Robotic liver transplantation (RLT) is a novel and rapidly evolving approach in transplantation, representing perhaps the final frontier in robotic surgery. The technique offers the potential benefits of minimally invasive surgery for what is traditionally a maximally invasive, complex, and technically demanding operation. This report presents a successful case of a robotic recipient hepatectomy and implantation. The procedure was technically complex due to a large caudate lobe and variant biliary anatomy. The hepatectomy and implantation were performed entirely robotically, including vascular and biliary anastomoses. The recipient recovered uneventfully post-operatively. This case highlights the feasibility of fully robotic deceased donor liver transplantation, demonstrating the safe and effective use of robotic techniques in complex dissection and vascular anastomosis creation.

RESUMO Introdução: O autotransplante renal é uma opção preservadora de órgãos para pacientes selecionados com patologias ureterais ou renovasculares complexas que não são adequadas à reconstrução in situ. O autotransplante aberto convencional, no entanto, está associado a morbidade substancial. O autotransplante renal robótico (ATRR) surgiu como uma alternativa minimamente invasiva, mas relatos técnicos detalhados de casos complexos que exigem reconstrução vascular ainda são limitados. Descrição Técnica: Relatamos a técnica de ATRR em uma mulher de 32 anos com estenose ureteral de alto grau induzida por radiação, refratária ao manejo endoscópico e não adequada à reconstrução ureteral padrão. O procedimento consistiu em nefrectomia robótica, reconstrução extracorpórea em bancada de artérias renais duplas usando técnica de boca de peixe, alongamento da veia renal direita curta com um conduto de pericárdico bovino, reimplante robótico nos vasos ilíacos externos direitos e neocistoureterostomia. Uma descrição cirúrgica detalhada é acompanhada por um vídeo cirúrgico narrado. Experiência Inicial: Os tempos de console para nefrectomia e implantação foram, respectivamente, 99 e 228 minutos. O primeiro tempo de isquemia quente foi de três minutos, o de isquemia fria, de três horas, e o de segunda isquemia quente, de 36 minutos. A evolução pós-operatória foi simples, e a paciente recebeu alta no terceiro dia pós-operatório, com função renal preservada e perfusão satisfatória do enxerto. Conclusão: O autotransplante renal robótico com reconstrução vascular extracorpórea é uma opção viável minimamente invasiva para pacientes com patologia ureteral complexa cuidadosamente selecionados. Este relato fornece uma visão técnica sobre a estratégia e os passos reconstrutivos envolvidos no ATRR.

BackgroundIn carefully selected patients, liver transplantation (LT) has provided encouraging outcomes for unresectable biliary tract cancers (BTC), including biphenotypic (cHCC-CC), perihilar (pCC), and intrahepatic cholangiocarcinoma (iCCA). This study aimed to characterize diagnostic discrepancies, recurrence patterns, and oncologic metrics in this unique LT population.Patients and MethodsPatients with BTC receiving LT within a single academic transplant center were included (n = 98 from 2007 to 2025). Survival and recurrence outcomes were analyzed by tumor histotype using Kaplan-Meier and log-rank tests. Univariate and multivariate Cox proportional hazards regression was performed.ResultsThe most common transplanted subtype was pCC (n = 54, 55.1%), followed by cHCC-CC (n = 28, 28.6%) and iCCA (n = 16, 16.3%). Pretransplant diagnoses frequently differed from final explant pathology in 26 patients (26.5%). Recurrence occurred in 40 (40.8%) patients with a median time to recurrence of 16 months (interquartile range 1-160 months). Estimated 1-, 3-, and 5-year overall survival rates for the entire cohort were 88%, 68%, and 58%, respectively. On multivariate analysis, lymph node positivity (hazard ratio [3.27, p = 0.010), iCCA subtype (HR 2.94, p = 0.030), and explant tumor size (HR 1.22 per cm, p = 0.005) were independent predictors of recurrence.ConclusionsThis is, to our knowledge, the largest single-center analysis of liver transplant recipients with BTC. Lymph node positivity, iCCA subtype, and tumor size are independent predictors of recurrence following LT for BTC. Despite the diagnostic challenges and high disease recurrence, LT is a promising option for unresectable BTC when no other surgical option exists.

