Objective: To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). Summary Background Data: Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. Methods: This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. Results: A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. Conclusions: Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

Liver transplantation remains the only treatment for end-stage liver disease; however, its application is critically constrained by the persistent shortage of viable donor organs. This shortage motivates the use of extended criteria donor livers, which increases the risk for primary non-function. Accurately assessing graft quality of marginal grafts remains a challenge due to a lack of predictive markers. Ex situ liver perfusion (EVLP) has emerged as a potential strategy to increase the time for assessment by introducing a platform that increases preservation times and mimics the in vivo environment for the graft. Unlike for static cold storage (SCS), oxygenated perfusates are continuously pumped through donor livers during EVLP providing an opportunity for viability assessment and potential rehabilitation of marginal grafts prior to transplantation. The transition from passive preservation via SCS to active EVLP enables continuous access to the perfusate of the metabolically active graft, enabling automatic real-time monitoring of biomarkers. Here, we describe the design and application of a real-time optical setup based on lock-in amplification for continuous monitoring of critical liver viability biomarkers-indocyanine green (ICG) and flavin mononucleotide (FMN)-during EVLP. ICG is well-established to visualize hepatic blood flow and clearance correlates with hepatic function. ICG is measured directly within the blood-filled perfusion tubing. This approach leverages the near-infrared absorbance of ICG to mitigate optical interference arising from blood turbidity. Concurrently, FMN, an early marker of mitochondrial damage and ischemia-reperfusion injury (IRI), is optically quantified in the transparent perfusate during hypothermic oxygenated machine perfusion or in waste dialysis during normothermic machine perfusion, effectively bypassing the optical interference inherent in direct blood measurements. This optical design successfully enabled continuous, quantitative measurements of both ICG and FMN, providing dynamic insights into IRI and metabolic status of ex situ perfused human and rodent livers, paving the way for further assessment of donor livers.

Liver transplantation outcomes have improved. However, immunosuppression also raises infection susceptibility. Potential differences in infections between donation after circulatory death (DCD) and donation after brain death (DBD) recipients remain unclear. This study analyzed postoperative infections and compared their incidence between DCD and DBD recipients. Patients undergoing liver transplantation from January 1, 2016, to December 31, 2022, were included. DCD and marginal DBD liver grafts underwent hypothermic oxygenated machine perfusion (HOPE). Bacterial, viral, and fungal infections were identified using standardized definitions. Infections were categorized into periods: 0-2 weeks (period 1), 3-4 weeks (period 2), 1-6 months (period 3), and beyond 6 months (period 4). The primary outcome was the occurrence of infection within the first post-transplant year, including pathogen spectrum, timing, and infection site. The secondary outcome was the assessment of infection risk factors investigated with Poisson regression. A total of 300 liver transplants were included. In all, 42.8% of DBD recipients and 44.3% of DCD recipients suffered from at least 1 infection. In total, 298 relevant infections occurred, with bacteria accounting for 73.2% in DBD and 86.4% in DCD recipients. Bacterial infections predominated in all periods. In periods 1 and 2, bloodstream infections, abdominal and surgical site infections were most frequent, while liver-related infections, especially in DCD, and bloodstream infections dominated in periods 3 and 4. Viral and fungal infections were less frequent. One-year survival was 87.1% for DBD and 87.7% for DCD recipients. Poisson regression identified DCD recipients (IRR 1.99, 95% CI 1.37-2.92, p <0.001) and younger age (IRR 0.98, 95% CI 0.97-0.99, p <0.001) as more likely to develop infections. DCD liver recipients experienced more infections in the first post-transplant year. While mortality was not different, the increased infection rates in DCD recipients highlight the need for infection prevention and surveillance.

