The consensus documents in question represent a genuine milestone. They establish standardized protocols for cDCDD across Europe, including detailed recommendations for abdominal NRP (a-NRP) and, more recently, thoraco-abdominal NRP (TA-NRP), in which donor blood is circulated via extracorporeal membrane oxygenation (ECMO) to reanimate abdominal organs and even the heart itself. In both scenarios, abdominal and cardiac graft management follows rigorous, written procedures. The lungs, however, are treated almost as an afterthought. Current clinical practice typically alternates between regional perfusion and immediate static cold storage, delaying lung reinflation until sternotomy and pulmonary artery cannulation in the operating room, long after the critical post-mortem window has closed.

The physiological argument at the heart of the Forum is elegant and, the authors insist, conceptually decisive. Unlike other solid organs, lung parenchyma does not depend on continuous blood perfusion to sustain aerobic cellular metabolism. Instead, the alveolus functions as its own oxygen delivery system: direct alveolar oxygen diffusion into the interstitial space and vascular endothelium is sufficient to prevent ATP depletion and ischemic cell collapse. This mechanism, sometimes described as the so-called pulmonary privilege, means the only truly effective way to preserve cellular metabolism during the immediate post-mortem period is alveolar oxygenation, achieved either through protective mechanical ventilation or continuous positive airway pressure (CPAP) with a high fraction of inspired oxygen. Framing lung preservation strategy exclusively around the a-NRP versus TA-NRP debate is, from a pulmonary perspective, conceptually flawed, because the lung’s preservation needs are met through the airway, not the vasculature.

Timing, however, is everything, and this is where the bioethical safeguards become inseparable from the physiology. The mandatory post-mortem observation or no-touch period, during which no intervention is permitted after cardiac arrest, varies internationally from 3 to 20 minutes, with a global average of 5 minutes. From both ethical and physiological standpoints, a minimum of 5 minutes must be respected to avoid auto-resuscitation of the heart. Initiating mechanical ventilation prematurely within this window is strictly forbidden, because hypoxic cardiac arrest might otherwise be reversed in the donor, or residual cerebral oxygenation could be compromised, violating the dead donor rule that underpins the entire ethical framework of donation after circulatory death.

Once the mandatory standoff period has been fully respected and death has been legally declared, the authors argue that initiating mechanical ventilation or CPAP represents minute zero of lung preservation. This early alveolar recruitment must not be deferred until chest opening in the operating room. Pathophysiological principles strongly support the strategy, international donor procurement guidelines advise it, and current ethical and legal regulations fully permit it as a post-mortem preservation maneuver. In other words, the simplest, cheapest, and most physiologically rational intervention available, reconnecting the ventilator or applying CPAP with a high fraction of inspired oxygen the moment death is declared, is already ethically sanctioned and guideline-endorsed, yet remains unrecognized as a standardized frontline maneuver in cDCDD protocols.

The authors insist that the lung cannot remain an overlooked organ in global DCD standards. In cDCDD cases managed with abdominal NRP, the overall preservation environment should be recognized as a dual-temperature preservation: abdominal normothermia combined with thoracic hypothermic or ischemic oxygenated preservation. Rather than relying solely on hypothermia to slow metabolic rates, early alveolar oxygen supply delivers what the authors call true oxygenated ischemia, which preserves pneumocyte viability and allograft quality over extended periods. This approach has been successfully demonstrated in uncontrolled donation after circulatory death, where long ischemic times have been managed with simple normothermic ventilation and ex vivo lung perfusion assessment, offering a template for what controlled donation protocols could achieve.

Technical standardization in cDCDD managed with TA-NRP, however, must extend beyond ventilatory parameters to address pulmonary hydrostatic safety, and here the picture becomes considerably more complex. Reanimating the donor heart inherently exposes the pulmonary vasculature to active perfusion. The ESOT Bucharest Consensus explicitly acknowledges the threat of lung congestion and cardiac distension during TA-NRP, and its guidelines rely on indirect right-sided decompression by optimizing venous return to the ECMO circuit via a centrally inserted dual-stage venous cannula. This approach, however, fails to prevent post-capillary congestion caused by left ventricular stunning or transient contractility failure. When antegrade perfusion is restored, blood pools retrogradely into the left heart while the ventricular apparatus is still arrested or stunned, causing devastating post-capillary damage if an active outflow tract is not provided.

