Background: Although the technique of liver transplantation is well developed, the invasiveness of the operation can be decreased with laparoscopic procedures.

Methods: We performed elective living donor liver transplantation (LDLT) through a midline incision combined with hand-assisted laparoscopic surgery (HALS). The indications for this procedure included no previous laparotomy, no hypertrophic change of the liver, and no significant collateral veins. Twenty-five selected patients with end stage liver disease underwent the procedure between July, 2010 and January, 2013 (median age 60, median Child-Pugh 9, median MELD score 14). Splenectomy was performed simultaneously in 19 cases. The liver (and spleen) were mobilized by a sealing device under a HALS procedure with an 8-cm upper midline incision, followed by explantation of the diseased liver (and spleen) through the upper midline incision which was extended to 12 to 15 cm. Partial liver grafts were implanted through the upper midline incision.

Results: The median duration of the operation was 756 minutes, the median time needed for anastomosis was 40 minutes, the median blood loss was 7,300 g. Seventeen recipients are alive and have good graft function. One patient required an additional right transverse incision as it involved a difficult implantation. When compared with 13 recent liver recipients who underwent LDLT with a regular Mercedes-Benz-type incision, no clinically relevant drawbacks of the HALS hybrid procedure were observed.

Conclusion: We have shown the feasibility and safety of LDLT performed through a small midline incision without abdominal muscle disruption with the aid of HALS.

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