Early allograft failure (EAF) after living donor liver transplantation (LDLT) remains a clinical challenge. Existing prediction models developed for deceased donor transplantation poorly apply to LDLT due to distinct surgical and physiological factors. This study identifies clinical determinants of EAF and develops an LDLT-specific prediction model. We conducted a multicenter retrospective cohort study from 17 high-volume LDLT centers (January 2016-December 2020) with external validation at a tertiary center in Saudi Arabia (January 2015-December 2022). The primary outcome was EAF (graft loss or patient death ≤90 d). Multivariable mixed-effects logistic regression identified preoperative/intraoperative risk factors. The EAGLE-LDLT model was constructed using postoperative laboratory values. Performance was compared against established models (EAD, MEAF, A2ALL) using ROC analysis and decision curve analysis. The development cohort included 2944 adult LDLT recipients (67.7% male; median age 55 y; median MELD 14) with a 5.5% EAF rate. External validation included 1020 recipients (median MELD 21, 6.7% EAF). Independent risk factors for EAF were MELD (OR 1.06, 95% CI 1.04-1.08), donor BMI (OR 1.05, 95% CI 1.00-1.10), portal vein thrombosis (OR 1.73, 95% CI 1.13-2.63), and hepaticojejunostomy (OR 1.58, 95% CI 1.06-2.36). The EAGLE-LDLT model incorporating peak ALT (>468 U/L), peak INR (>1.9), and bilirubin (>3.5 mg/dL) and INR (>1.3) at POD7, demonstrated superior discrimination (AUC=0.81) compared with MEAF (AUC=0.77, p =0.004), EAD (AUC=0.67, p <0.001), and A2ALL (AUC=0.65, p <0.001). EAGLE-LDLT achieved balanced sensitivity (75.0%) and specificity (73.7%), effectively stratifying patients into high-risk (15% of patients; 40.4% EAF incidence) and low-risk groups. Preoperative and intraoperative clinical factors predict EAF in LDLT. The EAGLE-LDLT model accurately identifies LDLT recipients at the highest risk for EAF postoperatively.

Extended-criteria donation after circulatory death (ECD-DCD) livers require functional assessment to ensure safe utilization. Sequential (dual) hypothermic oxygenated machine perfusion ((D)HOPE) with controlled oxygenated rewarming (COR) followed by normothermic machine perfusion (NMP) enables viability assessment of ECD-DCD grafts while promoting mitochondrial recovery. Previous work has investigated the added value of flavin mononucleotide (FMN) in risk stratification during DHOPE. This diagnostic accuracy study aimed to compare the predictive value of FMN release during DHOPE with bile quality assessment during subsequent COR-NMP in consecutively accepted ECD-DCD livers. FMN concentrations were measured fluorometrically in perfusate samples collected during DHOPE and not used to guide clinical decisions on transplantability. Viability assessment after 2.5 hours of NMP served as the reference standard. Associations between FMN levels and graft utilization were evaluated using receiver operating characteristic analyses. A total of 103 ECD-DCD livers were included, of which 67% were transplanted. FMN demonstrated discriminative ability for graft nonutilization based on bile quality assessment, with AUROC of 0.74 (95% CI: 0.60-0.86) at 30 minutes, 0.75 (95% CI: 0.63-0.85) at 60 minutes, and 0.70 (95% CI: 0.56-0.83) at 120 minutes of DHOPE. Exploratory FMN thresholds showed increasing specificity and positive predictive value over time, reaching 0.92 (95% CI: 0.83-0.98) and 0.75 (95% CI: 0.53-0.94), respectively, at 120 minutes. Transplanted livers had significantly lower FMN concentrations than declined livers at all time points, with Youden-optimal cutoffs of 9.32, 20.97, and 45.53 ng/mL at 30, 60, and 120 minutes, respectively. FMN release during DHOPE is associated with subsequent NMP viability outcomes in ECD-DCD livers. FMN concentrations may help identify viable and nonviable grafts early during DHOPE, potentially avoiding resource-intensive comprehensive viability assessment with COR-NMP.

The impact of preformed donor-specific antibodies (DSA) in liver transplantation (LT) remains controversial despite evidence linking their presence to an increased risk of early allograft damage, as well as antibody- and T-cell-mediated rejection. In this nationwide analysis, preformed DSA were assessed using single-antigen bead assays [positive if mean fluorescence intensity (MFI) ≥1000]. This study included all LT recipients enrolled in the Swiss Transplant Cohort Study (STCS) who underwent LT between 2014 and 2016. One-year post-LT outcomes, including cumulative allograft and patient survival, as well as the incidence of biliary, vascular, and infectious complications, were compared between DSA-positive (DSA+) and DSA-negative (DSA-) individuals. Among 321 LT performed in 306 patients, preformed DSA were detected in 92 (28.7%) and more frequently observed in patients with a history of prior transplantation ( p =0.008) or autoimmune liver disease ( p =0.036). Class I and II DSA were present in 48.9% and 71.1% of DSA+ cases, with concomitant class I and II DSA in 20.7%. The median (IQR) cumulative MFI (cMFI) of the preformed DSA was 3768 (1875-10,537), and 52.2% of DSA+ patients harbored multiple DSA. While overall patient survival did not differ between DSA+ and DSA- individuals, DSA+ patients with cMFI ≥5000 exhibited a higher incidence of allograft failure and biopsy-proven rejection. Multivariate analysis revealed that the presence of preformed DSA was independently associated with biliary complications (HR 2.26, 95% CI 1.17-4.37, p =0.02) but not with vascular or infectious complications. In summary, preformed DSA were associated with biliary complications, increased rejection, and reduced allograft survival. These findings suggest pre-transplant immunological risk assessment and the need for tailored immunosuppressive strategies in LT.

