First US Robotic Liver Transplant Performed

The first robotic liver transplant in the United States was conducted recently by a surgical team from Washington University School of Medicine in St. Louis. The successful transplant, performed in May at Barnes-Jewish Hospital, extends the benefits of minimally invasive robotic surgery to liver transplants: a smaller incision resulting in less pain and faster recoveries, as well as the precision required to perform one of the most difficult abdominal procedures.

The patient, a man in his 60s who had a transplant due to liver cancer and cirrhosis caused by the hepatitis C virus, is doing well and has returned to his normal daily activities. Typically, it takes at least six weeks for liver transplant recipients to be able to walk without pain. One month following surgery, the patient was not only able to walk easily but was also cleared to resume golfing and swimming.

“The transplant was a success: The operation went smoothly, the new liver started working right away, and the patient recovered without any surgical complications,” said transplant surgeon Adeel Khan, MD, the leader of the team that conducted the trailblazing surgery. Khan is an associate professor of surgery at the School of Medicine. “Liver transplantation is one of the most complex abdominal operations and heavily relies on a specialized team for good outcomes. Here at Washington University and Barnes-Jewish Hospital, we are very fortunate to have the support needed to develop a world-class robotic-transplant team that allows us to safely perform complex operations. This team is a big part of our success.”

Traditionally, a liver transplant is conducted as a “open” procedure, with a surgeon making a 3- to 4-inch vertical and 12- to 16-inch horizontal incision just below the rib cage to remove a patient’s diseased liver and replace it with a healthy donated liver. Transplant doctors have been pushing to make the surgery less intrusive, with smaller incisions that often result in less discomfort and speedier recoveries. However, most transplant surgeries have been deemed to be too complex for a minimally invasive method, whether conducted laparoscopically or robotically, with liver transplants being particularly difficult. Excessive bleeding occurs during surgery to remove diseased livers, and connecting the new liver to the patient’s circulatory system necessitates gently sewing numerous tiny blood arteries together.

Minimally invasive surgery includes robotic surgery. Surgeons keep total control of the robot’s equipment and execute procedures remotely — normally just a few feet away from the patient — using joystick-like controls. High-resolution cameras provide a magnified, three-dimensional view of the surgical site that may be viewed on a wide monitor. The advanced instrumentation enables highly accurate, fine operations that would be impossible with older approaches.

The doctors used many half-inch keyhole incisions and a single 6-inch vertical incision between the abdominal muscles to remove the old organ and place the replacement liver, which is about the size of a football, inside the abdomen for this robotic liver transplant. This incision is far smaller than the typical one and does not need cutting through abdominal muscles, allowing for a speedier recovery.

While the patient’s physical recovery has been on time, he did require additional hospitalization due to cognitive problems that are common in elderly people following major surgery.

The robotic liver transplant took slightly over eight hours, which is on the long side but within the range of traditional open liver operations, which typically take six to eight hours. Future robotic liver transplants would most certainly be conducted faster as the OR crew gains experience and becomes more accustomed to the nuances of the new surgical procedure, according to Khan.

In 2021, a South Korean team reported the world’s first robotic liver transplant. That procedure involved half a liver transplanted from a living donor rather than the entire organ, and it was partially robotic; the damaged liver was removed laparoscopically and the fresh liver inserted robotically. Khan claims that his team is the first to accomplish a robotic liver transplant involving the transplantation of a whole liver.

“Liver transplantation is the most difficult of the abdominal organs to consider for a minimally invasive approach — given the difficulty of removing a failing liver and successfully implanting the new organ — but Dr. Khan has shown that this is possible,” said William Chapman, MD, the Eugene M. Bricker Professor of Surgery, director of Washington University’s Division of General Surgery and chief of the transplant surgery section. “Further experience with this technique will be needed to establish the extent of the benefits of performing liver transplant as a minimally invasive approach.”

Washington University and Barnes-Jewish Hospital have invested extensively in robotic surgery as part of a concerted effort to advance minimally invasive surgeries and improve patient outcomes. The robotic transplant team was founded five years ago, with an initial focus on kidney transplants. To date, the team has done more than 30 robotic kidney transplants, all with positive outcomes. The team also performs living-donor kidney removal surgery, as well as other robotic surgeries involving the liver, bile ducts, pancreas, and stomach.

“Over the span of several years, we have built a dedicated robotic transplant team that is second to none and has been instrumental to our success,” Khan said. “Once we had this team in place, it allowed us to grow in both number and complexity of the cases while maintaining very good patient outcomes. We have five surgeons on the transplant service doing robotic surgery, and this number will increase to seven by the end of the summer. Since starting our program, we have mentored over 30 transplant centers around the country in building successful robotic programs of their own. Transplant teams from other centers come to observe our process, and we also visit their sites and mentor them as they develop their skills. We are probably one of the very few places in the country that has the support, expertise and team to take robotic transplant surgery to this level.”

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