Prolonged Donor Warm Ischemia in Pure Laparoscopic Donor Right Hepatectomy Is Associated With Increased Recipient Biliary Stricture Risk: A Retrospective Cohort Study

Background. Pure laparoscopic donor right hepatectomy has been increasingly adopted because of its minimally invasive nature and established donor safety. However, its impact on recipient biliary complications remains uncertain. This study aimed to evaluate biliary outcomes after pure laparoscopic donor right hepatectomy using accumulated single-surgeon experience and assess the effect of donor warm ischemic time (DWIT). Methods. We reviewed 264 living donor liver transplantations performed by a single surgeon between 2011 and 2023. Donor hepatectomies were categorized as open (group O; n = 103) or laparoscopic, which was subdivided into early (group EL; n = 49) and late (group LL; n = 112) periods. All recipients were ABO-compatible, underwent duct-to-duct reconstruction, and were followed up for ≥1 y. DWIT was defined as the interval between hepatic artery ligation and cold perfusion. The primary outcome was biliary strictures requiring intervention. Results. Biliary stricture-free survival did not differ significantly between groups ( P = 0.278). Receiver operating characteristic analysis identified a DWIT cutoff of 12.5 min as a potential reference point for increased biliary stricture risk (area under the curve, 0.543; P = 0.043). In the multivariate analysis, DWIT ≥13 min was an independent predictor (hazard ratio, 1.88; P = 0.020). Conclusions. Prolonged DWIT appears to increase the risk of recipient biliary strictures, suggesting that minimizing DWIT in laparoscopic donor hepatectomy could help optimize outcomes.