Full Robotic Whole Graft Liver Transplantation: A Novel Approach

摘要

Liver transplantation remains the only definitive treatment for end-stage liver disease and acute liver failure, providing patients the potential for long-term survival and significantly improved quality of life.1 Liver transplantation is traditionally performed via open or a laparoscopic-assisted surgery.2,3 However, recent advances in robotic surgery have opened the door to robotic-assisted liver transplantation. While robotic donor hepatectomy is now well documented, the application of a full robotic approach for whole liver graft transplantation remains a significant technical frontier.4,5 This technical video presents a detailed, step-by-step description of our technique for fully robotic whole graft liver transplantation, demonstrated in the case of a 49-year-old male patient with end-stage liver disease complicated by refractory ascites. The procedure was performed using the Da Vinci XI Robotic Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Pneumoperitoneum was established via a 10-mm periumbilical assistant trocar. Three 8-mm and one 12-mm robotic ports were placed in a standardized configuration for liver resection, and an additional 12-mm assistant port was inserted on the right side of the abdomen. The ports for arms 2 and 3 were alternatively used to insert the camera during the procedure. Following careful dissection and control of the hepatic artery and bile duct, the liver was fully mobilized and detached from the inferior vena cava (IVC) using a right-sided approach. Then, the portal vein was divided and the hepatic veins were stapled, completing the total hepatectomy. The robotic system was then undocked, and the liver was extracted through a 10-cm periumbilical incision performed after liver resection by expanding the periumbilical trocar incision. A GelPort system (Applied Medical, Rancho Santa Margarita, CA, USA) was used to facilitate the introduction and positioning of the deceased-donor whole liver graft in the abdominal cavity. Following redocking and reestablishment of pneumoperitoneum, an open vascular clamp was used to clamp laterally the IVC with preservation of blood flow and robotic implantation of the graft began. A side-to-side caval anastomosis followed by portal vein reconstruction was performed using two 5-0 Gore-Tex® running sutures. After graft reperfusion (warm ischemia: 60 minutes), arterial reconstruction was completed using 6-0 polypropylene running sutures (time to arterial reperfusion: 40 minutes). Biliary reconstruction was an end-to-side choledochoduodenostomy with interrupted 5-0 polydioxanone sutures. Whole graft robotic liver transplantation, while offering the advantages of minimally invasive surgery, presents several technical and logistical challenges that can compromise procedural efficiency and safety. First, the limited availability of robotic systems during the standard workweek often necessitates scheduling such complex procedures over the weekend. This arrangement may reduce access to full multidisciplinary support, potentially affecting intraoperative and postoperative management. Second, the clamping of the IVC is technically challenging due to the reliance on traditional open vascular clamps within a confined robotic environment, which limits precision and maneuverability. Third, achieving adequate caval hemostasis is particularly difficult, as liver mobilization—a prerequisite for proper exposure—is significantly constrained in the robotic setting and may increase the risk of vascular and liver injuries. Furthermore, biliary reconstruction requires special attention: to avoid the need for a bilio-digestive anastomosis, the recipient’s biliary duct must be sectioned at a very high level. Notably, few centers worldwide have previously performed whole graft robotic liver transplantation, making the acquisition of the technique particularly challenging, especially in the context of liver transplantation, which itself remains among the most complex surgica