Tolerance to ischemia–reperfusion injury in laparoscopic vs. open living donor hepatectomy with intermittent hepatic inflow occlusion: a retrospective cohort study

BACKGROUND: Donor safety is paramount in living donor liver transplantation. The safety of intermittent hepatic inflow occlusion (IHIO) during laparoscopic donor hepatectomy (LDH) remains uncertain due to concerns that pneumoperitoneum may impair hepatic venous backflow during inflow occlusion and exacerbate ischemia-reperfusion (IR) injury. This study aimed to compare the tolerance to IHIO-induced hepatic IR injury and clinical outcomes between LDH and open donor hepatectomy (ODH). MATERIALS AND METHODS: This retrospective, single-center cohort study included 914 adult living liver donors who underwent right hemi-hepatectomy from 2010 to 2024. After propensity score matching, 819 donors were analyzed. The exposure of interest was IHIO during either LDH or ODH. The primary outcome was tolerance to hepatic IR injury, defined as the increase in alanine transaminase (ALT) and aspartate transaminase (AST) per minute of IHIO. Secondary outcomes included postoperative complications. Quantile regression at the 50th percentile (median regression) was used for analysis. RESULTS: IHIO was performed in 87.2% of ODHs and 74.7% of LDHs. In ODH, each minute of IHIO increased median ALT and AST by 2.4 (1.7-3.2) U/L and 1.9 (1.2-2.6) U/L, respectively, vs. 1.2 (0.9-1.6) U/L and 0.8 (0.5-1.2) U/L in LDH. Tolerance to IHIO was significantly greater in LDH than in ODH (ALT: P = 0.007; AST, P = 0.003). Biliary complication rates increased with IHIO duration in ODH (0 min, 5%; >0‒30 min, 14.3%; >30 min, 12%), but not in LDH (4.2%, 3.9%, and 3.7%). When IHIO was used, biliary complication risk was significantly lower in LDH than ODH (>0-30 min, P = 0.028; >30 min, P = 0.004). CONCLUSIONS: We found no evidence that laparoscopic IHIO increases donor risk compared with open IHIO. Instead, LDH was associated with greater tolerance to IHIO-induced hepatic IR injury and lower biliary complication risk. These findings suggest IHIO can be used safely in LDH without added risk to open IHIO.