OBJECTIVE:To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). SUMMARY BACKGROUND DATA:Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. METHODS:This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. RESULTS:A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. CONCLUSIONS:Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

Background & Aims: Liver transplantation (LT) for hepatocellular carcinoma (HCC) is performed worldwide, with 5-year survival rates of approximately 70%. However, post-transplant HCC recurrence occurs in 15-20% of recipients. We aimed to evaluate, for the first time, long-term recurrence-free survival in a large international cohort of patients undergoing LT for HCC using grafts treated with hypothermic oxygenated machine perfusion (HOPE). Methods: This observational post hoc analysis of the multicenter European HOPE-REAL study (NCT05520320) included adult recipients with HCC (N = 599) who received a liver from either a donation after brain death (DBD) or donation after circulatory death (DCD) donor, preserved using HOPE, dual-HOPE (DHOPE), or normothermic regional perfusion followed by HOPE (NRP-HOPE) between 2012 and 2022. Propensity score matching was used to compare outcomes between HCC and non-HCC recipients within the HOPE-REAL cohort, and between HOPE-treated HCC recipients and an external control cohort receiving non-perfused livers (n = 484). Results: The overall HCC recurrence rate in the HOPE-REAL cohort was 6.9% (41/599), with no significant difference between DBD and DCD liver transplants (7.1% [25/350] vs. 6.4% [16/249]; p = 0.346). One-, 3-, and 5-year overall survival rates were 92%, 86%, and 81%, while recurrence-free survival rates were 90%, 83%, and 78%, respectively. Five-year overall survival was similar between 347 HOPE-treated HCC recipients (82%) and 347 matched non-HCC recipients (84%) (p = 0.625). In contrast, compared to an external cohort of 312 non-perfused HCC recipients, 5-year overall survival was significantly higher in 312 matched HOPE-treated HCC recipients (74% vs. 84%; p = 0.034). Conclusions: HCC recurrence was rare after transplantation of livers treated with HOPE. Long-term survival in HOPE-treated HCC recipients was significantly better than in those receiving non-perfused livers, and comparable to outcomes in non-HCC recipients. These findings warrant validation in a randomized clinical trial. Impact and implications: This post hoc analysis of the HOPE REAL study demonstrates, for the first time, low hepatocellular carcinoma (HCC) recurrence rates in a large cohort of hypothermic oxygenated machine perfusion-treated liver transplant recipients with HCC, and significantly better survival outcomes compared to matched recipients of non-perfused grafts. These findings may have important implications, particularly as tumor-related indications for liver transplantation continue to rise. Machine liver perfusion could emerge as a novel strategy to improve oncological outcomes in high-risk cancer conditions after transplantation, potentially via mitigation of inflammation and reduced tumor cell seeding. Clinical trial number: NCT05520320

Indocyanine green (ICG) fluorescence imaging is increasingly incorporated into robotic liver resections (RLR), yet clinical practice regarding timing, dosage, and staining techniques is divergent. This international expert survey aimed to characterize current practices for ICG in RLR. Experts in RLR were invited to participate based on surgical volume (experience of ≥ 50 RLR and ≥ 30 annual RLR). A 74-item questionnaire was developed following a literature search and reviewed by a steering committee. The survey addressed indications, timing, dosage, imaging technology, benefits, limitations, training, and future directions of ICG use. Responses collected between September and October 2025 were analyzed. Seventy experts from 19 countries completed the survey, corresponding to an 88

Liver transplantation is challenged by organ scarcity and ageing donors. Machine perfusion is a promising technique to enhance organ preservation and assessment, improving liver utilization and patient outcomes. Here, we discuss current practices in machine perfusion using the IDEAL framework and outline the steps needed to advance this technology clinically.

Open liver surgery is increasingly being replaced by minimally invasive surgery, especially using robot-assisted liver resections (RLR). Along the learning phases of a surgical procedure intraoperative, postoperative, and oncologic outcomes improve at different stages. The aim of this study is to evaluate the learning phases of RLR in a large retrospective international multicentre setting to determine the number of procedures required to achieve competency, proficiency and mastery. Consecutive patients from 5 international expert centres who underwent elective RLR were included. Three thresholds were used to define the learning curve based on the first 150 RLRs in each centre: Operative time for competency, major complications (Clavien-Dindo ≥III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the thresholds were compared. The learning curve analysis was performed on 662 RLRs. From competency to proficiency 23 cases and from proficiency to mastery 63 cases were required. The rate of technically major/major resections increased significantly throughout the three phases (p<0.001), while the rate of major complications (8.4% to 7.1%) and length of hospitalisation (4 to 3 days) remained stable. RLRs were associated with an excellent rate of patients reaching textbook outcome from the beginning (87%). Competency, proficiency and mastery of RLR were achieved after 23 and 63 cases respectively. Robotic liver surgery was associated with excellent perioperative results while the indications towards major liver resections were expanded gradually.