To address this, Van Raemdonck and colleagues argue that direct and immediate venting of the left atrium, by inserting a venting catheter via the interatrial groove at the initiation of TA-NRP, is required to prevent hydrostatic pulmonary edema. This direct approach, however, introduces significant surgical complexity and suffers from a profound lack of standardization. The 2024 American Association for Thoracic Surgery (AATS) Expert Consensus confirms that clinical utilization of lungs after TA-NRP remains highly controversial and data are limited, pointing directly to inconsistent venting practices as the primary cause of hydrostatic edema and variable graft outcomes. To date, there is no high-quality clinical evidence confirming that this in situ surgical maneuver increases the rate of valid donors. On the contrary, its technical difficulty in an unstable donor, combined with the absence of a uniform protocol, frequently deters transplant teams from accepting these grafts altogether out of fear of acute hydrostatic edema.

How to reliably protect the pulmonary vascular bed during TA-NRP therefore remains a poorly standardized frontier, as current guidelines fail to offer a clear, consensus-driven protective roadmap. Within this gap, inconsistent venting practices represent a critical technical failure and a lapse in procedural leadership that acts as a powerful deterrent for transplant teams, unnecessarily limiting lung graft utilization. The authors also raise the strategic allocation of high-cost healthcare resources: while ex vivo lung perfusion (EVLP) is an indispensable, vital safety net to evaluate and rescue borderline grafts, particularly those with suspected hydrostatic edema, it must never serve as a routine, high-cost bypass for suboptimal in situ preservation. Shifting the burden of graft protection from the donor’s bedside to ex situ platforms is both logistically and financially unsustainable, and clinical priority must remain focused on rigorous, proactive in situ donor care.

Ultimately, the Forum delivers a pointed challenge to the transplant community. While current consensus guidelines remain heavily focused on complex hepatic or cardiac preservation protocols, they frequently overlook simple, cost-effective, and highly viable maneuvers to safeguard the lung graft. While the community debates highly invasive and poorly standardized in situ surgical venting procedures to mitigate hydrostatic injury, the simplest protective strategy of all, early in situ alveolar oxygenation via ventilation or CPAP immediately following the mandatory 5-minute no-touch period, remains unrecognized as a standardized frontline maneuver. A paradigm shift is urgently required, the authors conclude: transitioning from static cold storage toward early in situ oxygenated preservation, as successfully demonstrated in uncontrolled donation after circulatory death. The lung, they insist, must no longer be the forgotten organ in regional perfusion strategies and cDCDD consensus guidelines.

Subject of Research: Transplantation

Article Title: Don’t forget to safeguard the lungs during DCD multi-organ retrieval! Early in situ oxygenated preservation matters

Article References: Jordá Aragón, C., & Fontana Bellorín, A. (2026). Don’t forget to safeguard the lungs during DCD multi-organ retrieval! Early in situ oxygenated preservation matters. Transplant International, 39, Article 17507. https://doi.org/10.3389/ti.2026.17507

Image Credits: AI Generated

DOI: 10.3389/ti.2026.17507

Keywords: lung transplant, DCD donation, normothermic regional perfusion, organ preservation, ESOT consensus, transplant surgery, forget, safeguard, lungs, during, multi-organ, retrieval

The editorial collection, assembled by Aleah L. Brubaker and Gabriel T. Schnickel of the University of California San Diego, frames the central shift of the past decade: clinicians are no longer merely preserving donated organs but resuscitating them, probing their function, and modifying their biology before implantation. Three main techniques anchor this transformation. Hypothermic machine perfusion (HMP) pumps chilled, oxygenated solution through the organ at low temperatures, reducing ischemic injury while allowing continuous delivery of protective agents. Normothermic machine perfusion (NMP) keeps the organ at body temperature with oxygenated blood or blood substitutes, sustaining near-physiologic metabolism so that bile production, lactate clearance, and other real-time markers can be measured. Normothermic regional perfusion (NRP) operates inside the donor, restoring circulation to the abdominal organs after circulatory death while excluding the brain, a strategy that has dramatically expanded the pool of usable organs from donation after circulatory death.

