Current status of minimally invasive liver transplantation: a narrative review

Background and Objective: Minimally invasive surgery (MIS) has transformed many general surgical procedures, yet liver transplantation (LT) has remained largely open. As early clinical experiences with minimally invasive LT (MI-LT) accumulate, clarifying patient selection, technical approaches, and early outcomes is timely. This narrative review summarizes the largest available clinical evidence on minimally invasive recipient LT and discusses optimal indications for laparoscopic and robotic approaches, including hybrid and fully minimally invasive techniques. Methods: In this narrative review of currently available reports on MI-LT, we identified studies [2020–2025] from transplant centers worldwide. Reports on donor hepatectomy were excluded. Key Content and Findings: Twenty-one studies from 10 centers published between January 2020 and November 2025 met inclusion criteria. Across the largest series from each center, at least 116 MI-LTs (including hybrid and fully minimally invasive approaches) have been performed. Seven centers reported deceased-donor cases; three reported living-donor cases. Centers favored smaller grafts and native livers to facilitate exposure. Recipient selection emphasized low to moderate Model for End-Stage Liver Disease (MELD), presence of ascites, non-obesity, moderate portal hypertension without thrombosis, and standard vascular/biliary anatomy. Most used a midline incision, with some living-donor programs using a Pfannenstiel incision. Reported operative metrics showed wide ranges. One case-control study found the robotic approach reduced blood loss, infections, and postoperative pain compared with open LT. Planned and unplanned conversions occurred but were generally uncommon. MI-LT may be unsuitable for candidates with high MELD scores, severe portal vein thrombosis, or complex anatomic variations, in whom its benefits remain uncertain and open LT remains the standard approach. Conclusions: MI-LT is feasible in carefully selected candidates and is being adopted at a small number of experienced centers. Early practice patterns converge on low-MELD, anatomically favorable recipients and smaller grafts, with potential benefits in blood loss, pain, and infections suggested by limited comparative data. Defining standardized indications is particularly important as programs progress along the learning curve.