In the 1990s, soon after Professor Suh Kyung-suk became a physician, Korea’s liver cancer surgery techniques were not very advanced, lagging far behind Japan’s.

About three decades later, a set of superlative modifiers -- the most, the first, and the leading -- follow Professor Suh and his liver transplant team at Seoul National University Hospital (SNUH).

“Currently, Korean surgeons conduct the most living donor liver transplants in the world per population. So naturally, surgery techniques develop,” Suh said in an interview with Korea Biomedical Review. “As the number of surgeries grew, we could also try out some world-first methods.”

He seemed to be a little too humble.

It is widely known that Korean physicians’ medical techniques are one of the best worldwide. And such high levels of medical arts are not possible without dedication. “In the past, we used to conduct overnight operations on emergency patients. Nothing was more rewarding than saving dying patients through such endeavors,” Professor Suh said. “I found it fascinating to save patients’ lives through transplants.”

Professor Suh graduated from Seoul National University College of Medicine with his medical degree in 1984 and received his diploma in General Surgery in 1989. He joined the Liver Support Lab unit of Cedars-Sinai Medical Center, California, between 1995 and 1997 as a visiting scientist.

“Back then, the surgeries for stomach and breast cancer were somewhat established. However, many patients who required liver transplants were on the verge of death. I remember about half of those who underwent liver transplants died of bleeding or incorrect surgeries," Suh said.

Liver transplant is divided into cadaveric whole liver and living donor liver transplantation.

In the cadaver liver transplant, patients receive the liver of a brain-dead person. In most cases, the entire liver is removed from the donor and transplanted to the patient with very poor liver function, while living donor liver transplants are mostly performed between family members.

Professor Suh, who had consistently improved liver transplant techniques to improve patients' prognosis, recently introduced a new surgical method as one of the pioneers in liver transplantation.

From a liver transplant laggard to a front-runner

Korean hospitals have been actively using and developing laparoscopic liver transplants, but not many foreign medical institutions can handle the surgery.

That explains why Professor Suh demonstrated a live laparoscopic donor liver resection at The Transplantation Society (TTS) last year. He also began performing laparoscopic liver transplants for recipients who have a higher risk of bleeding from the operation.

"We have also developed a new laparoscopic liver transplant using a robot arm and performed the first surgery in the world," Suh said. "Our goal is to speed up recovery and reduce pain after surgery by performing laparoscopic surgery on recipients in the future."

Unlike open surgery that requires a large incision to access the liver, the laparoscopic procedure is performed with surgical tools and a camera inserted through a few half-inch holes in the abdomen of the living donor, leaving a far less post-surgical scar.

"Some of our patients were foreigners. We have operated surgeries for patients from Mongolia, Saudi Arabia, the Middle East, Kazakhstan, and India. We even visited foreign countries to perform operations," Suh said. "I remember a Middle East anchorwoman and her brother coming to Korea a few years ago for the living donor liver transplant, which our team successfully carried out through laparoscopic liver transplantation."

Suh stressed that only a few countries could perform laparoscopic liver transplantation due to its complicated process.

Removing the right part of the liver with laparoscopic surgery is challenging as surgeons have to remove the liver from the donor without causing bleeding and spare arteries and veins.

However, both patients and donors express satisfaction with a laparoscopic liver transplant, not least because it leaves a minimal scar on the belly after the surgery.

Korean physicians don’t stop developing, improving surgical techniques

In a living donor liver transplant, 30 to 35 percent of the liver should be left in the donors as their health condition is considered most important.

"The donors can give up to 70 percent of their liver because the organ regenerates at an incredibly fast rate even after receiving critical damage, such as poisoned by a mushroom or partially removed," the SNUH professor said. "Normally, it grows twice in a week and recovers about 80 percent in four months, and slowly recovers back to the original size over time."

"We have developed various liver transplant techniques since the nation began transplanting livers, and some are world's first methods to resect living donor's liver," Suh said. "Although the liver transplants started in foreign countries, various new methods have been developed in Korea, and I can tell that the nation has been leading the world in living donor liver transplantation."

Suh said that there were cases that the general procedure of removing the liver from the right or left could not be applied. However, surgeons always looked for ways to overcome the limitations, such as resecting the liver into pieces for transplantation.

However, removing the patients' liver is still the first consideration when operating for liver cancer as it can reserve their functioning liver and increase survival rate, according to Suh. When patients receive a new liver, the blood must flow again between two different livers, forcing their hearts to overwork.

Suh pointed out that even in recent surgeries, his surgical team had to repair blood vessel ruptures or even open up the chest and squeeze patients' hearts while performing the surgery. He explained that liver transplantation is a difficult surgery where patients' blood vessels could be damaged for various reasons and result in an emergency.

Nation direly needs more cadaver donation

Korea is still far short of cadaver liver donation compared to other countries. The number of liver donations per one million people is about seven to eight in the nation, far lower than 20 to 30 people in Spain.

Suh said the government and the medical community should consistently conduct organ donation campaigns to raise the donation rate. "Some foreign countries perform liver transplants with organs donated not just from brain death but also cardiac death,” he pointed out.

Professor Suh stressed that cadaveric liver transplants should precede living donor transplants because removing and transplanting the liver from a healthy person cannot be a desirable option.

"Since one living person has to make a sacrifice, I wish there would be more cadaveric liver donors," Suh said.

Korea’s surgical methods have reached a high stage overcoming many problems. However, 20 to 30 percent of patients with biliary tract complications still have problems after receiving a liver transplant.

"We now have effective therapies for rejections, but the adverse effects of these drugs have not been addressed yet."

The chronic side effects may cause the patient's body to deteriorate and suffer kidney problems, diabetes, high blood pressure, and various lipid metabolic diseases. However, Professor Suh said he hopes to see drugs that can induce tolerance with reduced drug use in the next few years.

"These days, many patients know much about liver transplantation, but they should know that the surgery cannot save their lives if they ‘miss the right time,’” Professor Suh emphasized. "People with poor liver function should visit doctors before their conditions worsen, and it gets too late to receive a liver transplant."