A comprehensive review by Olaso and colleagues lays out the landscape across liver, kidney, pancreas, and intestinal transplantation, and its most important contribution may be its honesty about what the field does not yet know. Machine perfusion clearly offers opportunities for viability assessment, greater use of marginal grafts from older or steatotic donors, and therapeutic intervention during the perfusion interval itself. But the review emphasizes that the technology faces shared obstacles across all abdominal organs: high cost, logistical complexity, lack of standardized protocols, and unresolved questions about which organs and which clinical circumstances actually benefit. A steatotic liver teetering on the edge of usability may gain enormously from hours of normothermic perfusion and metabolic conditioning, while a pristine kidney from a young donor may derive little advantage that justifies the expense and infrastructure. Defining those boundaries is now a central research priority.

The most dramatic illustration of how perfusion is rewriting the rules of organ recovery comes from Assouline and colleagues, who describe a case in which surgeons converted from veno-arterial extracorporeal membrane oxygenation to abdominal NRP after extracorporeal cardiopulmonary resuscitation failed in a patient with a Stanford type A aortic dissection, one of the most catastrophic cardiovascular emergencies in medicine. Despite the extraordinary complexity of the scenario, abdominal NRP enabled successful organ recovery and transplantation, demonstrating how innovative preservation techniques can create donation opportunities that would have been impossible under traditional protocols. The case underscores a broader point: NRP is not simply a preservation tool but a recovery strategy that changes which donors the system can serve.

Yet NRP remains the most ethically contested technology in the field. Because the technique restores circulation after the declaration of death by circulatory criteria, critics and some health systems question whether regional reperfusion constitutes a violation of the dead donor rule, and rigorous safeguards are required to prevent any cerebral reperfusion. Some countries and health systems do not currently permit NRP recovery at all. The editorial authors argue that as adoption expands, transparency, continued engagement with clinicians, ethicists, donor families, and the public, and unambiguous safeguards against brain reperfusion will remain essential. The technology’s clinical promise cannot be separated from the social license that permits its use, and that license must be earned case by case, system by system.

Beyond rescue and assessment, machine perfusion is opening a genuinely new therapeutic frontier: using the perfusate itself as a drug delivery vehicle. Mayoral and colleagues reviewed the pharmacologic supplementation of hypothermic kidney preservation and identified a substantial body of preclinical work targeting the molecular pathways of ischemia-reperfusion injury, the cascade of oxidative and inflammatory damage that occurs when an organ is deprived of blood and then reoxygenated. Clinical translation remains limited, but the conceptual shift is profound. Preservation solutions and perfusates, once inert fluids, are becoming platforms for targeted therapy, allowing drugs, gene therapies, or metabolic modulators to be delivered directly to an organ in a controlled circuit, away from the systemic exposure and side effects that complicate treatment in a living patient.

Tropp and colleagues extend this logic to the ultimate therapeutic ambition: regeneration. Their review maps the complex cellular and molecular networks that govern hepatic regeneration and proposes ex vivo machine perfusion as a bridge between mechanistic biology and clinical transplantation. Because perfusion maintains whole-organ architecture in a controlled environment, regenerative pathways can be measured, manipulated, and augmented before the organ ever reaches a recipient. In this framework, the goal moves beyond preserving the organ that was donated toward improving the organ that will ultimately be transplanted, a distinction that could eventually allow marginal livers to be conditioned into high-quality grafts rather than discarded.

