From laparoscopy to robotics in living donor hepatectomy: a systematic review and meta-analysis of comparative outcomes.

Minimally invasive approaches have become integral to adult living donor hepatectomy, where protection of donor safety is paramount. Both laparoscopic and robotic techniques are increasingly implemented in specialized transplant centers for various graft types, including right lobe, left lobe, and left lateral sectionectomy. In this context, we conducted a systematic review and meta-analysis to synthesize the current evidence comparing robotic and laparoscopic living donor hepatectomy in adult liver transplantation. The analysis primarily focused on right lobe procurement while acknowledging that several large registry-based studies included mixed graft types. The methodology and reporting of this study followed the PRISMA 2020 statement, and the protocol was prospectively registered in the PROSPERO database. Electronic databases were systematically searched through December 2025 to identify comparative studies evaluating robotic and laparoscopic hepatectomy in adult living donors. Operative, donor, and recipient outcomes were synthesized using random-effects meta-analytic models. Methodological quality was appraised with the ROBINS-I tool, and the overall strength of evidence was graded using the GRADE framework. Seven comparative studies published between 2022 and 2025, comprising more than 15,000 adult living donors, met inclusion criteria. Baseline demographic and clinical characteristics were broadly similar across surgical approaches. Robotic donor hepatectomy was associated with a lower likelihood of perioperative transfusion (RR 0.27, 95% CI 0.09–0.76; p = 0.013) and a reduced incidence of overall donor morbidity (RR 0.47, 95% CI 0.25–0.89; p = 0.020) compared with laparoscopy. No significant differences were observed in major donor complications or mortality. Although operative duration was longer with the robotic technique, intraoperative blood loss was lower. Among recipients, robotic graft procurement was associated with reduced overall morbidity and fewer biliary complications, whereas vascular events and mortality were comparable between approaches. Robotic living donor hepatectomy appears to enhance donor safety, with lower transfusion rates and reduced overall morbidity, while maintaining comparable rates of major complications and mortality. These results suggest a potential advantage for the robotic approach in appropriately experienced centers. Nevertheless, confirmation through large, rigorously designed randomized trials is required to establish definitive comparative effectiveness and to clarify the optimal minimally invasive strategy.Registration: PROSPERO CRD420261299554.