Pediatric liver surgery is among the most complex and delicate procedures in modern medicine. And a new chapter is unfolding, one that combines thoughtful and dynamic surgical expertise with groundbreaking applications of robotic technology. As the first and likely only program in the United States performing robotic liver surgery in children, Columbia’s Robotic Liver Surgery Program is redefining the pediatric surgical landscape.
In this conversation, Chief of Hepatobiliary Surgery and Director of Robotic Liver Surgery Program Jason Hawksworth, MD, and pediatric transplant hepatologist Mercedes Martinez, MD, discuss the specific benefits of the robotic approach, explain the ins and outs of the surgical process, and the critical importance of expertise.
What does robotic hepatobiliary surgery involve, and how is it different from traditional approaches?
Dr. Hawksworth: Robotic surgery is still laparoscopy [a minimally invasive surgical approach wherein surgeons operate by passing a camera and tools through several small incisions rather than operating openly through one large incision]—it just represents a more advanced version. The camera provides 10x magnification and 3D depth perception, unlike standard laparoscopy, which is two-dimensional. That depth perception is critical for delicate dissection and suturing. We still use small laparoscopic incisions, but the robotic arms and enhanced camera allow us to perform complex operations with a minimally invasive approach that’s as safe and precise as open surgery.
When did you start using robotic techniques for pediatric patients at Columbia?
Dr. Hawksworth: We started in the summer of 2023, shortly after I arrived at Columbia. Before that, most pediatric liver surgeries were either open or done laparoscopically in limited cases. Working closely with Dr. Martinez and the team, we carefully started performing minor liver surgeries robotically.
Dr. Martinez: There’s no such thing as a “minor” liver surgery!
Dr. Hawksworth: You’re right, less complex!
Dr. Martinez: We started doing some small tumors that were localized in areas on both sides of the liver. We also did a lot of bile duct surgery. And now we are moving to major liver resections for larger tumors, even malignant tumors. Also, patient selection expanded. The team has been feeling more comfortable increasing the complexity of the surgery as well as decreasing the age of the patient. We began with children over 15 kilos and then 10 kilos and now babies less than five kilos.
Wow, an infant?
Dr. Martinez: Yes, our youngest patient so far was a two-month-old.
How do you decide which patients are eligible for robotic surgery?
Dr. Hawksworth: It depends on the indication for surgery. Whether it's benign or malignant is a decision branch point for whether we're going to do a minimally invasive approach or not. Common cancers in the pediatric population are hepatoblastoma; sarcomas are rarer. Hepatoblastoma is a very common indication for resection, or transplant in some cases. Because we're a referral center for New York City, we see a lot of these rare conditions.
The only cases that we wouldn't offer a minimally invasive robotic approach would be if a malignant tumor involves vasculature. If there's a blood vessel that needs to be reconstructed, that’s very difficult to do minimally invasively, whether it's robotic or not. If it's a very large tumor, you have to make a very large incision to take it out anyway. Those are a minority of cases; for the vast majority we can offer the robotic approach.
What challenges did you face adapting this technique to such small patients?
Dr. Hawksworth: The first was building the team. Robotic surgery is truly a team effort, and we had to train the team from scratch, really. While Dr. Martinez has always been a strong pro-innovation ally, we needed to train staff across OR roles—from circulating nurses to scrub techs. We do most of our robotic surgery in the adult hospital, so we brought pediatric staff from CHONY [Morgan Stanley Children's Hospital at NewYork-Presbyterian/Columbia] over to observe and learn, held weekend trainings, and did a lot of cross-institutional teaching.
Technically, there were also challenges. These abdomens are small, right? You have to find a way to maximize the capabilities of the robot. Getting the spacing right in a small abdomen was pretty tricky and took some time to figure out. And then how to extract the tumor was a challenge. So we adapted by using a small, low bikini-line incision, which is hidden below the waistline and far more cosmetic than the large upper abdominal scar from traditional surgery. That can make a huge difference in a child’s life.
Does the surgical workflow change when operating on children?
Dr. Hawksworth: Surprisingly, not much. The robotic platform allows us to approach the procedure the same way we would in adults. It’s the same principles, just scaled down.
How do families react when you introduce this as an option?
Dr. Hawksworth: They’re often relieved. When parents hear “robotic” and “minimally invasive,” and learn their child won’t have a large, visible scar for life, they’re thrilled. And when we explain that this is not experimental—Columbia is probably the only hospital in the country offering this, and we have the largest experience—they feel confident that they’re in the right place.
How do you work together to support families through this process?
Dr. Martinez: Families often come to me first, they’re referred to us. We explain the diagnosis and introduce the idea that surgery will be needed, which is always overwhelming. Kids, if they are a little older, start asking about the scar and “How do I look.” That is a very important part of the relationship we build. So we begin laying the foundation: this will be minimally invasive, the scar will be small, the recovery will be shorter. That preparation matters and our outcomes are excellent—even better than when we did open surgery in some cases. That helps families feel informed and empowered to move forward.