Technological transformation, the collection stresses, cannot occur independently of the people who deliver it. Mullens and colleagues examine machine perfusion from the perspective of the next generation of transplant surgeons, and their analysis reveals a double-edged sword. Perfusion may enable daytime transplantation, replacing the midnight urgency of cold storage with scheduled, physiologically informed decision-making, and it creates new opportunities for assessment and translational research. At the same time, it changes traditional training experiences and introduces new technical and cognitive competencies, from interpreting perfusion parameters to managing complex extracorporeal circuits. The transplant workforce must evolve alongside the technology, with training programs, staffing models, and professional expertise redesigned to match the capabilities of the machines.

Viewed together, the contributions sketch a field in the midst of systemic reorganization. Machine perfusion can expand organ utilization by recovering organs that might otherwise be lost and by providing additional information to guide acceptance decisions. It is transforming the organ from something that is simply preserved into something that can be assessed, treated, and potentially repaired. Technologies such as NRP and ex vivo perfusion are becoming increasingly interconnected within more complex donation pathways, requiring coordination across organ procurement organizations, donor hospitals, recovery teams, transplant centers, and perfusion platforms. Successful integration will depend not only on technological capability but on the infrastructure, ethical frameworks, and systems of care required to deliver these technologies safely and equitably. In this sense, machine perfusion is emerging as an enabling platform across the entire transplantation pathway rather than a single preservation technology.

The editorial closes with questions that will define the next decade. Perfusion requires personnel, infrastructure, expertise, and financial resources that are not uniformly available, and the field must determine not simply whether these technologies improve individual graft outcomes but how they affect organ utilization, access to transplantation, cost, sustainability, workforce demands, and equity. Enhanced data collection and multicenter collaboration will be essential to identify which approaches provide meaningful benefit, for which organs and recipients, and under what circumstances. What began as a strategy for keeping organs cold has become, in the authors’ framing, a catalyst through which transplantation itself can be reimagined, provided the field builds the systems, safeguards, and shared standards to match the ambition of its machines.

Subject of Research: Machine perfusion technologies for abdominal organ preservation, assessment, and transplantation

Article Title: Editorial: Advancing machine perfusion: navigating challenges in abdominal organ transplantation

Article References: Brubaker, A. L., & Schnickel, G. T. (2026). Editorial: Advancing machine perfusion: navigating challenges in abdominal organ transplantation. Frontiers in Transplantation, 5, Article 2001083. https://doi.org/10.3389/frtra.2026.2001083

Image Credits: AI Generated

DOI: 10.3389/frtra.2026.2001083

Keywords: machine perfusion, organ transplantation, normothermic perfusion, hypothermic machine perfusion, normothermic regional perfusion, liver transplantation, kidney transplantation, organ preservation, ischemia-reperfusion injury, organ donation, transplant surgery, organ viability

The research, published in Frontiers in Transplantation, used a mixed-methods exploratory sequential design to interview 15 consultant kidney transplant surgeons from seven UK transplant centres about adverse events they had experienced during their careers. Each participant underwent an individual, semi-structured qualitative interview lasting between 22 and 71 minutes, transcribed verbatim and analysed using Braun and Clarke’s reflexive thematic analysis framework. Alongside the interviews, participants completed two validated psychometric instruments: the 44-item Big Five Inventory, measuring the five-factor model of personality across extraversion, agreeableness, conscientiousness, neuroticism and openness, and the Domain-Specific Risk-Taking (DOSPERT) scale, which quantifies attitudes toward risk across ethical, financial, health and safety, social and recreational domains. Integration of the qualitative and quantitative datasets occurred at the analysis stage, allowing the researchers to triangulate how personality traits and lived experience interact in shaping surgeons’ responses to adverse events.

An adverse event was defined as an unintended event occurring during or following transplantation that resulted in patient harm, encompassing both preventable errors made during an operation and known procedural complications. This broad definition was deliberate, allowing the study to capture the full spectrum of harm that transplant surgeons confront. The stakes in transplantation are uniquely high: unlike most surgical fields, the surgeon is responsible for two patients simultaneously, the donor and the recipient, and must balance the imperative not to waste a scarce organ against the risk of implanting one that may fail. Outcomes are closely monitored, and once the operation is performed there is limited opportunity to rectify errors. A surgeon’s influence extends beyond the operating table to organ acceptance decisions, meaning that a shift toward risk aversion after an adverse event could translate into higher rates of organ refusal and fewer transplants performed.

