Changing the Future of Living Liver Donation: A Conversation about Columbia’s All-Robotic Approach

Columbia has long been a leader in the field of liver transplantation, pioneering advancements that improve outcomes for both donors and recipients. With the full transition to robotic surgery for all living donor liver operations, the program continues to push the boundaries of what’s possible in transplant medicine.

In this conversation, transplant surgeon Jason Hawksworth, MD, Chief of Hepatobiliary Surgery and Director of Robotic Liver Surgery Program, and transplant hepatologist Alyson Fox, MD, Medical Director of the Adult Liver Transplant Program, discuss how this shift is making transplantation safer, expanding access, and changing the way patients think about live liver donation.

Columbia has transitioned to performing all living donor liver surgeries robotically. Can you walk us through how that shift happened and what it means for patients?

Dr. Hawksworth: The Columbia program has historically performed laparoscopic hybrid procedures, where part of the case was done laparoscopically—namely the liver mobilization—and then a smaller incision was made in the upper abdomen to complete the case open. The idea was to reduce the size of the incision compared to a fully open liver case.

We combined that experience with my robotic expertise in liver surgery and began performing all living donor hepatectomies fully minimally invasively with robotic technology about a year and a half ago. We found that we could do every case 100 percent minimally invasively with the robot and have never gone back to laparoscopic hybrid or open hepatectomy. All living donor cases are now done robotically.

Wow. What are the key advantages of robotic technology for living liver donation?

Dr. Hawksworth: The advantage is that on the mid-upper abdomen, there are only laparoscopic incisions, each less than a centimeter. The liver is extracted through a bikini incision (a Pfannenstiel or C-section incision), which heals well and causes minimal pain.

It has almost become outpatient surgery. We still keep patients in the hospital for three to four days to monitor liver function before discharge. Most donors have minimal pain, require little to no narcotics postoperatively, and manage with Tylenol or Celebrex. They’re back to work quickly and regain full function in two to three weeks. It’s really been a game-changer—shorter hospital stays, near-zero narcotic use, and rapid recovery. It’s important to know: If they’re a candidate for living donor hepatectomy, we can do it robotically.

Dr. Fox: From the recipient side, this makes an enormous difference. Many recipients are hesitant about live donation, but when they hear the donor’s recovery is easier, it reassures them. It’s often the first thing they ask about.

That’s great. How have donors responded to robotic living liver donation as the mode of surgery?

Dr. Hawksworth: Donors have been really happy. They like the idea of new technology advancing their care. It’s become very popular, particularly in the local area—most donors come to us through word of mouth. Since we’re one of the few centers in the country offering robotic living donor hepatectomy, many donors, especially altruistic ones, seek us out.

Right now, we’re the highest-volume robotic living donor liver program in the country. And there are only six programs in the U.S. performing this procedure robotically.

Dr. Fox: I hear it from recipients too. When I explain that their donor will have a minimally invasive surgery and be back on their feet quickly, I see their relief. It changes the conversation.

Generally speaking, how does this approach impact transplant recipient’s experience and decision-making?

Dr. Fox: Every single recipient, when I first mention live donation, says, ‘There’s no way I’m letting my family member do that.’ They don’t want to put their loved one in harm’s way. Offering live donation in a minimally invasive fashion allows me to overcome that hurdle. I reassure them:

Their donor will be back on their feet quickly.
Dr. Hawksworth has done more of these than anyone in the country.
Our center is highly experienced.
The risk and morbidity to their donor is minimized.

I tell them, ‘You could be living anywhere, but you’re here. You have access to something most centers in the country—and even the world—don’t offer.’

Dr. Hawksworth: And that’s exactly why we’ve pushed to make this as safe as possible. The idea that donation is ‘too dangerous’ isn’t as true anymore, but people don’t know that yet. The more we do these, the more confidence people have in the process.

Columbia has a long history in liver transplantation. Can you share some key milestones that have shaped it?

Dr. Fox: Jean Emond started the program in the late ’90s and has been a pioneer in liver transplantation—especially living donor liver transplant. He participated in the first U.S. case while in Chicago.

Living donor liver transplant has always been a pillar of our program. There were times of explosive growth, but also setbacks—like in 2001, when a donor death shook the transplant community. Throughout, Columbia remained committed to comprehensive, safe care for both donors and recipients.

As organ allocation policies change and machine perfusion technology advances, some argue we should rely less on living donors. But I disagree—organ quality is declining, and we haven’t solved all the challenges. The liver’s ability to regenerate is remarkable. If we can safely use that to save lives, we should.

Dr. Hawksworth: That legacy is why we’re able to innovate now. You can’t just decide one day to start doing robotic living donor transplants—it takes years of experience and refining techniques. Columbia was built for this.

What are the biggest challenges currently facing liver transplantation, and how are you addressing them?

Dr. Hawksworth: Last year, the number of cadaveric liver transplants nationwide dropped. One reason is the opioid epidemic is subsiding, leading to fewer organ donors. While that’s good for society, the unintended consequence is fewer available livers.

As this trend continues, finding alternative organ sources becomes even more critical. Living liver donation is a major solution. Columbia is in a strong position because we’ve built a system that ensures donor safety—everything from advanced imaging to post-op care. Many centers don’t have the experience or infrastructure for high-volume living donation, but we do.

Dr. Fox: Right, exactly. That’s why we don’t just rely on the deceased donor system. Other centers might struggle with this change, but we’ve spent decades developing a strong living donor program—it puts us ahead of the curve.

What are some common misconceptions about living liver donation?

Dr. Fox: The biggest problem is that many people don’t even know it’s possible. Everyone knows you can donate a kidney, but most people have never heard of living liver donation.

Unfortunately, patients at centers that don’t offer live donation may never be informed about it. It’s an issue of access and equity. Another misconception is fear—patients instinctively reject the idea of a loved one undergoing surgery.

Education is key. That’s why we connect prospective donors with former donors and recipients, letting them hear firsthand experiences.

Dr. Hawksworth: And even when they do hear about it, they often assume the donor will have a long, painful recovery. That used to be true. But it’s not the case anymore, and we need to get that message out.

What does the support and follow-up for donors look like after surgery?

Dr. Fox: We treat donors like the VIPs they are—they’re saving someone’s life out of pure generosity.

We see them within a week after discharge, then at six weeks, four months, and one year. At four months and a year, we do MRIs to confirm liver regeneration, which usually reaches 80-90% by four months.

Many donors keep in touch for years—sending us updates, wedding invitations, even Christmas cards. They become part of a community, and we strive to make sure they feel that way.

What future advancements could further improve liver transplantation?

Dr. Hawksworth: As surgical and imaging technology advances, living donor surgery will become even safer.

We’re adopting Intuitive’s latest surgical robot—the DV5—which integrates AI and offers tactile feedback, a major leap forward. Older robots rely on visual cues alone, but this system allows us to feel what we’re doing. We’ll begin using it for living donor cases this year.

Another area of progress is desensitization therapy, which allows incompatible donor-recipient pairs to proceed with transplantation. Using plasmapheresis and medications to remove harmful antibodies, we can make transplants possible for patients who otherwise wouldn’t have a match.

For those considering donating or receiving a living liver transplant, what’s the most important thing to know?

Dr. Fox: The only way to have any control over end-stage liver disease is to have a living donor.

Dr. Hawksworth: And because we’ve made it safer, more people are willing to consider it. We’re seeing more donors step forward, and that’s exactly what needs to happen to expand access.

Dr. Fox: Instead of waiting, uncertain, you can say, ‘I’m having my surgery next Tuesday at 7 a.m.,’ and take ownership of your health. That’s life-changing.