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Robotic liver donor right hepatectomy: A pure, minimally invasive approach

We read with great interest the article by Chen et al. recently published in Liver Transplantation. We compliment the authors for their valuable contribution to the development of a minimally invasive approach to living donor liver transplantation (LDLT). In fact, although safety and feasibility of robotic surgery for liver resections have been described in the literature, the role of the robotic platform in liver transplantation is still a pioneering one. In particular, we strongly support their cautiousness for the diffusion of this technique that is so well described in their manuscript. First of all, we should notice that the robotic platform is currently lacking liverspecific tools for hepatic dissection. Therefore, the complex anatomy of the liver, together with the absence of inflow control and the need for a short ischemia time, may result in a higher risk for both donor and graft safety. The wider success of robotic kidney procurement and transplantation seems in fact mainly related to the more favorable anatomy of the kidney, compared with the complex vascular reconstruction needed in liver transplantation. Clear benefits of the robotic approach for LDLT are yet to be demonstrated, and given the significant risk of morbidity and mortality associated with this procedure, only experienced surgical centers should perform it. One of the most interesting perspectives is the possibility to integrate the robotic platform with intraoperative imaging guidance and augmented reality. However, as is well depicted by Iuppa et al. in their editorial, it seems not possible to navigate the replacement of an open approach with a minimally invasive one without taking risks. It is mandatory to preserve donor safety but also to identify a favorable milieu for such a transition, with an effort from institutions and local authorities to lead this development. We need formal indications by surgical societies to prevent reckless attempts by inexperienced surgeons, rigorous guidelines to guarantee that adverse events will not stop this process, and the development of robotic-friendly liver dissection tools to preserve donor safety. In conclusion, we believe that the development of robotic surgery for complex operations has been ignited and should not be discouraged. However, while developing new technologies, we should guarantee high quality standards and an ethics-driven surgical growth.