Authors: Pereira F et al.
Cureus, 18(1): e101604, January 2026 DOI: 10.7759/cureus.101604
Summary
This case report describes the anesthetic management of the first fully robotic simultaneous living donor liver transplant (LDLT) performed in Europe. The procedure involved two parallel operations conducted in adjacent operating rooms using dual robotic platforms: a robotic right hepatectomy in a healthy living donor and a fully robotic recipient hepatectomy with graft implantation. The report focuses on the anesthetic strategies required to safely coordinate two high-acuity procedures while minimizing ischemia time and maintaining donor and recipient safety.
The donor, a healthy 38-year-old woman, underwent robotic right hepatectomy under balanced general anesthesia with invasive hemodynamic monitoring, low-pressure pneumoperitoneum, reverse Trendelenburg positioning, and a low central venous pressure strategy to minimize blood loss. Multimodal analgesia and laparoscopic-assisted TAP blocks were used. The donor procedure was completed without conversion to open surgery, minimal blood loss, no transfusion or vasopressors, and uneventful postoperative recovery with discharge on postoperative day three.
Simultaneously, the recipient—a 64-year-old woman with hepatitis C–related cirrhosis and hepatocellular carcinoma—underwent total robotic recipient hepatectomy and graft implantation using a modified piggyback technique. Anesthesia focused on advanced invasive monitoring, preload optimization prior to reperfusion, vasopressor support during unclamping, and close hemodynamic control. Despite an intraoperative hepatic artery thrombosis requiring thrombectomy and redo anastomosis, cold ischemia time was limited to 15 minutes and warm ischemia time to 56 minutes, significantly shorter than traditional or sequential approaches.
Both patients were extubated in the operating room and transferred to the ICU for observation only. The recipient recovered without organ support, transitioned to anticoagulation therapy, and was discharged on postoperative day nine. The authors emphasize that careful anesthetic planning, synchronized timing between donor and recipient teams, and institutional expertise were critical to procedural success.
What You Should Know
This report highlights a new anesthetic paradigm in transplant surgery, where two concurrent robotic operations with competing physiological goals must be managed simultaneously. Key challenges include balancing low CVP strategies in the donor with preload optimization in the recipient, managing prolonged pneumoperitoneum and positioning in both patients, and coordinating graft extraction and implantation to minimize ischemia. The dramatic reduction in cold ischemia time represents a major potential advantage of the simultaneous robotic approach. However, this technique currently requires substantial institutional resources, dual robotic systems, and highly experienced multidisciplinary teams.
Key Points
• First reported fully robotic simultaneous living donor liver transplant in Europe
• Parallel donor and recipient anesthesia teams coordinated to minimize ischemia time
• Cold ischemia time reduced to 15 minutes with excellent early outcomes
• Demonstrates feasibility but highlights need for advanced expertise and resources
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