Robotic donor hepatectomy: Are we there yet?

Table 1 Evidence based comparison between open, conventional laparoscopic and robotic donor hepatectomy

	ODH	CLDH	RDH
Pre-operative aspects
Selection	Favourable anatomy during the learning curve	Favourable anatomy & body habitus during the learning curve[6,11,39,40,42]	Favourable anatomy during the learning curve[13-15,29,44]
Intra-operative aspects
Operative time	Comparable	Comparable[1,31-34]	Comparable[17,18,33,47,48]
Blood loss	Higher	Lower than ODH[1,31-34]	Lower than ODH[1,31-34]
Warm ischemia time	Shorter	Longer[1,31-34]	Longer[1,31-34]
Post-operative aspects
Pain scores	Higher	Lower[1,6,31-34]	Lower (similar to CLDH) [1,31-34]
Analgesic use	Higher	Lower[1,6,31-34]	Lower (similar to CLDH) [1,6,31-34]
Peak AST	Higher	Lower[1,6,31-34]	Lower (similar to CLDH) [17,18,33,47,48]
Donor morbidity
Overall donor complication rates	Standard[3,7-9]	Lower[1,6,31-34]	Lower (similar to CLDH)[17,18,33,47,48]
Biliary complications	Higher	Lower[6,10,32-34]	Lower[17,18,33,48]
Wound complications	Higher	Lower[1,6,31-34]	Lower (similar to CLDH)[17,18,33,47,48]
Return to work	Later	Earlier[1,6,31-34]	Earlier (similar to CLDH)[17,18,33,47,48]
Analgesic use	Higher	Lower[1,6,31-34]	Lower (similar to CLDH)[17,18,33,47,48]
Hospital stay	Longer	Shorter[1,6,31-34]	Shorter (similar to CLDH)[17,18,33,47,48]
QOL scores	Lower[7-10]	Higher[1,6,31-34]	Higher (similar to CLDH)[17,18,33,47,48]
Donor mortality	Reported[7-10]	None reported[1,6,31-34]	None reported
Recipient morbidity
Outcomes (overall Clavien-Dindo 3b-5 complication rates)	Standard	Higher in right lobe CLDH[6,37], higher early and late biliary complications[2,6,35,37], higher incidence of hepatic vein stenosis[2,35,37]	Lower (Similar to ODH)[15,16,30,44]
Primary-non function	Similar	Similar[6,36-38]	Similar[17,18,33,47,48]
90 d mortality	Similar	Similar[1,6,32-34]	Similar[15,16,30,44]
Surgical expertise
Learning curve	Gold Standard	Longer[6,11,39,40,42]	Shorter (comparable to ODH)[13-15,29,44]
Surgeon ergonomics & operative ease (vision, ease of suturing etc.)	Gold standard	Poorer[6,11,39,40,42]	Better (comparable to ODH)[13-15,29,44]
Haptic feedback	Present	Present	Absent[17,18,33]
Surgical adjuncts	Available	Available	Limited availability[13-15,29,44]
Surgical expertise required	Open donor surgery	Open and laparoscopic liver surgery[6,11,39,40,42]	Open liver surgery[33,47,48]
Logistics & infrastructure
Economics	Standard	Comparable to ODH	Expensive[15,16,30,44]
Availability	Every LDLT unit	Centres with expertise in liver and laparoscopic surgery[6,11,39,40,42]	Limited to centres with a robotic platform[17,18,33,47]

ODH: Open donor hepatectomy; CLDH: Conventional laparoscopic donor hepatectomy; RDH: Robotic donor hepatectomy; AST: Aspartate transaminase; LDLT: Living donor liver transplantation; QOL: Quality of life.