The Globalization of Robotic Living Donor Hepatectomy.

Since its inception, transplant surgeons have sought to minimize the trauma of live donor hepatectomy. Nonetheless, the global adoption of minimally invasive living donor hepatectomy has been slow despite decades of experience at a few expert centers. The limitations of conventional laparoscopy and its steep learning curve have largely hindered the widespread application of laparoscopic liver surgery. Robotic technology overcomes many of the technical challenges of laparoscopy, including advanced 3-dimensional vision and articulating instruments. This has translated to the widespread application of robotic hepatobiliary surgery in recent years. The hope in the living donor community is that robotic surgery will facilitate the global adaptation of minimally invasive living donor hepatectomy. In fully robotic hepatectomy, the entire procedure is accomplished without laparotomy. The extraction of the graft is usually done through a transverse suprapubic incision. In the referenced study,1 typical of analyses of surgical innovation, all robotic procedures were included in the analysis in an “intention to treat” approach, even if the procedure was not “fully robotic.” In general, “conversion” to open surgery is considered a failure of a minimally invasive procedure and is counted as such in the outcome analysis. The laparoscopic living donor hepatectomy experience has been limited to several expert centers, albeit with excellent outcomes. Outcomes from multicenter series demonstrate that laparoscopic donor hepatectomy is associated with reduced blood loss, shorter hospital stay, and lower postoperative pain compared with open surgery, while maintaining comparable rates of major complications and recipient graft survival.1,2 However, the learning curve for laparoscopic living donor hepatectomy is substantial. Data suggest that approximately 50 cases are required to achieve proficiency and minimize complications.3 Most living donor programs in the West do not have adequate volume to achieve proficiency in laparoscopic liver surgery and still perform open hepatectomy to maximize donor safety. Robotic living donor hepatectomy has experienced rapid growth and holds promise for global adaptation.4 Notably, the learning curve for robotic living donor hepatectomy is shorter than for traditional laparoscopic approaches. In a study by Cheah et al5, proficiency in robotic donor right hepatectomy can be achieved after 9–17 cases, significantly fewer than for laparoscopy.6 This is likely a result of the advanced technology, including enhanced dexterity, the 3-dimensional camera, enhanced ergonomics, and indocyanine green visual integration, which allow for more precise dissection and suturing in complex hepatobiliary anatomy. These advantages have even facilitated its adoption in centers without prior laparoscopic experience, including in Western countries.5,7 In the current study, 2600 living donors from 62 centers worldwide were included, using data from the prospective International Living Donor Liver Transplantation Registry.8 When comparing open to robotic and laparoscopic living donor hepatectomy, the robotic approach was associated with superior short-term outcomes, including the lowest intraoperative blood loss, lowest pain scores, shortest hospital stay, and, most importantly, lower complication rates. Remarkably, the major (grade 3a or higher) complication rate was 0.3% in robotic compared with 3.7% in laparoscopic and 1.9% in open approaches. The conversion from minimally invasive to open was also lower in the robotic (5.1%) compared with the laparoscopic (15.3%) group. It should be noted that although 632 (24.3%) of the cases were fully robotic, these were all from only 6 specialized centers included in the study. A limitation of this data analysis is that these high-volume center outcomes do not yet represent “real-world” results. Although the largest experience with robotic living donor hepatectomy is concentrated at a few high-volume centers, the robotic approach appears to be spreading globally. In a recent worldwide survey of 76 institutions, 34 (44.7%) reported active minimally invasive donor hepatectomy programs, and the majority (63.9%) of these minimally invasive cases were performed using robotic surgery.5 The United States, where laparoscopic liver surgery is limited to a handful of specialized centers, has witnessed a marked increase in robotic living donor hepatectomy. In a recent study presented at the 2025 International Liver Transplant Society Meeting, Gupta et al9 described a multicenter experience from the A2ROBOT Study Group. This cohort included 88 cases of robotic living donor hepatectomies from 5 US centers. In this analysis, there were 2 perioperative blood transfusions (2.3%), 5 (5.7%) bile leaks, 5 (5.7%) major (grade 3a or higher) complications, and the median length of stay was 4 d. There were no conversions from robotic to open hepatectomy. Recipient graft survival was 95.5%, and patient survival was 96.6%. These results demonstrate safety, with excellent donor and recipient outcomes in US centers that have traditionally largely performed open living donor hepatectomy. The classification of donor procedures is not different from the nomenclature that is standard in open surgery for LDLT. Due to the shape of the liver, the right lobe typically accounts for 60% of the liver volume and the left lobe, 40%, and these are adequate for most adult recipients. The left lateral section graft, typically used for infants and small children, accounts for about 20% of the liver, or about 250 g. Graft selection is not altered by the route of access, whether open, laparoscopic, or robotic. It should be noted that both conventional laparoscopy and robotic surgery are essentially laparoscopic; robotic surgery is laparoscopy with superior equipment. It is therefore inevitable that over time, robotic surgery will supplant older technology for all but the simplest procedures. For now, the limitation of the global adoption of robotic living donor hepatectomy is access to robotic technology and the high cost when compared with open and laparoscopic techniques. As robotic technology becomes more ubiquitous and additional systems come online, the availability of cost-effective robotic surgery will likely improve, alleviating these disparities. In conclusion, this study adds to the growing body of literature supporting the safety and efficacy of robotic living donor hepatectomy and the promise of minimally invasive surgery for donors worldwide.