From Resection to Transplantation: Rethinking Training and Certification for the Modern HPB Surgeon

Hepatopancreatobiliary (HPB) surgery has evolved beyond the confines of traditional liver and pancreatic resection. Contemporary practice increasingly encompasses advanced vascular reconstruction, extended hepatectomy in compromised livers, transplantation for malignancy, and complex operations following multimodality therapy. These developments have fundamentally altered the technical and cognitive demands placed upon HPB surgeons, raising an important question: which training pathway best prepares surgeons for the future of the specialty? Dedicated HPB, surgical oncology, and integrated transplant-HPB fellowships each provide valuable but distinct expertise. Surgical oncology emphasizes tumor biology, multidisciplinary cancer care, and clinical investigation. Dedicated HPB fellowships focus on advanced liver and pancreatic resection. In contrast, integrated transplant-HPB training uniquely combines these competencies with mastery of hepatic physiology, complex vascular reconstruction, management of portal hypertension and liver failure, transplantation, and operative rescue under extreme physiologic conditions. We contend that integrated transplant-HPB training now represents the most comprehensive preparation for modern HPB surgery. This argument is not intended to promote territorial ownership of the specialty but rather to advocate for competency-based training that reflects the realities of current practice. As transplant oncology, living donor liver transplantation, machine perfusion, and increasingly aggressive surgical strategies continue to redefine operability, developments now supported by randomized and large-registry data rather than qualitative impression alone, certification pathways should evolve accordingly. Rather than existing outside mainstream HPB training, integrated transplant-HPB fellowships should be fully embraced within HPB certification frameworks, ensuring that future surgeons are equipped to offer the complete spectrum of operative strategies available to patients with complex HPB disease.