A frequent and increasing indication for liver transplantation (LT) is hepatocellular carcinoma (HCC). However, despite strict selection criteria, HCC recurrence after LT occurs in a relevant proportion of patients and is associated with an unfavorable prognosis. Hypothermic oxygenated perfusion (HOPE) is a novel machine liver perfusion approach to optimize liver grafts before implantation and has been suggested to decrease graft inflammation with potential anti-cancer effects. HOPE4Cancer is an international, multicentric, parallel group, randomized controlled trial comparing HOPE performed after initial cold storage (intervention) with conventional cold storage alone (control) in a 1:1 allocation ratio. Adult recipients with proven HCC will be included for transplantation of a DBD (donation after brain death) Liver graft. The minimum perfusion duration is defined at 2 h and perfusion is generally continued until the recipient hepatectomy is completed. The conventional cold storage at 4 °C will be performed with a precooled preservation solution according to the local standard of care. The primary endpoint is defined as post-transplant HCC recurrence-free survival, i.e., the time interval a patient is alive without HCC recurrence after transplantation. Secondary endpoints are the single components of the events considered for the primary outcome (i.e., HCC recurrence, HCC-related death, death from any other causes than HCC), circulating tumor DNA, high-mobility-group-protein B1 in the blood, the Rejection Activity index, and the number of liver-related complications experienced by the patient. HOPE4Cancer investigates if cold storage plus end-ischemically applied HOPE in DBD LT is superior to conventional cold storage of liver grafts in terms of post-transplant HCC recurrence-free survival. The results will indicate for the first time whether ex situ HOPE before transplant has an anti-cancer potential compared to transplantation of un-perfused livers. ClinicalTrials.gov NCT06717919. Registered on December 5, 2024.

BACKGROUND:Increasing donor risk, particularly in liver transplantation, where organs are often marginal, has made dynamic organ preservation techniques and viability assessment essential to safely improve organ quality and increase utilisation. However, existing viability parameters are based on routine clinical assessment in patients with acute liver failure, trauma, or liver resections. These parameters often do not correlate with clinically relevant post-transplant outcomes. METHODS:This article presents a detailed protocol for the spectrophotometric quantification of Flavin mononucleotide (FMN), a marker of mitochondrial injury. FMN release from mitochondrial complex I was described many decades ago as the initial sign of ischaemia-reperfusion injury, i.e. when oxygen is reintroduced in ischaemic tissues during organ transplantation or machine perfusion. This study describes the detailed FMN quantification in donor plasma and various fluids obtained during machine perfusion, and discusses confounders, challenges, and the role of individual test components. FINDINGS:FMN quantification was identified as an immediate organ assessment tool, demonstrating a strong correlation with graft survival and other relevant complications after human liver transplantation. INTERPRETATION:The results highlight FMN quantification as a reliable and standardized method for assessing organ viability, offering significant potential for improving organ selection and better utilisation. This method could provide better a predictive value for transplant outcomes compared to existing parameters currently in use. FUNDING:This research received no external funding but was supported by the Catalyst grant No. CCG0280 at Cleveland Clinic Ohio, U.S. dedicated to A.S.

