Robotic-assisted donor and recipient hepatectomy in liver transplantation: An umbrella review of clinical outcomes, surgical performance, and cost-effectiveness

Abstract

BACKGROUND

Robotic assistance is increasingly used for donor and recipient hepatectomy in liver transplantation, yet existing evidence is fragmented and variably indirect.

AIM

To evaluate clinical outcomes, surgical performance, and economic effects of robotic-assisted donor and recipient hepatectomy in the transplant pathway.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 and a priori registration, systematic reviews were included with or without meta-analysis. Four databases were searched through July 2025. Methodological quality was appraised with a measurement tool to assess systematic reviews (AMSTAR 2), and certainty was graded with grading of recommendations assessment, development and evaluation (GRADE). Evidence overlap was calculated via a citation-matrix-based corrected covered area (CCA). Effect sizes were prespecified as risk ratios (RR) for dichotomous outcomes and mean differences for continuous outcomes.

RESULTS

Five reviews met the inclusion criteria, four with meta-analyses and one consensus review used only for context. Donor (direct) findings were more favorable for robotics in terms of estimated blood loss (≈ -117 mL) and length of stay (≈ -0.6 days), although with longer operative time (≈ +105 minutes). Absolute risks for donor complications were not estimable from ratio-only data. Recipient (indirect) meta-analysis indicated robotics to be favorable in terms of conversion (RR ≈ 0.41) and severe morbidity (RR ≈ 0.81), with a trend toward lower overall morbidity (RR ≈ 0.92) and no difference in 30-day mortality. Differences in length of stay and operative time were small and heterogeneous. Economic evidence (indirect, network meta-analysis) suggested higher procedural costs for robotic vs laparoscopic intervention, but lower hospitalization costs vs open intervention, with laparoscopy the least expensive overall. AMSTAR 2 ratings were moderate-to-high across the reviews, GRADE certainty was low for key donor continuous outcomes, and low-to-moderate for recipient and economic outcomes. Overlap was slight (graded-corpus CCA = 0.0%; including a contextual non-transplant review increased CCA to ≈ 1.25%).

CONCLUSION

Robotic donor hepatectomy confers perioperative advantages at the cost of longer operative time. Recipient and economic findings are indirect and considered hypothesis-generating. Transplant-specific, prospective comparisons using a minimum standardized dataset and uniform outcome definitions are needed to resolve remaining uncertainties and to clarify the cost-utility correlation.

Keywords: Robotic-assisted surgery; Hepatectomy; Liver transplantation; Living donor; Surgical outcomes; Cost-effectiveness; Minimally invasive surgery; Systematic review; Meta-analysis

Core Tip: This umbrella review separates donor (direct) from recipient/economic (indirect) evidence and standardizes effect reporting, heterogeneity, and grading of recommendations assessment, development and evaluation (GRADE). Donor robotics reduces blood loss and length of stay but lengthens operative time. Recipient robotics shows fewer conversions to open intervention and lower severe morbidity, with no mortality difference. Economic contrasts are context-dependent, with higher procedural but lower hospitalization costs for robotic vs open, and laparoscopy the least expensive overall. The Preferred Reporting Items for Systematic reviews and Meta-Analyses counts, citation-matrix/corrected covered area, AMSTAR 2, and outcome-level GRADE profiles are provided to ensure an audit-ready package and to map evidence gaps that future transplant-specific studies must address.