Advancements and challenges in robotic donor hepatectomy: current evidence and unresolved questions

Liver transplantation remains the definitive treatment for end-stage liver disease and other severe hepatic conditions. In some regions, reliance on living donors is necessary due to a deceased donor shortage and cultural or religious constraints. Ensuring living donor safety and minimizing invasiveness are essential in living donor liver transplantation (1). Minimally invasive donor hepatectomy, including laparoscopic and robotic approaches, has been increasingly adopted due to its benefits, such as reduced blood loss, lower pain scores, and faster recovery, while maintaining outcomes comparable to open surgery (2). A multicenter propensity score-matched analysis further confirmed the feasibility and safety of robotic donor hepatectomy (RDH), demonstrating reduced intraoperative blood loss and lower postoperative pain scores compared to both laparoscopic and open procedures, despite requiring longer operative times (3). These findings support RDH as a viable alternative to conventional techniques in specialized centers; however, its broader implementation requires further validation, specialized training, and careful donor selection (4).

A recent study by Raptis et al. evaluated the role of RDH and its integration with real-time indocyanine green (ICG) fluorescence cholangiography, reporting improved short-term biliary outcomes in adult living donor liver transplantation compared to the conventional open approach (5). The study demonstrated that robotic-assisted procedures facilitated more precise hilar plate transection, leading to a higher proportion of single-duct grafts and fewer biliary complications in both donors and recipients. Additionally, overall postoperative morbidity, including infection and bleeding rates, was lower in the RDH group. However, while these findings suggest potential advantages, the limitations of the study, particularly its retrospective design and single-center experience, require further investigation to validate the findings in diverse settings.

One notable advantage identified in the study conducted by Raptis et al. was the reduction in the number of graft bile ducts, primarily attributed to the integration of real-time ICG fluorescence cholangiography and the superior precision of robotic-assisted surgery. The robotic system provides high-resolution, real-time visualization of the biliary anatomy, allowing surgeons to identify the optimal bile duct transection site with greater accuracy. As a result, RDH facilitates more precise hilar dissection, increasing the likelihood of obtaining single-duct grafts and reducing the need for multiple anastomoses. In contrast, previous studies on laparoscopic donor hepatectomy have reported a higher number of reconstructed bile ducts and an increased risk of biliary complications, highlighting a limitation of minimally invasive donor hepatectomy (6). Raptis et al. demonstrated that RDH can overcome this drawback, achieving more precise bile duct transection and potentially reducing biliary complications.

A methodological consideration in the study by Raptis et al. is the use of intravenous ICG administration for biliary visualization. Although the study did not report any limitations related to this method, and living donors generally have normal hepatic function ensuring reliable excretion, theoretical concerns remain. Specifically, factors such as individual variability in biliary anatomy and perihilar tissue thickness could potentially affect the clarity of ICG imaging. However, as Raptis et al. did not encounter such issues in their cohort, these possibilities are likely infrequent in well-selected donor populations. Further research may help clarify whether alternative administration strategies could enhance visualization in rare challenging cases.

The learning curve for RDH remains a critical factor in its broader adoption. A multicenter study utilizing cumulative sum analysis demonstrated that total operative time stabilized after approximately 10–20 cases, indicating that initial proficiency can be achieved relatively early with structured training (7). Additionally, complication rates tended to decrease as surgeons gained experience, suggesting that proficiency in RDH may contribute to improved surgical outcomes (8). A single-center study comparing extended criteria donors and standard donors undergoing RDH further supports the influence of the learning curve, showing improvements in operative time and postoperative outcomes in later phases of the study (9). These findings suggest that while technical proficiency can be attained with structured training, broader adoption of RDH requires ongoing refinement of training protocols, standardization of surgical techniques, and long-term evaluation of clinical outcomes to ensure consistency and safety across different centers.

A major consideration regarding this study is whether the observed reductions in postoperative complications among recipients undergoing RDH are truly attributable to robotic surgery. Although RDH may contribute to improved donor outcomes, its direct impact on recipient outcomes remains unclear. The multivariable analysis of the study identified independent risk factors for short-term complications in recipients but did not account for the influence of era-specific factors, including advancements in surgical techniques, perioperative management, and institutional maturation. As open donor hepatectomy was performed in an earlier era, improvements in recipient surgery and perioperative care over time may have contributed to the observed reduction in complications. Consequently, the differences in recipient outcomes could, at least in part, reflect institutional evolution rather than a direct benefit of RDH.

In terms of cost, laparoscopic donor hepatectomy has been reported to be more cost-effective than RDH, which requires specialized equipment and is associated with longer operative times (10). Although RDH may offer advantages such as shorter hospital stays and lower postoperative morbidity, it remains uncertain whether these benefits outweigh the higher procedural costs. Direct comparative studies assessing long-term clinical and financial outcomes are necessary to determine whether RDH provides sufficient value to justify its higher costs. Large-scale multicenter trials are essential to evaluate its cost-effectiveness and establish its role in liver transplantation (11).

As RDH continues to evolve, addressing several challenges will be essential for its broader clinical adoption. Further research should focus on refining ICG administration techniques, minimizing operative times through enhanced training programs, and evaluating long-term outcomes for both donors and recipients, as these factors are critical for ensuring consistent safety and efficacy. While RDH shows promise, its widespread implementation will require continued advancements, rigorous validation, and comprehensive cost-benefit analyses to establish its role as a standard approach in living donor liver transplantation.

Acknowledgments

The author acknowledged the use of the OpenAI API for assistance with English language editing.

Footnote

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