The indications for robotic surgery in transplant and HPB procedures are rapidly expanding. However, there is growing concern about the adequacy of robotic training during fellowship in preparing trainees for the evolving demands of modern transplant surgery. This is a single center, retrospective review of the robotic experience of 9-abdominal transplant fellows (ASTS) over a 7-year period (2017–2024) at a high-volume center. A 10-question survey was administered to elicit fellow perspective on their training. The 9 fellows participated in 692 of the total 860 robotic cases (80

BACKGROUND:Most reported experience with robotic kidney transplant (RKT) has been limited to right-sided graft implantation, with left-sided implantation considered technically challenging. METHODS:We retrospectively reviewed consecutive left-sided RKTs at two transplant centres (01/2023-02/2026). A standardized operative technique with an accompanying surgical video is presented, and perioperative and postoperative outcomes are analysed. RESULTS:Seventeen patients underwent left-sided RKT. Fifteen were for retransplants, and two were for contraindications to right-sided implantation. Median warm ischaemia time was 37 min, operative time 229 min, and length of stay 4 days. No conversions to open surgery, intraoperative complications, or major postoperative complications occurred. Delayed graft function developed in five patients. At a median follow-up of 12.1 months, all patients were alive with functioning grafts. CONCLUSIONS:RKT with left-sided graft implantation is technically feasible and safe in experienced robotic transplant centres and was associated with favourable short-term outcomes.

BACKGROUND:Operating room turnover time is a major source of perioperative inefficiency affecting patient care, staff satisfaction, and institutional revenue. A multidisciplinary, collaborative approach to turnover time reduction is required to improve perioperative quality. METHODS:Surgeons, anesthesiologists, nurses, and perioperative leadership collaborated to develop 2 efficiency interventions. The "Showtime" initiative established a service-specific set-time for a surgical and anesthesia representative to meet in preoperative holding for the operating room's next patient. The "Intentional Rounding" initiative included the charge nurse performing room-to-room morning rounds to proactively identify and mitigate turnover time efficiency issues for the day. These interventions were initiated across the neurosurgery, orthopedics, otolaryngology, and transplant/hepatobiliary service lines within an academic medical center. RESULTS:Implementation of the Showtime and Intentional Rounding initiatives resulted in an average reduction in turnover time of 10.5 minutes (20%) across all service lines. Improvement was noted across each service line, with improvement times ranging from 7 to 22 minutes (17% to 32% improvement, respectively), as well as the ability to sustain higher monthly case volumes. An expected 440 hours of turnover time was recovered during the study period, associated with an estimated savings of $361,419 in direct "empty operating room" costs recovered over the 20-month study period (around $18,000/mo). CONCLUSION:Two multidisciplinary perioperative interventions focused on improving operating room turnover time efficiency resulted in a systemwide 20% reduction in average turnover time at an academic medical center, with estimated cost savings of more than $18,000 per month. These interventions are sustainable, low resource-intensive, and reproducible across multiple service lines.

Kidney transplantation is the gold standard for end-stage renal disease, and robotic kidney transplant is becoming increasingly common globally. There have not been large-scale studies, however, assessing national outcomes of robotic kidney transplant compared to open kidney transplant. This was a retrospective cohort analysis of adults undergoing kidney-only transplant from the National Inpatient Sample, 2016–2022. Comparative analysis was performed using log-transformed linear regression for continuous variables and Rao-Scott chi-square testing for categorical variables. Rates of delayed graft function, length of stay, and costs were regressed on age, sex, race, primary payer, median household income, diabetes, obesity, hospital size, region, and calendar year. Of an estimated 140,495 kidney-only transplants, 670 (0.48

Pancreas transplantation remains the only definitive therapy for restoring endogenous insulin secretion and physiologic glycemic control in patients with insulin-dependent diabetes mellitus. Utilization in the United States has declined, however, in part due to morbidity associated with open simultaneous pancreas-kidney transplantation (SPKT), secondary to the incision or bowel manipulation, and procedural concentration within high-volume centers. The dissemination of robotic kidney transplantation has demonstrated the feasibility of minimally invasive transplant surgery and provides a platform to reconsider pancreas transplantation using standardized robotic principles. We describe a reproducible technique for robotic pancreas transplantation (RPT), applicable to SPKT, pancreas-after-kidney transplantation, and pancreas-transplant-alone. Patient selection follows established criteria with multidisciplinary evaluation and preoperative vascular imaging. The operative workflow includes back-table vascular construction, limited iliac vessel dissection, extraperitoneal graft placement in a head-down orientation on the left iliac fossa, tension-free portal vein anastomosis to the external iliac vein, arterial anastomosis to the external iliac artery, controlled reperfusion, and side-to-side duodeno-ileostomy. Port placement mirrors robotic kidney transplantation to promote procedural standardization. Early experiences from high-volume centers demonstrate technical feasibility of RPT. Published series report successful implementation without routine need for hand assistance, and institutional experience supports reproducibility. Data remain limited, however, and are not powered to assess comparative outcomes or cost-effectiveness. A standardized approach to RPT is technically feasible and may reduce the surgical burden associated with open SPKT. While larger multicenter studies are required to define safety, graft outcomes, and economic impact, dissemination of a reproducible operative framework represents an essential first step toward broader adoption.

