Can robotic living donor hepatectomy be safely offered to all donors? evidence, experience, and program development

Robotic living donor hepatectomy (R-LDH) aims to improve the safety and experience of healthy donors by combining three-dimensional visualization, wristed instrumentation, precision, and stable ergonomics with the benefits of minimal access. This review article summarizes current evidence and offers a pragmatic approach for centers to transition from open to routine robotic donation. Available evidence from retrospective feasibility series, matched cohorts, multicenter analyses, and registry data suggests that R-LDH may reduce donor morbidity compared to open and some evidence of fewer recipient biliary complications, although current evidence remains heterogeneous and largely non-randomized. Available comparative data, including single-center and international registry analyses, suggest lower morbidity with the robotic approach than with laparoscopy, although these comparisons remain limited and would benefit from confirmation in prospective multicenter studies. Learning-curve studies and prospective series suggest that with standardized technique, simulation, and early proctorship, proficiency appears achievable within a limited number of cases, with reduced complications over time. A center-readiness structure focused on "People" (trained team), "Process" (protocolized pathways with explicit conversion criteria), "Platform" (reliable robot access, ICG, ERAS), and "Proof" (prospective audit and external validation) supports phased adoption from standard to complex anatomy. Persistent barriers include limited robotic platform access, scheduling constraints, heterogeneity in reporting, and incomplete cost data, though shorter hospital stay, less pain, and faster return to normal daily activities may partially or potentially offset procedural costs in high-volume programs. In appropriately prepared centers, routine consideration of R-LDH for eligible donors may represent a reasonable donor-centered strategy. Concrete steps are outlined that surgeons and hospital leaders can undertake to implement R-LDH safely, monitor outcomes, and improve equitable access.