Global Outcomes of Open Versus Laparoscopic Versus Robotic Donor Hepatectomy: A Prospective Study From the International LDLT Registry (LDLTregistry.org)

Background: Living donor liver transplantation is a critical solution to the global organ shortage. Comparisons of donor short-term outcomes according to the surgical approach are limited to a few single-center retrospective studies. This study aimed to evaluate the short-term outcomes of open, laparoscopic, and robotic surgical approaches to living donor hepatectomy using data from the prospective International Living Donor Liver Transplantation Registry (LDLTregistry.org). Methods: Data from 2600 living donors undergoing hepatectomy were prospectively collected from September 2023 to February 2025. Donors were grouped into open (1726; 66.4%), laparoscopic (242; 9.3%), and robotic (632; 24.3%) approaches. Results: The mean donor age was 33 (SD 9.4) y, with 45% women and a mean body mass index of 24.7 kg/m² (SD 6.5). Conversion rates were 15.3% for laparoscopic and 5.1% for robotic approaches (odds ratio, 0.30; 95% confidence interval, 0.17-0.50; P < 0.001). Robotic hepatectomy was associated with the lowest intraoperative blood loss (70 mL; interquartile range, 50-100), lowest pain scores on postoperative day 1 (visual analog scale, 2.3; SD 1.9), and shortest hospital stay (4 d; interquartile range, 3-5). Robotic hepatectomy was associated with the lowest overall (grade ≥1; 4.6%) and major (grade ≥3a; 0.3%) complication rates compared with laparoscopic (16.5% overall, 3.7% major) and open (10.4% overall, 1.9% major) approaches ( P < 0.001). Conclusions: This is the first global study to show evidence that robotic living donor hepatectomy offers superior short-term outcomes compared with laparoscopic and open approaches. Although open surgery remains the most common approach, robotic techniques show promise for improving donor safety and recovery.