Physiological and Anesthetic Considerations in Robotic Liver Transplantation: Implications and Comparison With...

Robotic liver transplantation (RLT) presents unique physiological challenges, including pneumoperitoneum, patient positioning, and restricted intraoperative access, which are not encountered in conventional open liver transplantation (LT). Complications specific to RLT-such as carbon dioxide embolism, prolonged anhepatic and warm ischemia times, intra-abdominal variceal bleeding, and limited patient access during emergencies-necessitate specialized anesthetic protocols that surpass those used in conventional LT. A narrative review was conducted using the PubMed/MEDLINE, Embase, and Google Scholar databases from inception through March 2026, following the Scale for the Assessment of Narrative Review Articles checklist. The literature search, performed by one author (C.P.) under the supervision of the senior author (J.C.), yielded 69 relevant references across all study designs. Institutional experience with robotic liver resection, robotic living-donor LT, and robotic recipient LT is included for the development of the described protocols. This review explores 3 previously unaddressed areas: (1) a comprehensive analysis of RLT-specific complications with mechanistic rationales and management strategies; (2) a 5-phase, goal-directed hemodynamic protocol integrating pulmonary artery catheter thermodilution calibration with continuous arterial waveform monitoring; and (3) a stepwise training pathway for institutions establishing RLT programs. Further, institutional patient selection criteria are detailed, including exclusion of patients with a Model for End-Stage Liver Disease score >30, significant cardiovascular or respiratory disease, pulmonary hypertension, or portal vein thrombosis. RLT introduces anesthetic challenges fundamentally distinct from those encountered in conventional LT. As RLT is adopted for higher-acuity recipients, prospective validation of hemodynamic protocols and development of standardized training curricula will be essential.