Advancing the standard in donor hepatectomy: reflections on pure laparoscopic donor right hepatectomy and the evolving role of minimally invasive approaches

The excellent recent report by Kim et al. (1), which presents the outcomes of 329 pure laparoscopic donor right hepatectomies (PLDRH) compared to more than 3,000 open donor right hepatectomies (ODRH) performed at Asan Medical Center, Seoul, marks a substantial contribution to the ongoing refinement of living donor liver transplantation. The authors’ findings—specifically the notably low rate of donor morbidity in the PLDRH group (1.0% vs. 3.3% post-matching) and the complete absence of biliary complications during follow-up—reflect not only an impressive degree of technical proficiency but also the institutional maturity required to safely implement and sustain such an advanced surgical program.

Beyond their statistical significance, these outcomes are deeply consequential in clinical terms. They reinforce the evolving notion that, under the right conditions, PLDRH can match or even surpass open surgery in selected donors. At the same time, they strengthen the broader narrative of minimally invasive donor hepatectomy (MIDH) as a viable and effective alternative to traditional approaches. Yet, as with all major innovations in surgical technique, the path to widespread adoption must be trod with caution and critical appraisal. Several key issues—ranging from anatomical complexity and training structures to technology integration and healthcare systems’ readiness—require deeper exploration before PLDRH can be embraced as a new standard.

One of the most pressing challenges relates to the anatomical variability, particularly involving the biliary and portal venous systems. Variants in these structures have long been associated with increased risks of intra- and postoperative complications for both donors and recipients. A pivotal study by Hong et al. sheds light on this issue by demonstrating a higher incidence of biliary complications in recipients of grafts obtained via PLDRH compared to open surgery, with risk amplification notably associated with donors presenting multiple bile duct openings or complex ductal anatomy (2). While this does not disqualify PLDRH as a safe option per se, it suggests a need for caution in its application among donors with atypical anatomy—particularly when performed by surgeons still navigating the earlier phases of their learning curve. This is indeed a critical factor. Although the exact inflection point may vary across centers, evidence from single-surgeon series suggests that procedural safety and efficiency improve substantially with increasing procedural experience. In particular, Rhu et al. reported that, after approximately 50 cases, operative times decreased and minor complications declined, despite the inclusion of more anatomically complex donors in the later phase of their experience. These findings reinforce the notion that surpassing this early learning phase may serve as a practical benchmark for institutions aiming to establish a safe and effective PLDRH program (3).

One of the main difficulties in adopting MIDH lies in the transition from standard cases to those involving greater anatomical complexity. While cumulative technical experience is undoubtedly important, the findings by Broering et al. provide compelling evidence that structured proctorship can significantly enhance both safety and efficiency during the early phases of implementation (4). In their single-center experience, the introduction of pure laparoscopic donor hepatectomy under expert supervision enabled a consistent and safe learning progression, with operative time and blood loss decreasing across successive phases, without compromising donor outcomes. These results highlight the value of formal proctorship programs in mitigating learning-curve-associated risks and support their integration as a cornerstone strategy for institutions aiming to safely expand the use of minimally invasive approaches in living donor liver transplantation.

It is in this context that the advent of the robotic platform can offer tangible advantages. The inherent technological strengths of robotics have the potential to improve precision during hilar dissection and bile duct division. Such refinements may be especially beneficial in anatomically complex donors, where the margin for error is narrower. This hypothesis is substantiated by the work of Raptis et al., who reported that robotic donor hepatectomy was safely and effectively extended to nearly all donor anatomies in a highly specialized, high-volume center, while also minimizing morbidity and virtually eliminating the need for open conversion (5). These findings lend strong support to the idea that robotics could play a critical role in expanding the boundaries of what is safely achievable in minimally invasive donor surgery. A recent survey reported that, in 2022, MIDH reached a penetration rate of 44.7% among specialized living donor liver transplantation centers, with nearly one in three donors undergoing minimally invasive hepatectomy (6). Notably, robotic assistance appears to have played a prominent role in supporting MIDH adoption by facilitating mentorship and implementation. There is no doubt that the robotic platform can facilitate the expansion of minimally invasive liver surgery by democratising it and allowing increased levels of complexity and quality in the hands of surgeons who are experienced but have had greater difficulties with laparoscopic approaches than others (7,8).

