Minimally invasive liver transplantation: technical evolution, evidence maturity, and translational boundaries

Liver transplantation is an established treatment for end-stage liver disease and selected hepatic malignancies, but conventional open transplantation remains associated with substantial operative trauma and incision-related morbidity. With the expansion of laparoscopic, robotic, and digital platforms, minimally invasive concepts have progressively entered donor hepatectomy, recipient hepatectomy, and graft implantation. This narrative review searched PubMed/MEDLINE, Embase, and the Web of Science Core Collection from January 2020 to 1 June 2026 and prioritized guidelines, consensus statements, systematic reviews, meta-analyses, multicenter studies, prospective registries, and representative case series. The available evidence indicates asymmetric maturity across the minimally invasive liver transplantation spectrum. These maturity judgments represent an interpretive synthesis of predominantly nonrandomized and center-specific evidence. Laparoscopic donor hepatectomy has the most mature evidence, while robotic-assisted donor hepatectomy has a growing evidence base; both may reduce donor trauma and facilitate recovery in selected donors at experienced centers. In contrast, recipient-side minimally invasive procedures remain at the feasibility stage, whereas evidence for fully robotic liver transplantation remains preliminary because of limited exposure, bleeding-control demands, vascular and biliary reconstruction, ischemia-time constraints, anesthetic complexity, cost, and learning-curve requirements. Digital adjuncts, including fluorescence imaging, three-dimensional reconstruction, simulation, and artificial intelligence, may support planning, navigation, reconstruction, and training, but their value should be judged by clinical outcome validation rather than feasibility alone. Clinical translation should therefore remain stepwise: donor-side integration may be considered in trained teams, whereas recipient-side and fully robotic approaches should remain within prospective registries, ethical oversight, standardized reporting, and safe conversion pathways.