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Next year will mark two decades since the first minimally-invasive donor hepatectomy (MIDH) was performed in Paris to facilitate an adult-to-child live donor liver transplant (LDLT). Despite improvements and widespread proliferation of LDLT throughout the world, a concomitant broader application of the MIDH technique has not been wholly realized due to concerns over donor safety and the technical difficulties inherent to MIDH. On the contrary, during the same time period, minimallyinvasive liver surgery (MILS) rapidly evolved into a standard approach for many benign and malignant forms of liver disease. To support this growth, numerous novel technologies such as advanced laparoscopy and robotic surgical systems, three-dimensional (3D) flexible videoscopy, real-time near-infrared fluorescence cholangiography with indocyanine green (ICG), and a variety of thermal energy devices and endovascular staplers have evolved and matured in the setting of MILS. A handful of select, high-volume liver transplant centers have incorporated these MILS advancements into their established segmental liver surgery and LDLT programs in order to develop the requisite technical sophistication to execute MIDH in an impactful manner. Two techniques, pure laparoscopic donor hepatectomy (PLDH) and robotic donor hepatectomy (DH), have emerged as the dominant modalities in MIDH surgery with each having their proponents and detractors. A few centers in Asia, France, the United States, and Saudi Arabia have recently reported series of sufficient volume and nuance to be instructive for the field in general. The intent of this review is to describe the experience to date in MIDH with a particular focus on lessons learned at these pioneering institutions who navigated through the learning curves in these demanding technical endeavors. The tricks, observations, and recommendations gleaned from this article should serve as a vital resource for those motivated surgeons embarking upon the challenging but rewarding field of MIDH surgery.

Minimally-invasive donor hepatectomy at the dawn of a decade: can we pick up the pace?