Robotic Revolution in Liver Transplantation

Overview

This lecture by Prof. Hugo Pinto Marques explores the emerging role of robotic surgery in liver transplantation, covering both living donor hepatectomy and recipient implantation, and evaluating its safety, feasibility, and potential to become the new standard of care.

Key Clinical Topics

• Historical milestones in minimally invasive and robotic liver transplantation
• First pure laparoscopic and first fully robotic living donor liver transplantation
• Robotic versus open donor hepatectomy: comparative outcomes
• Robotic graft implantation in recipients
• International consensus statements on robotic liver transplantation
• The Lisbon program's early experience with robotic living donor liver transplantation
• Intraoperative use of ICG (indocyanine green) fluorescence imaging

Key Learning Points

• First pure laparoscopic living donor liver transplantation: Performed by the Seoul National University team; notable for a warm ischemia time of 84 minutes and portal vein clamping of 212 minutes, raising early safety concerns
• First fully robotic living donor liver transplantation: Performed in August 2023 by Prof. Dieter Boehring, encompassing both donor and recipient operations
• Warm ischemia time in robotic donor hepatectomy: Reported at approximately 48 minutes; prolonged compared to open but does not negatively influence recipient outcomes per consensus data
• ICG fluorescence guidance: Used intraoperatively to delineate biliary anatomy and improve safety during robotic donor hepatectomy
• Robotic versus open donor outcomes: Robotic approach associated with less postoperative pain, fewer biliary complications in recipients, lower overall morbidity, and shorter hospital stay
• Comprehensive complication index: Lower in fully robotic liver transplantation recipients compared to open recipients
• ICU and hospital stay: Both reduced in the robotic cohort compared to open transplantation
• Graft survival: Slight advantage observed at six months in robotic recipients, though not yet statistically significant
• Paris jury-based consensus conference: Concluded robotic donor hepatectomy performed with expertise is feasible and may offer advantages in patients with anatomical variations and complex bile duct division
• Riyadh consensus conference (end of 2024): Expert group concluded robotic liver transplantation should no longer be considered an experimental procedure, given sufficient worldwide center experience
• Safety versus laparoscopy: Prof. Marques emphasizes the robotic platform offers superior visibility and significantly improved safety compared to laparoscopy for donor hepatectomy

Clinical Data & Study Results

• Annals of Surgery (November 2024): Comparison of 414 open donors versus 425 robotic donors at Riyadh; robotic group demonstrated less postoperative pain, fewer biliary complications, lower overall morbidity, and shorter hospital stay
• Riyadh robotic LDLT series: Warm ischemia time ~48 minutes; one conversion reported out of 54 cases; comprehensive complication index and ICU stay lower in robotic group; graft survival advantage at six months
• First robotic implantation series: Operative time approximately 12 hours; 10 units of red blood cells transfused; warm ischemia time 83 minutes

Practical Takeaways

• Robotic living donor hepatectomy should be considered a viable and increasingly reproducible alternative to both open and laparoscopic approaches at experienced centers
• ICG fluorescence imaging should be incorporated into robotic donor hepatectomy to enhance biliary identification and reduce bile duct complications
• Centers should no longer classify robotic liver transplantation as experimental; program development supported by international consensus
• Collaboration with high-volume robotic transplant centers is recommended when establishing new programs, as demonstrated by the Lisbon experience
• Robotic approach may be particularly advantageous in donors with anatomical variations of the bile duct or vasculature