The thematic analysis identified four main themes with nine subthemes. The first and most visceral theme was that adverse events have a profound psychological impact. Every surgeon described an immediate emotional response, sharing in the trauma of the patient with feelings of sadness, anxiety, guilt and frustration. One participant described being “devastated, devastated, obviously, really upset,” while another recounted mentally replaying the entire operation on the drive home, unable to stop. The long-term emotional response proved more varied: some surgeons continued to feel the same intensity of distress years later, while others reported a more subdued reflection over time. In both cases, the emotional burden faded from daily consciousness but remained accessible, resurfacing when the surgeon encountered the same patient’s name or faced a similar clinical scenario. One surgeon reflected, “You don’t forget about it. And it carries with you. And you still think about it. And every time you see their name, you shudder.”

The second theme centred on how the surgical environment shapes the response to an adverse event. Participants consistently emphasised that a cohesive, supportive unit was foundational in navigating the aftermath. Informal peer support, colleagues offering perspective and reassurance, was regarded as the most effective coping mechanism, often described as an inherent part of team culture rather than a formal service. This relational support was preferred over accessing structured support services, which surgeons said they would not routinely rely upon. Conversely, a fragmented team dynamic was found to add to the burden. The study also revealed a darker side of the surgical environment: scrutiny following an adverse event evoked doubt in surgical capabilities, with some surgeons admitting that their decision-making became governed by concern over peer perceptions rather than clinical reasoning. One participant noted that at times they had considered changing their mind not because they felt the decision was wrong, but because of “the perception of your peers in a heavily scrutinised environment.” Pressure from external bodies reviewing departmental metrics compounded this anxiety, with one surgeon describing fear that statistics would be processed “without knowing the context” in a way deleterious to the department.

Yet scrutiny was not uniformly destructive. A positive aspect emerged within the morbidity and mortality (M&M) meeting process, where surgeons found value in thorough, non-personalised review of errors. Participants distinguished this constructive accountability from perceived colleague scrutiny, which they described as harmful and associated with self-doubt. A well-conducted M&M process allowed surgeons to learn from mistakes and take responsibility in a manner that, as one put it, “you can’t be personal about.” This distinction reinforces the importance of psychological safety, an environment where staff are comfortable admitting mistakes and learning from them, which is shaped by continuous interpersonal interactions among co-workers and ultimately benefits patient outcomes.

The third theme concerned changes in practice following an adverse event. Surgeons commonly expressed a desire to improve, driven by surgical pride and a sense of responsibility to every patient who comes to harm. Some sought out colleagues to observe alternative techniques, such as reviewing how peers perform arterial anastomoses after their own approach failed. Critically, participants reported that changes to practice should be based on decision-making processes rather than outcomes alone, warning against overcorrecting based on isolated incidents while remaining alert to patterns suggesting systemic issues. Some surgeons reported formalising their consent process and risk explanation when counselling future patients. Perhaps most significantly, the study documented shifts in risk attitude: many surgeons described a natural, often temporary, move toward conservatism in the immediate aftermath of an adverse event, followed by a recalibration of risk appetite based on surgical confidence and patient need. One surgeon observed that a disastrous first case could have a massive impact on the rest of a career, making a surgeon “much more conservative and much less willing to accept risk.” Others noted that the easiest path is risk aversion, which they considered “very bad medicine because patients are not getting the treatment that they deserve.”

