*Purpose: To improve access to quality care, the surgical outcomes and influencing factors were investigated for a new hepatobiliary surgery program established by a transplant surgeon in a community teaching hospital located 70 miles from the nearest major academic institutions.

*Methods: This is a single surgeon, single institution, prospective study of all open and robotic hepatobiliary surgery patients from November 2016 through March 2020. The surgeon had completed an American Society of Transplant Surgeons accredited Abdominal Transplant Surgery fellowship and was proctored by an expert in robotic hepatobiliary surgery. Outcomes included operative time, estimated blood loss, microscopic margin-positive resection (R1), reoperation, bile leak, Clavien-Dindo grade III-IV complication (CDC), length of stay (LOS), readmission, and mortality. Institutional Review Board approval was obtained.

*Results: Of the 64 total surgeries (average 19 per year), 80% (n = 51) were open, 20% (n = 13) were robotic, and 39% (n = 25) were performed for cancer. Hepatic surgery outcomes included the following. Older age was associated with fewer bile leaks or CDCs (p = 0.0152, 0.0366). Reoperation or CDC was associated with readmission (p = 0.0001, 0.0016). Cancer surgery had longer operative time (p = 0.0218). Robotic surgery was reduced in operative time and blood loss (p = 0.0019, 0.0113). It also averaged a shorter LOS, but this was not statistically significant. Bile duct surgery outcomes included the following. Longer operative time was associated with R1 (p = 0.0007) but not cancer surgery itself. CDC was associated with readmission (p = 0.0006). In common bile duct explorations, robotic approach averaged a shorter LOS (p < 0.0001).

R1 rate for the 25 cancer surgeries was 16% (n = 4). Bile leak rate for the total 64 surgeries was 4.7% (n = 3). Specific to hepatectomies, leak rate was 7.4% (n = 2 of 27), which is within the range reported in literature of 2.7-17%. Leak rate for hepaticojejunostomy was 7.1% (n = 1 of 14) compared to 5.6% in literature, and rate for the other surgeries including common bile duct exploration was 0% (n = 0 of 5) compared to 3.8% in literature. Bile leak was associated with readmission in both hepatic (p < 0.0001) and bile duct (p = 0.0168) groups. There were two total mortalities within 90 days, both due to stroke. Specific to hepatectomies, mortality was 3.7% (n = 1 of 27), which is within literature’s range of 1-10.2%.

*Conclusions: Careful planning and assembly of a multidisciplinary team enabled the surgeon trained in transplant surgery to establish a quality hepatobiliary program in a community teaching hospital and improve access to care.

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