Jessica Lindemann

This study describes our institutional experience with robotic hepatectomy, analyzes trends, and evaluates intraoperative and postoperative outcomes stratified by IWATE-defined procedural difficulty. Retrospective cohort study of the first 100 consecutive robotic hepatectomies performed by the abdominal transplant division at a high-volume center (2017–2025). Outcomes were compared across IWATE groups and between early (2017–2021) and late (2022–2025) cohorts. Logistic regression was used to examine the association between IWATE score and conversion to open surgery, 30-day complications, and major complications (Clavien–Dindo ≥ IIIa). Median age was 61 years (IQR 47–70), 52% were female, and 77% had malignant disease. 28% of resections were major. IWATE categories were low in 29%, intermediate 46%, advanced 7%, and expert 18%. Median operative time was 217 min (IQR 160–294), estimated blood loss was 150 mL (IQR 50–300), and length of stay was 3 days (IQR 2–4). Conversion to open surgery occurred in 22% with no emergent cases; 30-day complications occurred in 21%, major complications in 10%, readmission in 5% and 90-day mortality in 1%. Over time, expert cases and major hepatectomies increased without statistically significant differences in conversion or complication rates. Across IWATE groups, operative time, Pringle use, blood loss, transfusion, conversion, and length of stay increased with complexity ( p < 0.001). Each 1-point increase in IWATE score independently increased the odds of conversion (adjusted OR 1.45, 95% CI 1.12–1.88) but not overall or major complications. Robotic hepatectomy was feasible across IWATE-defined difficulty levels while maintaining good perioperative outcomes. Increasing IWATE difficulty was associated with greater intraoperative complexity and a significantly higher likelihood of conversion to open surgery, although it was not independently associated with increased postoperative morbidity.

Primary liver cancer was the third most common cause of death due to cancer worldwide in 2020. As the predominant type, hepatocellular carcinoma (HCC) represents the overwhelming majority of newly diagnosed primary liver tumours. Liver transplantation remains the treatment of choice for a cure in otherwise unresectable HCC. For nearly thirty years, the Milan and Barcelona Clinic Liver Cancer (BCLC) criteria have guided physicians' clinical decision-making for selection of liver transplant candidates in the treatment of HCC. More recently, studies have demonstrated survival benefit for patients transplanted beyond Milan criteria. This remains an area of active research and includes advancements in local-regional therapies and their role in downstaging tumours to within transplant criteria as a bridge to transplant. Other advancements on the horizon include the identification of tumour biomarkers that may lead to earlier diagnosis and more accurate prediction of prognosis and risk of recurrence, as well as new neoadjuvant therapies and post-transplant immunosuppression regimens that may allow for further expansion of transplant eligibility criteria. Additionally, several recent studies have investigated the potential survival benefit of combination therapy using local-regional intervention with systemic immunotherapy to downstage otherwise unresectable disease that is beyond Milan criteria. Liver transplantation will continue to play an important role in the treatment of HCC for the foreseeable future and based on currently available evidence, both local-regional therapies and immunomodulation in combination are poised to change the landscape of liver transplantation for HCC as we currently know it.

Background: Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs.Methods: Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30‐day follow‐up between LSC and LC were compared using univariate and multivariate analyses.Results: Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p < 0.01) and patients requiring LSC were significantly older (p < 0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p < 0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p < 0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p < 0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p < 0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien–Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n = 8, 15%) (p < 0.001). There were two readmissions within 30 days, one mortality, and no BDIs occurred in the LSC cohort.Conclusion: LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

Purpose Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world. Methods A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns. Results Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems. Conclusion Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns.