suspicion of malignant transformation during work-up. Histopathology confirmed intrahepatic adenosquamous carcinoma in the background of MHL, with a T2N0M0 pathological stage (stage II). The surgical margin was free from tumor cells. The patient fully recovered postoperatively and started receiving adjuvant chemotherapy. Previous case reports have only reported about the development of undifferentiated embryonal sarcoma or angiosarcoma as malignant transformation of MHL. Cases of other malignancies have not been published; however, it is difficult to rule out the occurrence of various malignancies related to the portal tract when considering the pathogenesis of the disease. To the best of our knowledge, this is the first case report of adenocarcinoma of bile duct origin secondary to MHL. This case report suggests that aggressive surgical management should be considered after the initial diagnosis of MHL.

Pure laparoscopic versus open right donor hepatectomy including the middle hepatic vein: a comparison of outcomes and safety.

Purpose: Analyses on pure laparoscopy in donor hepatectomies, including the middle hepatic vein (MHV), are still scarce. This study aimed to compare the outcomes of donor right hepatectomy, including the MHV, when performed laparoscopically with conventional open surgery. Methods: Data from living donors who underwent donor right hepatectomy between January 2012 and December 2020 were retrospectively analyzed. The intraoperative and postoperative complication rates of the pure laparoscopic donor right hepatectomy (PLDRH) with MHV inclusion (PLDRHM) group were compared with the conventional open donor right hepatectomy with MHV inclusion (CDRHM) group and the PLDRH without MHV inclusion [PLDRHM(-)] group. Results: Compared to the CDRHM group, the PLDRHM group had a longer bench time (P < 0.001) and higher Δ%, calculated as [(preoperative value - postoperative value)/preoperative value] × 100, of AST (P < 0.001), ALT (P < 0.001), and total bilirubin (P = 0.023), but shorter hospital stay (P = 0.004) and a lower rate of complications (P = 0.005). Compared to the PLDRHM(-) group, the PLDRHM group had fewer male donors (P < 0.001) and a lower body mass index (P < 0.001), estimated total liver volume (P < 0.001), and real graft weight (P < 0.001). Results of laboratory changes, hospital stays, and complication rates were similar between the 2 groups. Conclusion: PLDRH with the inclusion of the MHV in selected donors and recipients is feasible and safe when performed by surgeons experienced in laparoscopic surgery, with favorable complication rates compared to CDRHM and PLDRHM(-).