Intermittent Inflow Occlusion in Robotic Right Donor Hepatectomy: A Randomized Controlled Trial

To assess the safety and efficacy of intermittent inflow occlusion (IIO) during robotic right donor hepatectomy (RDH) for adult living donor liver transplantation.

Although evidence supports minimally invasive donor hepatectomy, its adoption by surgeons remains limited. Key challenges include bleeding during parenchymal transection and prolonged warm ischemia during graft extraction, resulting in morbidity in both the donor and recipient.

Between April 2022 and June 2023, out of 123 donors suitable for RDH, 113 were randomized to undergo robotic RDH with (n=56) or without (n=57) IIO. The primary endpoint was the blood loss during robotic RDH. The secondary end points included peak levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, international normalized ratio, and complications in donors and recipients. In addition, peak lactate levels and the need for blood transfusion were assessed in donors.

The mean duration of IIO was 42.48±11.21 minutes. Blood loss during parenchymal transection [235 (186.25-375) vs 295 (235-475), P =0.006] and total blood loss [275 (212.5-430) vs. 330 (272.5-520), P =0.018] were significantly lower among donors in the IIO arm. In recipients belonging to the IIO arm, peak alanine aminotransferase ( P =0.032) and international normalized ratio ( P =0.012) were significantly low. Although statistically similar, the peak aspartate aminotransferase ( P =0.064) and acute kidney injury ( P =0.061) in the IIO arm among recipients were also lower. Other perioperative outcomes, including complications in donors/recipients and overall mortality in recipients, remained comparable.

IIO during robotic RDH is safe. It led to reduced blood loss among donors and improved graft parameters in recipients during the immediate postoperative period.