A single-center experience establishing an adult living donor robotic hepatectomy program for liver transplantation in North America: a retrospective cohort review of the first 50 cases

Background: Robotic donor hepatectomy (RDH) for living donor liver transplant (LDLT) has emerged as a safe approach globally. Most published reports originate from Asia, with volumes significantly greater than anything reported in the West. Our goal was to establish an RDH program for LDLT, without prior laparoscopic experience, and to describe the institutional safeguards implemented to ensure patient safety.

Methods: Our pre-requisites for establishing an RDH program were defined as: (I) open living donor hepatectomy experience; (II) robotic liver resection experience; and (III) a dedicated, experienced, and multidisciplinary team. The graduated approach, incorporating guiding principles and ethical practice, establishment of the surgical team, surgical training and expertise, and program safety, oversight and development are all described. Donor and recipient cohort outcomes, and a learning curve analysis are retrospectively reported.

Results: Fifty consecutive RDHs were completed (October 2021 to January 2025), representing the largest North American experience to date. One patient was converted to open for bleeding which was controlled. Donation was aborted, and the patient is well after 18 months. Median donor age was 39 [interquartile range (IQR) 32–46] years, 52% were female. Median donor body mass index (BMI) was 26.7 (IQR 24.5–28.7) kg/m². Median graft weight was 871 (IQR 792–1,005) g. No donor mortalities occurred. Aberrant biliary anatomy was seen in 17 donors (34%), with outcomes equivalent to those of donors with standard anatomy. Two donors had transection surface bile leaks, managed with drainage and endoscopic retrograde cholangiography (ERCP) with complete resolution. Recipient and graft survival at 90 days were both 94%. Arterial complications occurred in 8%, and biliary complications in 24% of recipients. Median operative time with robotic instruments active was 260 (IQR 227–305) min, and cumulative sum curve (CUSUM) plot analysis determined that a learning time of 270 min was reached after 19 cases.

Conclusions: Our results demonstrate RDH can be safely performed with a short learning curve, provided pre-requisite safeguards are established. Lower volumes of LDLT in North America should not be a barrier to adopting RDH in appropriate institutions.