Establishment and standardization of a robotic donor hepatectomy technique for liver transplantation: a pure surgical approach based on 1400 cases

Introduction: The robotic platform is emerging as the optimal setting for live donor hepatectomy offering precision, minimal invasiveness, better outcomes for donors, and potentially also for recipients. Nevertheless, there has not been a worldwide implementation of the technique due in part to lack of proper training and adequate access to robotic platforms. We present a single center 1,400 case experience (n = 658 right, 338 left, 404 left lateral) with step-by-step description of a standardized technique for robotic live donor hepatectomy. Surgical Technique: A detailed description of the operating room setup, patient positioning, and port placement for the robotic donor hepatectomy approach is provided. The transection planes are outlined for right lobe, left lobe, and left lateral segmentectomies. Bile duct division is performed under indocyanine green (ICG) guidance using a corridor-based approach. Techniques to address anatomical variations, as well as steps for vascular clamping and graft extraction are also described. Results: The standardized technique described can accommodate any anatomical variation otherwise considered for the open approach. Patients that underwent robotic donor hepatectomies experienced significant less morbidity than those with laparoscopic or open approaches. Streamlined techniques can be taught and replicated with a gradual decrease of assistance and teaching console support. Conclusions: Robotic donor hepatectomy can be safely performed in high-volume experienced centers with excellent outcomes for donors. Careful technical details must be followed to assure success of the procedure. This standardized and reproducible technique supports broader adoption of robotic donor hepatectomy, including centers aiming to establishing their robotic liver transplant programs.