Aim While portal vein thrombosis (PVT) is well described in patients with cirrhosis, no guidance on de-novo cases following liver transplantation (LT) exists. We describe our experience with new-onset PVT in liver allografts post-LT. Methods Transplant recipients between 2002 and 2024 were reviewed from an institutional database excluding patients with pre-LT PVT. Early (<30 days) and late (>30 days of LT) PVT was defined accordingly. Results Out of 2273 LTs, PVT occurred in 32 recipients (age 51 ± 11 years; early n = 15; late n = 17). Median time to PVT was 42 days (range 3– 5042 days).Complete thrombus resolution was achieved following re-transplantation (n = 4) and surgical thrombectomy (n = 3). Venoplasty (n = 1) and stenting (n = 1) were performed for late PVT events. Using anticoagulation-only strategies, complete resolution was achieved in 16/17 recipients. The remaining 6 did not receive any medical or surgical intervention.Both 1-, 3- and 5-year overall (p < 0.05) and graft survival (p = 0.02) were lower in LT recipients with de novo PVT when compared to non-PVT cases. Discussion Although infrequent, PVT post-LT is a difficult clinical scenario with no clear treatment algorithm in the transplant literature. Non-operative management is feasible, however, surgical and radiological interventions are merited for LT recipients with compromised allograft function.

This study describes our institutional experience with robotic hepatectomy, analyzes trends, and evaluates intraoperative and postoperative outcomes stratified by IWATE-defined procedural difficulty. Retrospective cohort study of the first 100 consecutive robotic hepatectomies performed by the abdominal transplant division at a high-volume center (2017–2025). Outcomes were compared across IWATE groups and between early (2017–2021) and late (2022–2025) cohorts. Logistic regression was used to examine the association between IWATE score and conversion to open surgery, 30-day complications, and major complications (Clavien–Dindo ≥ IIIa). Median age was 61 years (IQR 47–70), 52

Background Operating room turnover time is a major source of perioperative inefficiency affecting patient care, staff satisfaction, and institutional revenue. A multidisciplinary, collaborative approach to turnover time reduction is required to improve perioperative quality. Methods Surgeons, anesthesiologists, nurses, and perioperative leadership collaborated to develop 2 efficiency interventions. The “Showtime” initiative established a service-specific set-time for a surgical and anesthesia representative to meet in preoperative holding for the operating room’s next patient. The “Intentional Rounding” initiative included the charge nurse performing room-to-room morning rounds to proactively identify and mitigate turnover time efficiency issues for the day. These interventions were initiated across the neurosurgery, orthopedics, otolaryngology, and transplant/hepatobiliary service lines within an academic medical center. Results Implementation of the Showtime and Intentional Rounding initiatives resulted in an average reduction in turnover time of 10.5 minutes (20%) across all service lines. Improvement was noted across each service line, with improvement times ranging from 7 to 22 minutes (17% to 32% improvement, respectively), as well as the ability to sustain higher monthly case volumes. An expected 440 hours of turnover time was recovered during the study period, associated with an estimated savings of $361,419 in direct “empty operating room” costs recovered over the 20-month study period (around $18,000/mo). Conclusion Two multidisciplinary perioperative interventions focused on improving operating room turnover time efficiency resulted in a systemwide 20% reduction in average turnover time at an academic medical center, with estimated cost savings of more than $18,000 per month. These interventions are sustainable, low resource-intensive, and reproducible across multiple service lines.

