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

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.