The fourth theme explored the influence of personality on responses to adverse events. Participants consistently believed there to be a link between personality and how they processed these events. The Big Five Inventory findings provided descriptive context: mean neuroticism scores were higher among surgeons reporting greater long-term emotional impact (3.28) than among those reporting lesser impact (2.08), though the researchers caution that given the limited sample size this comparison is descriptive rather than associative. DOSPERT scores were comparable across all domains. Two subthemes emerged as protective mechanisms. The first was “robustness,” the ability to draw a line after an adverse event, temporarily pausing one’s own emotional response to continue clinical tasks and process the trauma later. Participants described compartmentalising emotions, with one stating, “Frankly, your emotions, in my opinion, are in that situation, secondary. You just got to put them away somewhere, compartmentalise them.” The second was “purpose”: surgeons described a period of introspection that reinforced the fundamental values of their career, a duty to patients, to shoulder responsibility, and to perform to the standards their training has allowed. One participant asked whether their core purpose was to massage departmental figures or to act in the patient’s best interests, concluding that declining to implant a kidney would have served statistics rather than the individual.

The researchers also identified external factors that modulated the emotional response, including the severity of the adverse event, whether it involved an overtly technical error, the surgeon’s seniority at the time, and the reaction of the patient’s family. More severe events and technical errors were associated with greater and more lasting emotional impact, possibly because surgeons view complications as an inevitability of surgery while errors feel like personal failures. Seniority cut both ways: reduced clinical experience was perceived to increase vulnerability in surgical confidence, yet being among the most experienced surgeons in a department carried its own burden, with an expectation of emotional resilience and a perceived lack of peer reassurance. Antagonistic responses from patients’ families amplified the emotional toll, forcing surgeons to confront hostility while still processing the event itself.

The findings map closely onto the “Second Victim Syndrome” framework, a term coined by Albert Wu in 2000 to describe the harm clinicians incur from adverse events, encompassing guilt, fear, anger and concerns about professional reputation and confidence. The study’s authors situate their results within the Bowlby and Parkes model of grief, attributing interview responses across its four stages and supporting the concept that all surgeons experience an acute reaction while longer-term emotional impact varies. Notably, a recent systematic review co-authored by members of this study team found that over half of surgeons experience anxiety, guilt and sleep disturbance following an adverse event. What makes the transplant context distinct is that the psychological consequences may ripple outward: risk aversion following an adverse event could reduce organ acceptance rates, meaning the second victim phenomenon in transplantation carries implications not just for surgeon wellbeing but for patients on dialysis who may never receive the transplant they need. The researchers argue that avoiding surgery because of personal risk perception may be as paternalistic as proceeding based solely on belief in its benefit.

Perhaps the most striking finding is what surgeons did not rely upon: formal support services. Existing literature has highlighted the limited effectiveness of single-session psychological debriefing following traumatic events, and aspects of surgical culture, the expectation that surgeons should cope alone, act as barriers to engagement with structured support. Instead, the most effective mechanism came from collegial relationships within a cohesive team. The authors point to evidence supporting Schwartz rounds, which improve team cohesion, support staff wellbeing and encourage compassionate reflection, as potentially beneficial in the complex, multidisciplinary transplant setting. They also highlight emerging resilience-focused interventions, such as Enhanced Stress Resilience Training, which showed improvements in burnout, stress and mindfulness among surgical trainees who fully engaged with a five-week course. Whether such training could benefit transplant surgeons warrants further investigation. The study acknowledges its limitations, including its modest sample size concentrated across two centres, the interviews being conducted by a medical student introducing a potential power dynamic, and quantitative data serving only descriptive rather than inferential purposes. Nevertheless, the findings open a conversation long overdue in transplant surgery, suggesting that strengthening collegial support within units, and re-evaluating formal support systems that remain underused, could protect both the surgeons who perform these operations and the patients whose lives depend on their willingness to take calculated risks.