The introduction of robotic technology has revolutionized the field of surgery. Although transplantation initially lagged behind other subspecialities in adopting a robotic approach, interest is growing as the advantages of robotic surgery are being recognized, including enhanced 3-dimensional visualization, tremor filtration, and wristed instrumentation. While the efficacy of robotic surgery for kidney and pancreas transplant has been established, robotic liver transplantation is still in its infancy. There have been almost 100 cases of robotic liver transplantation reported in the literature from 5 transplant centers, with additional unpublished data bringing the total worldwide volume to ~200 cases. This early experience has shown it to be safe and feasible in carefully selected patients. In this manuscript, we present a comprehensive overview of the current world experience with robotic liver transplantation, including deceased donor and living donor transplants. The evolution of the procedure, indications for robotic transplantation, principles of donor and recipient selection, and the nuances of the robotic operative technique are also discussed, including annotated intraoperative photographs and links for narrated videos. Robotic liver transplantation is a complex, technically demanding operation with early positive results. However, the field is still in its infancy, and adoption of this technique should continue at high-volume centers with appropriate resources, including a dedicated, multidisciplinary robotic team.

The field of liver transplantation (LT) has evolved rapidly since its conception in 1963. With improvements in surgical techniques and greater understanding of immunosuppression, LT has gained wide popularity in treating end-stage liver disease as well as carefully selected hepatic malignancies. In the past decade, several centers across the world have implemented minimally invasive approaches in donor hepatectomy as well as LT. In donor operations, the robotic platform has been utilized safely to offer several advantages such as reduced pain, shorter hospital length of stay, improved cosmesis while maintaining graft quality and donor safety.

OBJECTIVE:While robotic surgery has expanded in living donor and transplant operations, it is unclear how the next generation of transplant surgeons will be trained to incorporate robotics into their practice. This study aims to assess current opinions regarding robotics training in transplant fellowship. DESIGN:This was a cross-sectional survey of 2025-2026 American Society of Transplant Surgeons (ASTS) abdominal transplant fellows and program directors (PDs), assessing experiences with robotics during fellowship, barriers to training, and future directions in robotic transplant education. SETTING:Surveys were sent electronically across North America. PARTICIPANTS:This study included 2025-2026 ASTS abdominal transplant fellows and PDs. RESULTS:Eighty-one fellows and 19 PDs responded (response rates 55% and 45%, respectively). Seventy-three percent of fellows expected to participate in fewer than 50 cases during fellowship, 94% desired more robotic experience, and 35% expressed dissatisfaction with their training. Satisfaction correlated with higher transplant center volume, console exposure, and confidence in robotic procedures (all p < 0.05). CONCLUSIONS:This study highlights limitations in robotic surgery training during abdominal transplant fellowships, revealing a gap between fellow expectations and current practice, and underscoring the need for standardized curricula and training.

ABSTRACT Introduction: Kidney autotransplantation is an organ-preserving option for selected patients with complex ureteral or renovascular pathology not amenable to in situ reconstruction. Conventional open autotransplantation, however, is associated with substantial morbidity. Robotic kidney autotransplantation (RKAT) has emerged as a minimally invasive alternative, but detailed technical reports of complex cases requiring vascular reconstruction remain limited. Technical Description: We report the technique of RKAT in a 32-year-old woman with a radiation-induced high-grade ureteral stricture refractory to endoscopic management and not amenable to standard ureteral reconstruction. The procedure consisted of robotic nephrectomy, extracorporeal back-table reconstruction of dual renal arteries using a fish-mouth technique, extension of the short right renal vein with a bovine pericardial conduit, robotic implantation to the right external iliac vessels, and neocystoureterostomy. A detailed operative description is accompanied by a narrated surgical video. Initial Experience: Console times for nephrectomy and implantation were 99 and 228 minutes, respectively. First warm ischemia time was 3 minutes, cold ischemia time was 3 hours, and second warm ischemia time was 36 minutes. The postoperative course was uncomplicated, and the patient was discharged on postoperative day 3 with preserved renal function and satisfactory graft perfusion. Conclusion: Robotic kidney autotransplantation with extracorporeal vascular reconstruction is a feasible minimally invasive option for carefully selected patients with complex ureteral pathology. This report provides technical insight into the operative strategy and reconstructive steps involved in RKAT.