Importance:Surgical site infections (SSIs) are one of the most common health care-associated infections. Surgical site infections can have harmful effects in liver transplant (LT) recipients. Objective:To assess the incidence of SSI after LT and identify risk factors associated with SSIs and whether SSIs are associated with death and graft loss. Design, Setting, and Participants:A multicenter cohort study encompassing data on LT performed at all Swiss transplant centers between May 1, 2008, and September 30, 2020, was conducted. Data analyses were performed in 2023. Exposure:Liver transplant. Main Outcomes and Measures:Frequency of SSIs within 90 days after transplant, risk factors associated with SSIs, and association of SSIs with 1-year death or graft loss. Surgical site infections were defined according to Centers for Disease Control and Prevention criteria with SSIs occurring within 90 days after LT. For association with posttransplant outcomes, 1-year follow-up data were analyzed. Results:Among 1333 LT recipients in the Swiss Transplant Cohort Study, 1158 adults were included in analyses. Median age was 57.2 (IQR, 49.3-62.8) years and 792 were men (68.4%). Seventy patients (6.0%) had an SSI. Most SSIs were deep incisional (9 [12.8%]) or organ-space infections (54 [77.1%]). In most SSIs (56 [80.0%]), bacteria were detected, most frequently Enterococcus spp (36 of 75 [48.0%]) and Escherichia coli (12 of 75 [16.0%]). In multivariable analysis, prior liver transplant (odds ratio [OR] 4.01; 95% CI, 1.44-11.18; P = .008) and living liver donation (OR, 4.08; 95% CI, 1.37-12.16; P = .01) were independent risk factors associated with SSIs. Surgical site infections were independently associated with graft loss and/or death (hazard ratio [HR], 3.24; 95% CI, 1.82-5.79; P < .001); this association was observed in separate analyses on graft loss (HR, 2.97; 95% CI, 1.32-6.68; P = .02) and death (HR, 3.25; 95% CI, 1.44-7.35; P = .01). Conclusions and Relevance:The findings of this study suggest that prior liver transplant and living liver donation are independent risk factors associated with SSIs and that SSIs are independently associated with graft loss and/or death, highlighting the relevance of this health care-associated infection.

Background. Early allograft dysfunction (EAD) affects outcomes in liver transplantation (LT). Existing risk models developed for deceased-donor LT depend on posttransplant factors and fall short in living-donor LT (LDLT), where pretransplant evaluations are crucial for preventing EAD and justifying the donor’s risks. Methods. This retrospective study analyzed data from 2944 adult patients who underwent LDLT at 17 centers between 2016 and 2020. We developed a logistic regression model to predict EAD based on this development cohort. We used data from 1020 patients at the King Faisal Transplant Center for external validation. Results. In the development cohort, 321 patients (10.9%) experienced EAD. These patients had poorer health status, more liver decompensation, and higher requirements of hospitalization than those without EAD. Multivariable logistic regression identified independent pretransplant predictors of EAD: laboratory Model for End-Stage Liver Disease score (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.06-1.09), the necessity for hospitalization at the time of transplant (OR, 2.58; 95% CI, 2.00-3.30), and graft weight in kilogram (OR, 0.27; 95% CI, 0.17-0.45). Using these predictors, we developed the model for EAD after LDLT, which demonstrated strong discriminative ability in the development cohort with an area under the curve (AUC) of 0.71 (95% CI, 0.68-0.74). The model maintained high discrimination during internal validation (AUC, 0.70; 95% CI, 0.67-0.73) and showed a modest reduction in discriminative power in external validation (AUC, 0.65; 95% CI, 0.61-0.68). Conclusions. EAD post-LDLT is influenced by the recipient’s pretransplant health condition and the graft weight. Integrating the model for EAD after LDLT into the pretransplant process of pairing donors and recipients can enhance the safety and efficacy of LDLT.

Objective:This study aimed to identify benchmark values for robotic right hepatectomy (RH) based on a low-risk cohort treated at expert centers. Background:Robotic liver surgery is emerging as a preferred minimally invasive approach to the liver. To enable conclusive comparisons with the standard open or laparoscopic approaches, reference values are needed. Methods:Outcomes from consecutive patients undergoing robotic RH for malignant or benign indications at 22 international expert centers between 2018 and 2024 were analyzed. Low-risk, benchmark patients were without significant comorbidities such as portal hypertension, Child B cirrhosis, cardiac disease, chronic pulmonary disease, and renal failure. Patients undergoing robotic RH for donor hepatectomy were excluded. Fifteen reference values were derived from the 75th or the 25th percentile of the median values of all centers. Reference values were compared with a laparoscopic cohort from 4 centers and published benchmark values for laparoscopic and open RH. Results:Of 357 patients, 172 (48%) qualified as the benchmark cohort. The main indications were hepatocellular carcinoma (31%) and colorectal liver metastases (27%). Reference values included: operative time (≤476 min), conversion rate (≤8.2%), bile leak (≤15.4%), major complications (≤23.1%), and comprehensive complication index at 90 days (≤15.6). Robotic RH compared favorably to a multinational cohort series of laparoscopic RH with lower conversion (10.0% vs ≤8.2%) and R1 rate (10.9% vs ≤0%). Compared to open robotic hepatectomy, cutoffs for major complications (≤50.0% vs ≤23.1%) and liver failure (≤22.0% vs ≤2.7%) were lower for robotic right hepatectomies. Conclusion:This international benchmark study on robotic right hepatectomy (RRH) demonstrates that the robotic approach provides advantages compared with laparoscopic and open RH. RRH can be expected to become the minimally invasive approach of choice for tumors in the right liver.