Subject of Research: Psychological and professional impact of perioperative adverse events on kidney transplant surgeons

Article Title: The impact of perioperative adverse events on kidney transplant surgeons: a mixed-methods study

Article References: Laverty, D., Stevenson, K., Jones, C., Bisset, C., Moug, S., & Aitken, E. (2026). The impact of perioperative adverse events on kidney transplant surgeons: a mixed-methods study. Frontiers in Transplantation, 5, Article 1959604. https://doi.org/10.3389/frtra.2026.1959604

Image Credits: AI Generated

DOI: 10.3389/frtra.2026.1959604

Keywords: kidney transplant, adverse events, second victim syndrome, surgeon wellbeing, surgical psychology, risk aversion, organ acceptance, Big Five Inventory, DOSPERT, thematic analysis, peer support, transplant surgery

The study, led by Katharine E. Caldwell of the Medical University of South Carolina with Dominic E. Sanford of Mayo Clinic Arizona and Natasha Leigh of Washington University in Saint Louis, examined de-identified case logs from the Fellowship Council for fellows graduating between 2014 and 2023 who pursued certification through the Americas Hepatopancreatobiliary Association (AHPBA). The cohort comprised 146 fellows from dedicated HPB programs, 55 from complex general surgical oncology (CGSO) programs, and 51 from transplant (TXP) programs. Because CGSO and TXP fellowships are all two-year programs while HPB fellowships included both one-year and two-year tracks, the researchers compared total operative experience per fellowship rather than per year, ensuring that differences in program length did not distort the comparison.

The structural differences between the pathways are central to the story. Dedicated HPB fellowships immerse trainees almost entirely in liver, pancreas, and biliary operations, although fellows may spend up to one month per year on a transplant rotation. CGSO fellows pursuing an AHPBA-certified track may spend six to ten months across their two fellowship years on HPB-focused rotations, with the remainder devoted to broader surgical oncology. TXP fellows on HPB tracks may spend only three to six months on HPB services, and the exact duration varies considerably between programs, with some centers caring for non-transplant HPB cases alongside routine liver transplant work depending on the attending surgeons’ practice patterns. These competing clinical mandates, the authors hypothesized, would translate into different case mixes by the end of training.

The data confirmed that hypothesis in striking detail. HPB fellows completed the highest average total case volume at 187.4 cases, compared with 147.2 for CGSO and 160.9 for TXP fellows. HPB fellows also logged significantly more total pancreas operations, 82.0 on average, driven largely by open pancreaticoduodenectomy, the most technically demanding standard pancreatic resection, of which they performed 35.9 compared with 28.3 in CGSO and 29.8 in TXP fellows. Total liver resection volumes were broadly comparable across the three pathways, but the composition differed: transplant fellows led in open anatomic liver resections at 35.2 cases, reflecting the vascular and hepatic expertise central to transplantation, while HPB fellows performed the most non-anatomic resections at 67.3.

The most consequential divergence, however, emerged in robotic surgery. Across all three cohorts, average robotic case volume rose nearly elevenfold over the decade, from 1.7 to 18.7 cases, a signal of how rapidly the field has pivoted toward robotic platforms. But the distribution was starkly uneven. HPB fellows averaged 12.5 robotic HPB cases, CGSO fellows 8.5, and transplant fellows just 1.0, a statistically significant gap that persisted across nearly every operation type. HPB fellows logged 4.4 robotic pancreaticoduodenectomies and 3.8 robotic distal pancreatectomies on average, compared with 0.2 and 0.6 respectively for their transplant counterparts. Robotic anatomic liver resections, at 2.1 cases in the HPB track, were more than sixty times the transplant figure of 0.03.

Those numbers matter because of what is known about learning curves in robotic HPB surgery. Published analyses suggest that surgeons need roughly 40 robotic pancreaticoduodenectomies or 30 robotic major hepatectomies to reach proficiency, with learning curve estimates for these complex operations generally falling between 30 and 50 cases. Not a single fellow in the entire ten-year series exceeded those thresholds, although several HPB-track trainees came within five cases of them. In other words, even in the highest-volume pathway, the average graduate leaves fellowship well short of the published proficiency boundary, meaning the steepest part of the learning curve must be climbed in early independent practice, often without the structured mentorship, simulation, and coaching that fellowship uniquely provides.

