Stepping forward, treading wisely: a crossed frontier in robotic liver transplantation

Robotic liver transplantations (RLTs) using full liver grafts from deceased donors are now a reality (1). The first world series comes from two Western institutions: the Hepato-Biliary-Pancreatic and Transplantation Center at Curry Cabral Hospital/Local Health Unit of So José, NOVA Medical School in Lisbon, Portugal, and the Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit at University Hospital of Modena, University of Modena and Reggio Emilia, Italy. To briefly resume the authors’ report, patients with well-compensated cirrhosis, with or without hepatocellular carcinoma (HCC) and low Model for End-stage Liver Disease (MELD) scores, underwent a deceased donor RLT following a standardized approach between the two centers with only minor differences in perioperative management. Patients with coagulopathy, thrombocytopenia, or severe portal hypertension with collateralization were excluded and specific anatomical factors were also considered: patients with a body mass index >35 kg/m², abdominal obesity, thick abdominal walls, large livers, or a large caudate lobe were excluded, as these conditions could complicate the phases of hepatectomy and implantation. Refractory ascites was not a contraindication. All liver grafts were subjected to hypothermic oxygenated perfusion (HOPE) for at least two hours. The robotic DaVinci XI platform (Intuitive Surgical, Sunnyvale, CA, USA) was used for the procedure, with four robotic ports and two additional 12 mm assistance ports. The procedure involved detaching the liver from the inferior vena cava (IVC), complete mobilization of the retrohepatic IVC, and then total hepatectomy after stapling and dividing the portal and hepatic veins. The graft was removed through an upper midline or periumbilical incision, and the deceased-donor liver graft was placed through the same incision. Robotic implantation began with a side-to-side caval anastomosis, followed by a terminoterminal reconstruction of the portal vein. After reperfusion, arterial and biliary reconstructions were performed. Six patients underwent RLT using liver grafts. Of these, five had HCC as the main indication for liver transplantation (LT), patients presented only a few comorbidities and variable MELD scores ranging from 6 to 25. Donors had a relatively short stay in the intensive care unit (ICU), ranging from 2 to 4 days, and no prolonged vasopressor support. Four out of the six donors were older than 65 years. The warm ischemia time (WIT) during RLT ranged from 55 to 90 minutes, with a total surgery duration ranging from 440 to 710 minutes and a median total operative time of 595 minutes (±111.3 minutes). Hemorrhage ranged from 300 to 5,000 cc with variable transfusion rates: two patients did not receive transfusions, while two received one unit of packed red blood cells (pRBCs) each, one patient received five units, and another patient received eight units. No recipients required conversion to open surgery.

The postoperative course was uneventful in five out of six patients. None developed acute kidney injury, vascular thrombosis, biliary fistula, bleeding, or organ rejection. Patient 2, a 69-year-old man with serious intraoperative bleeding (5,000 cc), required prolonged ventilatory support and had transitory hyperbilirubinemia. The hospital stay was 40 days. The median duration of hospital stay for all patients was 7.5 days (±4.8 days), and the median follow-up period was 85 days (±13 days).

In 2022, Seoul National University Hospital made the first report of a completely laparoscopic living donor liver transplant (LDLT) (2). Subsequently, the same team described performing a laparoscopic hepatectomy on the recipient, followed by implantation of robot-assisted graft in LDLT (3). More recently, Broering et al. published the inaugural report on a fully robotic LDLT that included procedures on both the donor and the recipient (4). Finally, in August 2024, Khan et al. achieved a landmark by publishing the world’s first whole-liver robotic transplant using a liver from a deceased donor (5). The present publication marks the first series of RLTs utilizing full liver grafts from deceased donors (1).

