With evolving expertise, criteria to select donors for living robotic donor hepatectomy (RDH) have expanded. We studied the comparative donor and recipient outcomes in RDHs with standard grafts and complex grafts. We performed 360 right lobe RDH (RRDH) of 4296 living donor liver transplantations, with 280 having >6 months follow-up. The first 53 cases were excluded as we used a different (cut-suture) technique for hepatic duct division. The subsequent 227 RRDHs were then divided into donors with standard (group S, n = 76) and complex grafts (group C, n = 151). Three donors in each group were converted to open midline incision. In groups S and C, 1 (1.3%) and 3 (1.9%) donors developed biliary complications (P = .741). Both recipient groups had similar early and late postoperative complications. Group C recipients had a nonsignificant higher incidence of late biliary complications (3 [3.9%] vs 17 [11.2%]; odds ratio, 3.09; 95% confidence interval, 0.88-10.88; P = .067). Early (<30 days) recipient mortality was similar with 4 (6.6%) in group S and 11 (7.3%) in group C (P = .755), all sepsis-related. The outcomes were similar among donors and recipients with both standard and complex grafts. With experience, RDH can be safely offered to "all-comer" donors and has the potential to become standard of care.

Living donation in many countries is the main resource of organs. Healthy, volunteering individuals deserve the highest safety standards possible in addition to the least invasive technique to procure the organs. Since the introduction of living donor liver transplantation, many efforts have been made to minimize the surgical trauma inherent to living donor surgery. The journey started with a large Mercedes incision and evolved to reverse L-shaped and small upper midline incisions before the introduction of minimally invasive laparoscopic techniques originated. The technical difficulties of the laparoscopic approach due to suboptimal instrumentation, challenging ergonomics, and the long learning curve limited the application of the fully laparoscopic approach to a few centers. The recent introduction of the robotic platform with its superb optical system and advanced instruments allows for the first time, a genuine emulation of open donor surgery in a closed abdomen, thus allowing all liver donors to benefit from minimally invasive surgery (better cosmesis, less pain and morbidity, and better quality of life) without compromising donor safety. This attribute in combination with the ubiquitous presence of the robot in major transplant centers may well lead to the desired endpoint of this technology, namely, the widespread dissemination of minimally invasive donor surgery.

In living donor liver transplantation (LDLT) the safety of the live donor (LD) is of paramount importance. Despite all efforts, the morbidity rates approach 25%-40% with conventional open donor hepatectomy (DH) operations. However, most of these complications are related to the operative wound and despite increased self- esteem and satisfaction in various quality of life analyses on LD, the most common grievance is that of the scar. Performing safe and precise DH through a conventional laparoscopic approach is a formidable task with a precipitous learning curve for the whole team. Due to the ramifications the donor operation carries for the donor, the recipient, the transplant team and for the LDLT program in general, the development and acceptance of minimally invasive DH (MIDH) has been slow. The robotic surgical system overcomes the reduced visualization, restricted range of motion and physiological tremor associated with laparoscopic surgery and allows for a comparatively easier transition from technical feasibility to reproducibility. However, many questions especially with regards to standardization of surgical technique, comparison of outcomes, understanding of the learning curve, etc. remain unanswered. The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH, appreciating the existing challenges and its future role.