The authors are careful to note that the fellowship’s goal is not to produce fully mastered robotic surgeons, which requires years of practice, feedback, and failure. Rather, fellowship should supply adequate exposure, autonomy, and mentorship so that graduates can continue developing safely in their first jobs. The concern is that the observed gaps, particularly the near-total absence of robotic experience among transplant-track fellows, may leave some graduates poorly positioned for a job market in which patient demand and clinical evidence increasingly favor minimally invasive approaches. Prior research cited in the study indicates that fellowship type independently influences early-career perioperative outcomes, with HPB-specific training associated with superior results, underscoring that these training differences have real clinical consequences.

The study also highlights a structural shift that may widen the disparity. Historically, high-volume HPB fellowships could compress all case requirements into a single year, and most of the high-robotic-volume programs in this dataset were one-year tracks. AHPBA certification requirements are now transitioning to mandate two full years for all fellowships, and current proposals plan to increase both total HPB case requirements and the number of required minimally invasive cases. Doubling the training duration at high-volume centers could give HPB fellows substantially more time to accumulate robotic experience, while many transplant fellowships, the authors note, would already fall below the proposed case volume increases, especially if minimally invasive requirements rise significantly. Canadian programs, which are predominantly two-year and have adopted robotics more slowly due to publicly funded health system structures and reimbursement differences, add further regional variability.

Importantly, the transplant pathway is not uniformly left behind. The authors acknowledge that some transplant programs are outliers with extensive robotic expertise spanning both HPB and transplant operations, and faculty experience, access to dual-console robotic systems, and local practice patterns all shape what an individual fellow encounters. The study also carries methodological limitations that temper its conclusions. The data are fellow-reported and retrospective, and inaccuracies in case logging are well documented, though they diminish with training year and are likely distributed evenly across pathways. Because the data were anonymized, the researchers could not link residency and fellowship experience, meaning each fellow’s cumulative operative exposure across their entire training lifespan is underestimated, nor could they control for the exact months spent on HPB services. The CGSO and TXP fellows studied represent only those programs that chose to offer AHPBA-certified HPB tracks, the most HPB-focused subset of their fields, so the true disparity for the average surgical oncology or transplant graduate is likely even larger than these figures suggest.

Perhaps the deepest question the study raises is whether case counts are the right measure at all. Volume, the authors argue, is an imperfect surrogate for competence: a fellow logged as primary surgeon may have performed very different proportions of an operation at different programs, and current case logs do not capture the degree of attending involvement. As surgical training shifts toward outcomes-based assessment and Entrustable Professional Activities, the traditional case log may need to give way to careful observational evaluation of genuine operative independence. Deliberate practice, coaching, simulation, and post-fellowship mentorship all shape the path to mastery in ways that raw numbers cannot capture. Still, the message for training programs is unambiguous: minimally invasive exposure is distributed unevenly across the pipelines that feed the HPB workforce, graduation volumes fall short of established learning curve thresholds for the most complex robotic operations, and standardized, platform-specific curricula with competency-based assessment are urgently needed. As more residency graduates than ever pursue fellowship and patient demand for robotic liver and pancreas surgery grows, the programs that train tomorrow’s HPB surgeons will need to decide, deliberately and soon, whether they can deliver expertise across transplant, oncology, and HPB domains and across open, laparoscopic, and robotic platforms within a single two-year fellowship.

Subject of Research: Variation in minimally invasive and robotic operative training across hepatopancreatobiliary fellowship pathways

Article Title: Training the next generation of minimally invasive HPB surgeons: are current fellowships crossing the learning curve?

Article References: Caldwell, K. E., Sanford, D. E., & Leigh, N. (2026). Training the next generation of minimally invasive HPB surgeons: are current fellowships crossing the learning curve?. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 186. https://doi.org/10.1007/s44186-026-00602-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00602-7

Keywords: HPB surgery, robotic surgery, fellowship training, minimally invasive surgery, surgical education, learning curve, pancreaticoduodenectomy, liver resection, transplant surgery, surgical oncology, AHPBA, case logs