To Err Is Robot - an analysis of complications following robotic donor hepatectomy.

Background: Robotic donor hepatectomy (RDH) has been reported with lower morbidity than its open counterpart. Donor safety remains the primary concern precluding its wide adaption. We aimed to evaluate donor complications following RDH and identify their predictive factors.

Study Design: Out of 348 live donor liver transplants performed between 2018-2021, the prospective data of 202 RDH were analyzed for complications by modified Clavien-Dindo grading system. Multivariate analysis of donor and operative parameters was done to identify factors predicting complications and CUSUM analysis was done to evaluate the effect of learning curve.

Results: Out of 202 RDH [mean age: 37.5(±10.4); f:m-133:69; mean BMI: 25.2±3.84], 196 (97%) were modified right lobe grafts. Conversion to open occurred in 7(3.4%) [5-bleeding, 1-hepatic duct injury & 1-portal vein kink]. Post-operative complications occurred in 33(16.3%), the most common being bile leak (5.9%) and bleeding(3.9%). Grade IIIa, IIIb & Iva complications were seen in 3.4%, 3.4% and 0.9% of patients respectively. Re-operation was required in 3 cases for portal vein thrombosis, narrowing of inferior vena cava and biliary peritonitis respectively. At a follow up of 4 year period, these patients are doing well. Although in univariate analysis, higher blood loss and basal metabolic index appeared to be significant, a multivariate analysis did not reveal any donor factor that could predict complications (biliary anatomy, portal anatomy, blood loss, BMI, duration of surgery or FLR volume). The number of overall complications (21.7% vs. 9.9%; p= 0.020; OR 2.53) came down significantly in the second half. On RA-CUSUM analysis we identified that it took around 130 cases for our unit to collectively overcome the learning curve.

Conclusion: Although RDH appears to be safe, critical complications can occur in a minority of cases. Safety lies in flattening the learning curve.