*Purpose: HPB surgery is an evolving specialty, but only about 15% of the active HPB surgeons have undergone training in a dedicated HPB program – the majority has been educated in other fellowships, including transplant. Little is known to date about the specifics and extent of HPB training in transplant fellowships.

*Methods: HPB training in ASTS-accredited transplant programs was evaluated with an IRB-approved, anonymous survey, administered online via Survey Monkey. The questionnaire included 37 items concerning demographics, education, exposure to core HPB procedures and competency, didactic environment and evaluation of program strength and weaknesses. The target population were current and previous fellows in ASTS clinical training programs. A total of 110 trainees/graduates participated in the survey. Responses are given as % of total answers.

*Results: The age of responders ranged from 31 to 60, 30% were female. A sizeable number attended an international medical school (44%) and/or trained abroad (34%). 94% trained in a program with an ASTS-accredited liver transplant track, 44% of these fellowships did not have an official HPB or HB accreditation. At least 60% of surgeons did more than 10 major hepatectomies (≥3 segments) and more than 10 minor hepatectomies (<3 segments) during fellowship, the majority felt comfortable performing these procedures independently (66% for major and 89% for minor hepatectomy). For biliary procedures about 2/3 of the trainees had performed more than 10 hepaticojejunostomies and felt very confident to operate alone (93%). With radical cholecystectomy the comfort level was still high (77%), although most fellows had done only between 0 and 5 procedures during their training. Resection of hilar cholangiocarcinoma was equally rare for most fellows, but 60% of the responders did not feel competent to operate on these patients. For 58% of fellows more than 25 overall liver cases was the norm, whereas the exposure to biliary cases was less robust (72% with < 25). Areas with room for improvement most commonly cited were exposure to laparoscopic procedures (76%), overall case load (51%) and consistent use of intraoperative ultrasound (45%).

*Conclusions: ASTS fellows receive training in hepatic and biliary surgery aside from their transplant experience. The majority of trainees feels confident performing these cases independently, yet case volumes in some programs may fall short of current recommendations for HPB training (either according to ASTS or AHPBA standards). Programs should focus on case volume and diversity, ideally within a certified HB/HPB training track, to improve the HPB competence of their trainees.

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