Robotic liver transplantation surgery: A comprehensive review of minimally invasive techniques, surgical and educational advancements

Table 1 Current robotic surgical approaches for donor and recipient hepatectomy

	Surgical approaches
Donor hepatectomy[3-7]	Minimally invasive approaches are increasingly applied to right lobe, left lateral lobe, and adult or paediatric grafts
	Robotic assistance allows improved control of parenchymal transection and may reduce donor morbidity
	Patient positioning: Trendelenburg position to enhance upper abdominal exposure
	Port placement: Five ports (one 12-mm camera port and four 8-mm robotic working ports) arranged in a semicircular or fan-shaped configuration for optimal triangulation
	Liver mobilization: Atraumatic robotic manipulation enables precise division of hepatic ligaments
	Intraoperative imaging: Robotic intraoperative ultrasound facilitates detailed vascular mapping
	Vessel and bile duct dissection: High precision achieved using robotic bipolar forceps and energy devices, minimizing thermal injury
	Parenchymal transection: Performed using ultrasound and bipolar energy devices, frequently guided by indocyanine green fluorescence to visualize bile ducts and vascular structures
Recipient hepatectomy[3-7]	Patient positioning: Supine with reverse Trendelenburg tilt to improve venous return and exposure
	Port placement: Similar to donor configuration, adjusted for patient anatomy and prior surgical history
	Native liver removal: Robotic mobilization with precise control of the hepatic artery, portal vein, and bile duct, minimizing blood loss
	IVC: Preservation of the retrohepatic IVC using the piggyback technique
Graft implantation[3-7]	Caval anastomosis: Performed robotically in side-to-side or end-to-end fashion
	Portal vein anastomosis: Completed under robotic visualization with fine sutures
	Hepatic artery anastomosis: Performed robotically using microsurgical techniques or via mini-laparotomy with a surgical microscope
	Biliary reconstruction: End-to-end anastomosis preferred; Roux-en-Y hepatojejunostomy used when necessary. Robotic suturing enhances precision and may reduce bile leak rates
Operative outcomes[3-7]	Robotic liver transplantation offers stable instrumentation and tremor reduction, facilitating high-quality vascular and biliary anastomoses
	Operative time is influenced by team experience, anatomical variability, and graft complexity
	Reported hospital length of stay is approximately 7.5 days

IVC: Inferior vena cava.

Table 2 Key studies for robotic liver transplantation: Procedures and surgical outcomes

Ref.	Procedures	Outcomes
Muttillo et al[37], 2025	Multicenter retrospective series of robotic liver resections for malignant tumors. Lesions stratified by vascular proximity: NCMV: No contact with major vessels; CMV: Contact with portal and/or hepatic veins without invasion. All resections performed with Da Vinci Xi by expert HPB surgeons. Comparable surgical complexity after PSM (anatomical resections, major hepatectomies, IWATE ≥ 7)	Intraoperative outcomes: (1) Operative time: No difference after PSM; (2) Blood loss/transfusions: Comparable; (3) Conversion rate: No difference after PSM; and (4) Pringle maneuver: More frequent in CMV 49.8% vs 31.2% (P = 0.001). Postoperative outcomes: (1) Overall morbidity: Comparable; (2) Major complications (CD III-IV): No difference; (3) Length of stay: Similar; (4) Reoperation, readmission, 90-day mortality: No differences; and (5) Oncological radicality (R0): Preserved
Broering et al[38], 2025	Single-center analysis of 339 living liver donors (comparative study). Left lobe donor hepatectomy performed via: (1) Robotic approach (n = 267); and (2) Open approach (n = 72). All cases derived from a prospectively maintained registry (2011-2023). Fully robotic technique used for donor hepatectomy focus on donor safety and perioperative outcomes	Donor outcomes: (1) Estimated blood loss: Robotic: 77 mL vs open: 316 mL (P < 0.001); (2) Overall donor morbidity: Robotic: 6% vs open: 18% (P = 0.003); (3) Length of hospital stay: Robotic: 3 days vs open: 5 days (P < 0.001); and (4) No increase in donor complications with robotic approach. Recipient outcomes. Overall recipient morbidity: Lower with robotic graft retrieval 40% vs 59% (P = 0.033)
Chiarella et al[39], 2025	Multicenter retrospective study of robotic liver resections. 10 European HPB centers, 1070 consecutive robotic liver resections. 921 resections for malignancy included in analysis. Patients stratified by parenchymal transection technique: (1) MAMBA technique: Clamp-crush method using double bipolar robotic forceps, no laparoscopic ultrasonic dissector; and (2) Robo-lap technique: Hybrid approach combining laparoscopic ultrasonic dissector, robotic energy devices for dissection and hemostasis. 1:1 PSM to balance baseline and surgical complexity	Intraoperative outcomes: (1) Operative time: No significant difference after PSM; (2) Estimated blood loss: Comparable between techniques; and (3) Conversion rate: No difference between groups. Postoperative outcomes: (1) Overall morbidity: Similar between MAMBA and Robo-lap; (2) Postoperative complications: No significant differences; and (3) No increase in adverse outcomes with fully robotic transection
Haruki et al[40], 2025	10025 donor hepatectomies (open/hybrid: 8310, laparoscopic: 1479, robotic: 236). Vanguard multicenter retrospective study (16 institutions, 2013-2022). Analysis focused on severe donor complications (Clavien-Dindo IIIb-V). Donor hepatectomies stratified by approach: Open/hybrid, MIS (laparoscopic, robotic). Complications recorded using standardized case report forms	Donor outcomes: (1) Overall severe complications: Grade IIIb: 1.17%, grade IV: 0.12%; (2) Donor mortality: 0%; and (3) Comparison by approach: Grade IIIb: Open 1.08% vs MIS 1.57% (P = 0.09), grade IV: Open 0.14% vs MIS 0% (P = 0.12), no significant difference in severe complication rates. Bleeding-related complications: (1) Postoperative bleeding: More frequent in MIS cases (P < 0.01); and (2) Bleeding source differed by approach: IVC bleeding: Higher in MIS (P = 0.05); abdominal wall bleeding: Higher in MIS (P < 0.01)

NCMV: No circumferential margin involvement; CMV: Circumferential margin involvement; HPB: Hepato-pancreato-biliary; PSM: Positive surgical margin; IWATE: Iwate difficulty scoring system; MAMBA: Moisture Assisted Multiple BipolAr; MIS: Minimally invasive surgery; IVC: Inferior vena cava.