What are the benefits you’re seeing for patients—especially in terms of recovery?
Dr. Hawksworth: At a recent international meeting in Korea, we presented our data comparing robotic and open pediatric liver surgeries. We found no difference in complications or cancer outcomes. But we did see shorter hospital stays, significantly lower narcotic use, and less postoperative pain in the robotic group. These are major advantages—faster return to normal life, fewer medications, better cosmetic results. My colleague Dr. Nathaly Llore presented the work. She titled it “Bots for Tots,” which we all really love.
When it comes to training, how long does it take a surgeon to become comfortable with robotic pediatric liver cases?
Dr. Hawksworth: First, you need deep experience, mastery, in doing these cases open, the traditional way. Then, you need to transition to being able to do the case the same way minimally-invasively. And then there’s learning the robot technology. And finally, you need to understand transplant principles. It’s really a rare and unique blend of skills—pediatric surgery, transplant surgery, and robotic surgery—and that’s why very few centers can do this. Columbia is one of the only programs that brings all three together, there are not a lot of places that can combine those skill sets.
Dr. Hawksworth: First, you need deep experience, mastery, in doing these cases open, the traditional way. Then, you need to transition to being able to do the case the same way minimally-invasively. And then there’s learning the robot technology. And finally, you need to understand transplant principles. It’s really a rare and unique blend of skills—pediatric surgery, transplant surgery, and robotic surgery—and that’s why very few centers can do this. Columbia is one of the only programs that brings all three together, there are not a lot of places that can combine those skill sets.
Do you think this will become more common nationally?
Dr. Hawksworth: Eventually—but I think there’s a significant lag. It may take another decade. Very few teams have this combination of skills and resources. On the adult side, we’re starting to explore robotic liver transplants, and already do all living liver donor surgery robotically. I imagine pediatric transplant could follow, starting with older kids. But like everything we do, we’ll move slowly and safely, methodically.
Do the robotic tools differ for children?
Dr. Hawksworth: No, the instruments are the same size as standard laparoscopic tools. I’ve asked Intuitive to build a pediatric robot, but they weren’t exactly jumping on the idea. Maybe in a decade.
What should families know when facing a complex pediatric liver surgery?
Dr. Martinez: These are times of highest stress for any family. You're delivering a diagnosis that maybe isn’t life threatening, but it's life changing. They will need a major surgery, and people can die from those. We’ve become so efficient and our surgeons are so excellent that we don't always think about those complications.
Families should know this is not something to have done just anywhere; it requires the right center. These procedures need a full ecosystem—surgeons, anesthesiologists, hepatologists, ICU teams, pathology, post-op care. That’s what makes it successful. We’ve seen families come to us in terrible shape after attempted surgeries elsewhere, some needing transplants due to complications. It’s not about blaming those surgeons. It’s about understanding that experience matters. They may be outstanding surgeons but if they’re performing this surgery one or twice in a lifetime, they shouldn’t be the surgeon for your child.
Not any surgeon can just go read up on the technique, and I mean the open technique, robotic is not even an option. So that’s the most important: look for the expertise. And then the robotic approach makes it extraordinarily successful, children can be home in four or five days.
What specific questions should families ask their care team if their child needs liver surgery?
Dr. Martinez: When parents get a diagnosis these days, everybody goes to the internet, which may not the best thing but it’s part of life at this point. Sometimes I tell families not to look at the internet, and I tell them, don’t be afraid to ask:
- How many times have you done this surgery?
- How many patients with this diagnosis do you see each year?
- Who are your partners? Do you have a full team—hepatologists, oncologists, ICU, anesthesia—to support my child?
These are rare conditions. We are in New York City and have a very large pediatric hepatology practice in the tristate area; we get referrals from all over. And still, we do 30 or 40 of these surgeries a year. Now you can imagine what other centers are doing.
Dr. Hawksworth: And the other part is oncologic support. I can’t overstate how important the oncologic expertise is. You’re managing complex liver cancer in children, where these cases are extraordinarily rare unless you’re a large referral center.
Dr Martinez: Absolutely. If it’s a malignant tumor, they should ask:
- Do you work with an oncologist who has expertise in this exact cancer?
Important advice. Do you have any closing thoughts?
Dr. Martinez: Building a great team isn’t just about the team, but it's also about having leadership and talent. And I really can't underscore enough Dr. Hawksworth's talent for the robotic technique, and also his leadership. He’s come here, put it all together with the right people around him, including those he's training. Many people don't think about training somebody until they have the whole team functioning, but he started from the very beginning. Without him, we couldn’t do this.
Related:
- Changing the Future of Living Liver Donation: A Conversation about Columbia’s All-Robotic Approach
- On Changing the Standard of Care for Children: What the Evolution of ECMO Can Teach Us
- Caracas to Santo Domingo: Creating Access to Pediatric Liver Transplant from the Ground, Up