Robotic Whole-graft Liver Transplant: Lesson Learned And Outcomes After 45 Cases.

Abstract

Robotic liver transplantation (RLT) represents the latest evolution in solid organ transplantation. While early reports demonstrated technical feasibility of whole-graft RLT, evidence on clinical outcomes benchmarked against established standards remains limited. This study aimed to evaluate perioperative post-transplant outcomes of whole-graft RLT and to assess whether benchmark performance can be achieved in clinical practice. This retrospective multicenter cohort study included consecutive patients undergoing whole-graft RLT at 2 European centers between February 2024 and October 2025. Preoperative, perioperative, and follow-up data were retrieved from prospectively maintained databases. The primary endpoint was comparison of outcomes with LT benchmark criteria. Forty-five patients met inclusion criteria; one was excluded due to conversion before robotic docking, yielding a final cohort of 44 patients. Hepatocellular carcinoma was the leading indication for transplantation (47.7%). Median MELD score was 11 (range 6-28), and 61.4% of recipients had clinically significant portal hypertension. Median operative time was 551 minutes, with a median warm ischemia time of 60 minutes. Conversion to open surgery occurred in 4 cases (9.1%), all of which recovered uneventfully. Median ICU and hospital stay were 2 and 10 days, respectively. Overall mortality was 2.3%. All benchmark thresholds were met except operative time, which significantly improved over time. Robotic whole-graft liver transplantation achieved benchmark-level outcomes for major perioperative and early post-transplant parameters. Despite prolonged operative duration related to procedural complexity and learning curve, RLT appears safe and reproducible when implemented in highly specialized centers with advanced robotic hepatobiliary expertise.