BACKGROUND:Large livers undergoing normothermic machine perfusion are believed to demonstrate altered homeostasis and heterogeneous graft perfusion during normothermic machine perfusion; these features of large livers may dissuade their use for normothermic machine perfusion and transplantation, reducing the donor pool. However, it remains unclear if liver size has an impact on transplant outcomes following normothermic machine perfusion. METHODS:A retrospective, single-center review of all transplanted livers that underwent normothermic machine perfusion (OrganOx metra) over a 32-month period was conducted. Livers were categorized by weight into 3 equal tertiles: small (<1,570 g), medium (1,570-1,870 g), and large (>1,870 g). Perfusate lab metrics during normothermic machine perfusion and recipient outcomes were analyzed. RESULTS:During the study period, 151 livers underwent normothermic machine perfusion with subsequent transplantation, with 50, 51, and 50 livers in small, medium, and large weight groups, respectively. During normothermic machine perfusion, the perfusate of large livers had significantly higher transaminase levels than the perfusate of medium and small livers, on average, over time. Perfusate glucose, pH, and lactate levels were similar across weight groups. There was a trend toward elevated post-transplant transaminases (P = .026) with increasing liver weight. Large liver recipients had no increase in 90-day mortality or graft failure, 30- or 90-day readmission, intensive care unit/hospital length of stay, or vascular/biliary complications. In multivariable analysis, large liver size was independently associated with cradle compression; cradle compression was independently associated with early allograft dysfunction. CONCLUSIONS:Use of normothermic machine perfusion for large livers results in similar clinical outcomes compared with smaller allografts despite higher on-pump and post-transplant transaminase release. These findings suggest that size-universal normothermic machine perfusion viability criteria can be used for large livers to safely expand the pool of eligible donor organs.

BACKGROUND:Combined heart-liver transplantation (CHLT) is a high-risk procedure that is infrequently performed in select patients with end-stage heart and liver disease. This study details a single center experience with simultaneous (en bloc or sequential) CHLT. METHODS:This is a single center retrospective review of 12 simultaneous CHLT performed over a 12-year period. Studied variables included basic clinical data, intraoperative and postoperative details, and outcomes. A comparison of our outcomes to the national cohort was also performed using the UNOS registry. RESULTS:Twelve CHLTs (five pediatric, seven adult) were performed between 2011 and 2023. Mean age was 32 years (range 7-62 years, 75% male). Congenital heart disease with cardiac cirrhosis (58%) and amyloidosis (25%) were the most common indications. Liver and heart wait list times were 125 and 116 days, respectively. The majority of CHLTs were performed en-bloc (n = 8; 67%) and four (33%) were performed sequentially (liver following heart). Mean post-operative ICU and total length of stay (LOS) were 16 and 28 days, respectively, with six patients requiring unplanned return to OR (three for hemoperitoneum, three for hemopericardium). There were no intraoperative deaths, and one patient died on POD 1 from hyperacute rejection. None of the patients required re-transplant after a median follow-up of 37.5 months. Both overall and graft survival for the cohort at 1-, 3-, and 5-years remained 92%. CONCLUSION:CHLT remains the only viable option for carefully selected patients with end-stage heart and liver failure and is associated with excellent patient outcomes.

BACKGROUND:Historically, ABO incompatibility (ABOi) has been considered a relative contraindication to liver transplant (LT) due to inferior postoperative outcomes. We seek to reassess ABOi LTs as an underused graft supply. METHODS:We retrospectively reviewed all adult and pediatric patients who underwent LT, 1987-2022. Recipients were categorized by donor blood type compatibility: incompatible (ABOi), compatible (ABOc), and identical (ABOid). Propensity scoring of 1:1:1 was performed to account for recipient age and acuity at transplant. RESULTS:Of 193,751 LTs, 2699 were ABOi (1.4%). ABOi recipients had the highest proportion of status 1 listings (22.5% versus 20.5% ABOc, 4.9% ABOid, P < 0.0001) and the highest model for end-stage liver disease (30 versus 28 ABOc, 26 ABOid, P < 0.0001) and pediatric end-stage liver disease scores at transplant (33 versus 28 ABOc, 25 ABOid, P < 0.0001). When analyzing the unmatched cohort, ABOi was associated with worse GS (HR 1.2, P < 0.001), OS (HR 1.1, P = 0.033), and increased rates of retransplantation (HR 1.35, P = 0.001). However, after performing propensity matching, there were no differences in GS, OS, or retransplantation between groups. CONCLUSIONS:There is no difference in outcomes between ABOi LT recipients and recipients of ABOc and ABOid grafts after accounting for recipient age and acuity. ABOi LT may decrease blood group disparities and improve timely LT access.