Robotic Donor Hepatectomy: A Major Breakthrough in Living Donor Liver Transplantation

Dieter Broering; Mark L. Sturdevant; Ahmed Zidan


American Journal of Transplantation. 2022;22(1):14-23. 

In This Article

Abstract and Introduction


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.


Living donor liver transplantation (LDLT) is one of the main resources to address the increasing imbalance between the need for liver transplant and the availability of deceased donor organs. Moreover, in many Middle Eastern and Asian countries, access to deceased donor liver transplantation is limited due to cultural and religious factors, effectively rendering LDLT as the only realistic option for those with end-stage liver disease and hepatocellular carcinoma.[1,2]

An expansive accumulation of global experience in LDLT has fostered technical development and innovation, but concerns regarding donor safety and quality of life remain which have hindered the universal progression and spread of LDLT. Studies suggest that donor hepatectomy introduces a 0.2%–0.6% mortality rate and a 20%–40% incidence of overall morbidity.[3–5] Most of the morbidity associated with open living donor hepatectomy is associated with the operative approach manifesting with incisional pain, surgical site infection, disfiguring scar, hernia, and adhesive intestinal obstruction.[6–8] Two of the most commonly reported donor complications by the A2ALL study group are infection and incisional hernia which can be attributed to the extensive tissue manipulation and abdominal wall trauma in open live donor hepatectomy.[9]

With the revolutionary development of minimal invasive liver surgery (MILS), an international expert panel in Louisville in 2008 promoted the attributes of laparoscopic liver resection for minor and some major liver resections in selected patients at experienced centers.[10] Multiple meta-analyses have demonstrated that laparoscopic liver resection not only outperforms open liver resection in terms of blood loss, but may also convey a survival benefit in favor of laparoscopic liver resection, with lower overall and major morbidities in the laparoscopic group.[11–13] The first application of MILS in the field of living liver donation occurred in Paris in 2002 by Cherqui and Soubrane resulting in a sentinel proof-of-concept series in donor left lateral sectionectomy (LLS).[14] Several years later in Chicago, Koffron and colleagues utilized hand-assistance to initiate MILS applicability in hemi-liver donation.[15] Technical advancements continued and pure laparoscopic donor hepatectomy (PLDH) techniques were developed by Han in Korea (right side PLDH, 2010) and Troisi in Ghent (left side PLDH, 2013), which formed the origins of minimally invasive donor hepatectomy (MIDH).[16,17]