Global Dissemination of Robotics in Liver Transplantation: The Way Forward

Abstract

We thank Bonaccorsi-Riani et al1 for their interest in our article. We presented our model of setting up the robotic donor hepatectomy (RDH) program to provide a real-world view of overcoming local hurdles in ensuring a safe surgical option for donors.2 If the same living donor liver transplantation (LDLT) template were to be used for proficiency in RDH in the West, given the relatively limited LDLT activity, only a few centers would have the surgical load to achieve mastery of RDH within a reasonable amount of time. We concur with the authors and the editorial on our article by Asher et al regarding the concerns and considerations surrounding the development of robotic liver transplant (RLT) programs in the West, which is likely to be an inevitable eventuality.1,3 In this regard, a recent analysis of 360 000 surgical procedures across surgical specialties in the United States concluded that based on the recent trends of rapid adoption of the robotic platform, it is likely to dominate minimally invasive surgery and surpass laparoscopy and open surgeries for most surgical procedures by 2025.4 Looking back at history, it is interesting to see the differential growth of LDLT and deceased donor liver transplantation (DDLT) globally driven by the need for organs and the sociocultural considerations inherent to these regions (East versus West).5 Notwithstanding these different approaches (LDLT versus DDLT), it remains indisputable that LT, in general, has grown many folds during the past 3 decades. We hypothesize, based on the early trends, that a not-so-dissimilar phenomenon will occur in the field of RLT. Centers in Asia, including ours, have led the way in RDH primarily because of the heavy reliance on LDLTs, which in turn hinges on improving and ensuring excellent donor outcomes. The inherent advantages of the robot allow for safe donor operations with shorter learning curves than laparoscopic surgery. Furthermore, as our team has shown, prior knowledge of advanced laparoscopic surgery is not an absolute prerequisite to performing RDH.2 We have now extended our RDH program to adult LDLTs and have performed 270 RDHs with 115 right lobe, 21 left lobe, and 134 left lateral segment RDHs, with a minor complication (Clavien-Dindo <IIIb) rate of 12.6%. Further pushing the envelope, we have now robotically completed 9 LDLT recipient explant hepatectomies and 3 allograft implantations. We feel that this is where the 2 realms (East and West) will converge with regard to expertise in RLT. The West has taken a different route to adopting robotic surgery in LT that of performing the DDLT operations robotically. Inspired by the successes of robotic renal transplantation, to our knowledge 7 DDLTs (personal communication) have been performed robotically across Europe and America, and more teams are considering adopting this innovative approach. Thus, while we agree that due to intrinsic differences in the system, it may not be feasible to replicate our model of operational logistics for RDH uniformly across the globe, it is foreseeable that the “robotic revolution” in the field of LT will catch on in the West, albeit via a different route.