Application of "parenchyma-first" approach in laparoscopic living donor left lateral sectionectomy.

Objective: This study aimed to evaluate the safety and feasibility of a "Parenchyma-First" approach for laparoscopic left lateral sectionectomy (LLS) in living donor hepatectomy, with the primary goal of minimizing vascular injury. Methods: To avoid premature and excessive dissection of the portal vein and hepatic artery at the first hepatic hilum-which increases the risk of vascular injury-and to prevent torsion or occlusion of these mobilized vessels during parenchymal transection, we adopted a technique that prioritizes liver parenchymal transection before dissecting the left hepatic artery and left portal vein branch. A single-center, retrospective, descriptive study of 46 donors and pediatric recipients (April 2023-June 2025). No control group was included. Results: Mean donor operative time was 289.7 ± 66.7 min, blood loss 71.5 ± 60.3 mL, and warm ischemia time 297.8 ± 98.6 s. No donor vascular or biliary complications occurred; one donor underwent reoperation for omental bleeding. Among recipients, mortality was 4.3% (2/46) due to recipient-related vascular complications. Vascular or biliary interventions were required in 10.9% (5/46) of recipients. Early allograft dysfunction occurred in 17.4% of recipients. Conclusion: The "Parenchyma-First" approach for left lateral section graft procurement is technically feasible, provides excellent donor safety by protecting hilar vasculature, and yields acceptable recipient outcomes comparable with international series.