Full robotic liver transplantation in recipients: a narrative review of three competing surgical strategies

Robotic liver transplantation (RLT) has emerged as the latest frontier in minimally invasive transplant surgery. Since the first fully robotic living donor liver transplant in 2023, multiple centers worldwide have reported their initial experiences, leading to the development of three distinct technical strategies. This review systematically compares these three competing approaches: the Asian strategy (partial caval clamping, no veno-venous bypass, Pfannenstiel incision) reported by Broering et al., the American strategy (total caval clamping with veno-venous bypass, upper midline incision) reported by Khan et al., and the European strategy (total caval clamping without bypass, upper midline incision, routine machine perfusion) reported by Pinto-Marques, Di Benedetto, and colleagues. Key technical differences, patient selection criteria, and perioperative outcomes are analyzed. Notably, the most recent European case employed partial caval clamping, suggesting a trend toward convergence. While all three strategies have demonstrated feasibility with excellent short-term outcomes, no standardized approach currently exists. This review provides a framework for understanding current RLT techniques and offers guidance for centers considering adoption of robotic liver transplantation.