Recently, Dr. Kyung-Suk Suh and colleagues¹ reported pure laparoscopic living donor liver transplantation, which raised great interest. Both explant hepatectomy and implantation of a modified graft were performed by laparoscopy for a 60-year-old recipient with alcoholic cirrhosis and hepatocellular carcinoma. This epoch-making work was the world's first liver transplantation (LT) totally accomplished by laparoscopy. However, we have the following concerns.

First, safety is our chief concern. In this single case, a hand port from suprapubic incision and an extracorporeal-controlled Chitwood clamp for inferior vena cava (IVC) clamping were prepared for catastrophic events. As the portal vein (PV) and IVC have high blood flow volume, massive hemorrhage of the trunk would be difficult to handle even in open surgery, let alone laparoscopy with a single hand from hypogastrium without a direct view. In this patient with PV thrombosis, thrombectomy via laparoscopy was dangerous and sudden massive blood flow from PV raised a safety concern.

Second, the risk of harm to the patient distinctly increased with the duration of all procedures being extended. Including explant hepatectomy, which took 369 min, the total operative time was 16 h, which was unduly longer than the standard transplantation time of 5–8 h. The warm ischemic time (WIT) was 84 min longer than the mean time of 33 min with the open technique. WIT is widely recommended to be no longer than 30 min, and a long WIT is associated with multiple complications.² The entire PV clamp time was 212 min. Even authors stated that in patients with esophageal and perigastric varices with the presence of a varix or shunt that prevents bowel congestion, a lengthened PV clamping time may severely harm body homeostasis. The anastomosis times for the hepatic vein, PV, hepatic artery, and bile duct were 42, 34, 49, and 45 min, respectively; these times are considerably longer than those with open surgery. In conclusion, the extended surgery time obviously aggravated damage.

Third, long-term complications, especially biliary complication (BC) of nonanastomotic stricture, should be considered. This case report included only the perioperative data of the patient; BC was not reported. An extended cold ischemic time is highly recognized as a risk factor for BC.³ Laparoscopic LT undoubtedly increased the CIT and the risk of BC. In our opinion, optimizing the LT incision at the cost of BC risk may not be applicable.

Unlike standard ectopic kidney transplantation with laparoscopy or robot assistance,⁴ LT is more complicated. An inverted “L” incision is adequate for LT with an incision of 30 cm; in this patient, a long suprapubic incision and multiple trocars were used, which may not lead to reduced damage, let alone risk. Within the past two decades, our center has completed more than 5000 laparoscopic hepatectomies, but we are still hesitant to perform pure laparoscopic LT even in highly selected patients, and this technique may not be suitable for promotion. Techniques like laparoscopy-assisted LT with a median incision might be a compromise for minimally invasive surgery applications.

最近，Kyung-Suk Suh 博士及其同事¹报道了纯腹腔镜活体肝移植，引起了人们的极大兴趣。一名患有酒精性肝硬化和肝细胞癌的 60 岁接受者通过腹腔镜进行了外植体肝切除术和改良移植物的植入。这项划时代的工作是全球首例完全通过腹腔镜完成的肝移植手术。但是，我们有以下担忧。

首先，安全是我们最关心的问题。在这个案例中，耻骨上切口的手端口和用于下腔静脉 (IVC) 夹紧的体外控制的 Chitwood 夹钳是为灾难性事件准备的。由于门静脉（PV）和下腔静脉血流量大，躯干大出血即使开腹手术也难以处理，更不用说单手下腹腹腔镜不能直视的腹腔镜检查了。在这名患有 PV 血栓形成的患者中，通过腹腔镜进行血栓切除术是危险的，并且 PV 突然大量血流引起了安全问题。

其次，随着所有程序持续时间的延长，对患者造成伤害的风险明显增加。包括耗时 369 分钟的外植体肝切除术，总手术时间为 16 小时，比标准移植时间 5-8 小时长得过长。热缺血时间 (WIT) 比开放技术的平均时间 33 分钟长 84 分钟。WIT 被广泛推荐不超过 30 分钟，而长时间的 WIT 与多种并发症有关。^2个整个 PV 钳位时间为 212 分钟。甚至作者也表示，在食管和胃周静脉曲张患者中，存在防止肠充血的静脉曲张或分流器，延长 PV 钳夹时间可能会严重损害身体稳态。肝静脉、PV、肝动脉和胆管的吻合时间分别为42、34、49和45分钟；这些时间比开放手术的时间要长得多。综上所述，手术时间的延长明显加重了损伤。

第三，应考虑长期并发症，尤其是非吻合口狭窄的胆道并发症 (BC)。本病例报告仅包括患者的围手术期数据；BC 没有被报道。延长的冷缺血时间被高度认为是 BC 的危险因素。³腹腔镜 LT 无疑增加了 CIT 和 BC 的风险。我们认为，以 BC 风险为代价优化 LT 切口可能不适用。

与腹腔镜或机器人辅助的标准异位肾移植不同，⁴ LT 更为复杂。倒“L”形切口适用于 30 厘米切口的 LT；在该患者中，使用了较长的耻骨上切口和多个套管针，这可能不会减少损伤，更不用说风险了。在过去的二十年里，我们中心已经完成了 5000 多例腹腔镜肝切除术，但即使在经过严格筛选的患者中，我们仍然对是否进行纯腹腔镜 LT 犹豫不决，这项技术可能不适合推广。腹腔镜辅助 LT 等正中切口技术可能是微创手术应用的折衷方案。