Robotic recipient liver transplantation worldwide: a systematic review and meta-analysis of the first 93 patients, from feasibility to early outcomes.

BACKGROUND

Robotic liver transplantation (rLT) has emerged as a minimally-invasive approach to the liver transplant operation, but global experience remains limited and fragmented. A synthesis of existing data and outcomes is needed to define its current role and inform wider adoption.

METHODS

We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines. PubMed, Embase, and Web of Science were searched for English-language human studies reporting rLT published between January 1, 2021, and October 31, 2025. Methodological quality was assessed using Joanna Briggs Institute tools (case reports/series) and the MINORS tool (observational cohorts). Pooled event rates and means with 95% confidence intervals (CI) were calculated using fixed- or random-effects models according to heterogeneity. Publication bias was assessed with Egger's test. This trial is registered with PROSPERO, number CRD420251111186.

FINDINGS: Ten studies published between 2021 and 2025, encompassing 93 rLT procedures from five countries, met inclusion criteria; three larger series were eligible for meta-analysis. Most cases were living-donor right lobe grafts performed with the Da Vinci Xi platform in highly selected, low-to-intermediate MELD (Model for End-Stage Liver Disease) recipients without severe portosystemic shunting. Pooled rates were 7.0% (95% CI 3.0-15.8) for bleeding, 3.1% (0.6-13.9) for wound infection, 9.2% (4.3-18.5) for acute kidney injury, 8.5% (3.9-17.7) for biliary complications, 3.2% (0.8-12.0) for portal vein events, and 4.3% (1.4-12.4) for hepatic artery thrombosis, with no detected statistical heterogeneity (I2 = 0% for all pooled complication endpoints). Conversion to open surgery occurred in 2.9% (0.6-13.1), major morbidity (Clavien-Dindo ≥3a) in 17.2% (9.9-28.2), and pooled 6-month survival was 98.0% (86.9-99.7).

INTERPRETATION: Robotic liver transplantation is technically feasible, associated with low perioperative morbidity, and has excellent short-term survival in carefully selected recipients treated at experienced centres. Multicentre registries, robust benchmarking against open LT, and standardised training pathways may accelerate implementation.

FUNDING: No specific funding was received for this study.