From a technical point of view, RLT can be challenging in terms of bleeding control and prolonged vascular clamping. LT is a highly complex procedure typically performed in patients with severe conditions, such as cirrhosis, portal hypertension, and decreased clotting factors. Major bleeding can lead to catastrophic outcomes, including intraoperative death. Although such incidents can generally be managed quickly during open surgery, it is uncertain whether the same rapid response is possible with robotic techniques. The use of GelPort in the median incision facilitates hand assistance, which is crucial to managing sudden bleeding. Major bleeding not only obscures the surgical field but also splashes the optical system, and both loading needles onto robotic arms and conversion to open surgery are time-consuming procedures (6). Furthermore, although GelPort use was only reported by the Modena team, the Lisbon team closed the abdominal wall after the introduction of the graft, thus restricting access in the event of hemorrhage. In fact, in this series, two patients (number 1 and 2) experienced significant bleeding (1,900 and 5,000 cc) and received 5 and 8 units of pRBC, respectively. It should be remembered that these patients had low MELD scores, minimal portal hypertension, and no coagulopathy, probably indicating relatively easy transplants that would otherwise experience minimal bleeding by laparotomy (7).

Prolonged clamping of the IVC and portal vein also presents significant technical challenges, with extended clamping of the IVC leading to hemodynamic and renal repercussions. This challenge is further amplified by the need for total IVC clamping in the RLT approach, unlike open transplantation, which typically involves only partial IVC clamping, allowing greater hemodynamic stability. Extended clamping of the portal vein during LT procedures significantly affects the overall surgical timeline due to necessary bowel congestion management and swelling of bowel congestion. Although portal flow is generally maintained during native liver, full clamping is unavoidable during graft insertion and subsequent venous reconstruction. This report did not specify the exact duration of the portal clamping. However, the aggregate time of native liver removal, warm ischemia, and both the caval and portal vascular reconstruction phases lasted up to two to three hours.

Patients who lack cirrhosis and portal hypertension generally have a lower tolerance to the extended portal vein clamping time. Therefore, the authors suggested selecting patients who exhibit moderate portal hypertension, which helps mitigate the risk of bleeding during dissection, while not too much to complicating the procedure. Predicting tolerance for prolonged portal clamping is challenging, as mild portal hypertension does not consistently prevent bowel congestion. Addressing the challenges of extended clamping time, implementing a temporary portocaval shunt and partial clamping of the IVC may provide partial solutions to current RLT problems by mitigating hemodynamic issues. A recent randomized trial evaluated the routine use of a temporary portocaval shunt in LDLT (8). This technique was found to maintain intraoperative hemodynamic stability, reduce the need for vasopressors, minimize blood loss, and improve renal perfusion and urine output during surgery, thus shortening the duration of the surgery. However, the trial showed marginal benefits for early postoperative outcomes, such as enteral feed tolerance and graft function.

From a functional point of view, the major drawback of the RLT described in this study is the prolonged WIT. RLT WIT was reported to be between 55 and 90 minutes and, therefore, significantly longer than the usual <30 minutes in open surgery (9). Furthermore, the unpredictable nature of the graft implantation can significantly increase WIT due to technical issues such as bleeding control or vascular stapler complications (10). WIT is known to have a significant impact on both short- and long-term graft survival (11). This impact is mainly due to reperfusion injury after reperfusion of the graft and biliary epithelium ischemia. Although WIT is likely to improve with experience, the systematic use of hypothermic machine perfusion may offer a useful approach to graft preconditioning and reduction of ischemia-reperfusion injury. In the present study, the authors did not report any liver dysfunction related to prolonged WIT; however, these observations may probably not be generalized to extended criteria donors, subject to more severe ischemia-reperfusion injury related to prolonged WIT. Moreover, long-term effects, especially non-anastomotic biliary complications, need further evaluation.

The successful application of robotic technologies in LT depends on having an expert team, selective patient criteria, and adherence to ethical standards that prioritize the health and safety of recipients and respect the donor’s contribution. While this technology offers benefits such as smaller incisions and potentially shorter hospital stays, it is crucial to remember that the primary goals of LT are to ensure the functionality and survival of the graft and the recovery of the recipient, rather than focusing solely on cosmetic outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-167/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-167/coif). The authors have no conflicts of interest to declare.

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