In the past two decades, there have been numerous laparoscopic liver resection techniques developed and described in the literature, with many benefits compared to traditional open surgery (Nguyen and Geller 2010). Several surgical techniques of MIDH have been created in the literature since the introduction in pediatric (Cherqui et al. 2002) and adult donor hepatectomy (Koffron et al. 2006). Summary of case studies and series is collected in Table 1.

Cherqui et al. was the first group to describe two cases of laparoscopic donor left hemihepatectomy. They performed the left hepatectomy by pure laparoscopy along with a 10-cm Pfannenstiel incision for extraction (Fig. 2i). Two cases took 420 and 360 min with estimated blood loss of 150 and 450 ml, respectively. Those patients were hospitalized for 7 and 5 days with uneventful recovery. They describe these findings very comparable and competitive to conventional open left segmentectomy, which takes 342 min with blood loss of 192 ml and hospital stay of 15 days on average from the analysis of 282 cases (Fujita et al. 2000).

Koffron et al. (2006) were the first to report a case of laparoscopic-assisted right donor hemihepatectomy in 2006. They used “hybrid technique” that combined two laparoscopic sites with a subxiphoid midline incision for hand assistance and graft extraction during a 235-min operation (Fig. 1d or 2a). They used this incision to directly visualize parenchymal transection to minimize risk of bleeding. Many groups adopted this technique and have made variations. Suh et al. (2008) reported two cases of modified right hemihepatectomy including transection completely by laparoscopy with a 9-cm incision for hand port and extraction at the right upper quadrant (Fig. 2b). They reported operative times of 765 and 898 min, significantly longer than the previous cases, as they spent 218 and 310 min for transection alone. Both patients experienced minor complications of pleural effusion and abdominal fluid collection and required hospitalization for 10 and 14 days. In the following year, the same group also reported seven more cases of laparoscopy-assisted donor right hemihepatectomy while preserving the middle hepatic vein with similar outcomes (Suh et al. 2009). In 2012, Giulianotti et al. (2012) published the first case of robot-assisted donor right hemihepatectomy with operative time of 480 min and blood loss of 350 ml. With known advantage of robotic system in 3-dimensional visualization and versatile manipulation of instruments, this approach enabled the use of sub-umbilical incision for better pain control and prevention of pulmonary complication (Fig. 2e). In the same year, Choi et al. (2012) used the single-port laparoscopy-assisted approach to keep only one 15-cm right subcostal incision at the end of harvest (Fig. 2c). Compared to laparoscopy-assisted or conventional open hepatectomy, they reported significantly less operating time and blood loss. Soubrane et al. (2013) used pure laparoscopy for right hemihepatectomy in a similar fashion described in left hepatectomy by the same group in 2002 and achieved decrease in blood loss to 100 ml during 480 min of operative time (Fig. 2g). Finally, Soyama et al. (2012) reported a case series of 15 hand-assisted laparoscopic donor hepatectomies, including six right and nine left hemihepatectomies. They reported one donor complication of portal venous thrombosis but otherwise comparable results among their cases.

Minimally invasive donor hepatectomy has multiple conceivable benefits proven from other minimally invasive surgeries that can be also applied to the organ donors. The minimally invasive procedure reduces the hospital stay length and recuperation time while improving long-term quality of life. Smaller incision size would also decrease need for pain medication and risk for incisional hernia. To date, a few studies have compared laparoscopic versus conventional incision donor hepatectomy for LDLT (see Table 2). Baker et al. (2009) published a comparative analysis between 33 of each laparoscopy-assisted and open donor right hepatectomy that showed reduced operative times and less estimated blood loss, while having similar complication rates, length of stay, and hospital costs. Nagai et al. (2012) compared 28 minimally invasive cases, which include hand-assisted laparoscopy and mini-laparotomy, to 30 conventional donor hepatectomy cases. More recent study by Makki et al. (2014) also compared 24 laparoscopy-assisted donor hepatectomies to 26 conventional donor hepatectomies with 6-month follow-up and concluded that patients from former procedures experienced significantly less pain, reduced complication, and better quality of life without compromising safety. Another prospective case-matched study by Zhang et al. (2014) showed improved outcomes in similar fashion when two study groups of 25 cases were matched with age, gender, and body mass index. While all the above studies mainly examine donor right hemihepatectomy for adult, Marubashi et al. (2009) compared laparoscopy-assisted donor left hemihepatectomy to conventional open procedure, resulting in similar pattern of outcome. There is an interesting trend that even though the reported morbidity is generally lower in Eastern countries, the overall length of hospital stay is longer. One possible explanation is different healthcare reimbursement system that drives faster discharge in the United States.