Technological adjuncts continue to play a central role in enhancing intraoperative safety and surgical precision in living donor hepatectomies. Among these, indocyanine green fluorescence imaging has emerged as a valuable tool for improving biliary anatomy visualization. In particular, the “negative fluorescence” technique has proven particularly effective during hilar dissection, offering a critical advantage in minimally invasive approaches, and especially in robotic procedures where tactile feedback is absent. Despite its increasing adoption in many centers, it remains unclear whether this technique has been systematically applied in large PLDRH series. Recent evidence, such as the review by Ducas et al., supports the integration of negative fluorescence into routine surgical workflows in liver transplantation, especially in cases involving biliary variants or resections near the hepatic hilum (9). Its consistent use in PLDRH could represent a low-risk, high-yield innovation with the potential to reduce bile duct injury and improve surgical safety.

Another practical concern often raised in discussions of robotic donor hepatectomy is the limited compatibility with ultrasonic surgical aspirators such as the CUSA^®. However, this limitation may be less significant in the context of right lobe donor hepatectomy, where parenchymal transection generally follows a relatively linear trajectory. Unlike segmentectomies or full left lobe resections, which require more intricate parenchymal sculpting, right lobe procedures can often be accomplished with more straightforward transection techniques. Recent technical experiences, such as those described by Hawksworth et al., demonstrate the feasibility of integrating the CUSA^® into a two-surgeon robotic approach using auxiliary laparoscopic ports, thereby extending the range of safe and precise dissection options available during robotic liver resections (10). Similarly, Takagi et al. reported a large single-center series of robotic liver resections in which the CUSA^® was routinely used in conjunction with the clamp-crush technique, further supporting its adaptability and utility even in the robotic setting (11). This evidence suggests that, while compatibility issues exist, they are increasingly being addressed through procedural adaptations, and their impact may be limited in standard right lobe resections.

Despite these promising developments, it is important to acknowledge that the robotic platform is not without limitations. Recent early comparative data from an American center have shown that, while robotic donor right hepatectomy can be safely implemented and may reduce blood loss, it is consistently associated with longer operative and warm ischemia times (12). This represents, at present, the price to pay for the adoption of this approach; however, these limitations may be progressively mitigated as surgical teams advance along the learning curve and refine their techniques. Taken together, these observations underscore the need for further, larger-scale studies before firm conclusions on the safety and feasibility of the robotic platforms can be drawn.

While these technical limitations highlight the importance of continued refinement and evaluation, broader structural and systemic factors must also be taken into account. In countries where living donation represents only a marginal proportion of liver transplantation—typically those with deceased-donor-dominant models—the feasibility of implementing and sustaining a MIDH program is inherently limited. In such contexts, low case volumes make it difficult to maintain surgical expertise, justify investments in specialized equipment, and ensure continuity of training pathways. These realities raise important questions about equity in innovation and underscore the need for context-sensitive strategies to advance surgical practice.

Finally, as the focus of surgical outcomes continues to evolve, it is essential to recognize the importance of donor-reported metrics. To date, the literature remains limited in the exploration of patient-reported outcome measures and patient-reported experience measures. A recent systematic review showed that living donor liver transplantation can have a long- lasting negative impact on physical quality of life (QOL) in 9.1% of donors (13). Given that living donors are otherwise healthy individuals making a profoundly altruistic choice, their postoperative experiences—ranging from pain and physical recovery to emotional impact and long-term QOL—deserve greater attention. Future research must incorporate these dimensions to fully capture the cost and benefit of the surgical techniques we seek to refine.

In conclusion, the outcomes reported by Kim et al. represent a new benchmark for PLDRH and underscore the promising role of minimally invasive approaches in living donor liver transplantation. However, caution is warranted in extending these findings beyond the unique setting of high-volume, highly experienced centers. Technical complexity, surgical learning curves, anatomical variability, and systemic capacity all continue to shape the boundaries of what is safe and achievable. As we look toward the future of MIDH, the integration of robotic technologies, standardization of intraoperative guidance tools, and inclusion of donor-centered outcomes will be essential to translating surgical innovation into sustainable clinical excellence.

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-2025-570/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-2025-570/coif). The authors have no conflicts of interest to declare.

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