Outcome and Learning Curve in 159 Consecutive Patients Undergoing Total Laparoscopic Hemihepatectomy

Abstract

28Importance 29Wide spread implementation of laparoscopic hemihepatectomy is currently limited by its 30 technical difficulty, paucity of training opportunities and perceived long and harmful learning 31 curve. Studies confirming the possibility of a short and safe learning curve for laparoscopic 32 hemihepatectomy could potentially benefit the further implementation of the technique. 33Objective 34To evaluate the extent and safety of the learning curve for laparoscopic hemihepatectomy. 35 Design 36A prospectively collected single-center database containing all laparoscopic liver resections 37 performed in our unit between 2003-2015 was retrospectively reviewed. 38 Setting 39Tertiary referral center, specialized in laparoscopic hepato-pancreato-biliary surgery. 40 Participants 41Included were all patients in whom a total laparoscopic right or left hemihepatectomy 42 procedure was started (intention-to-treat analysis), including laparoscopic extended 43 hemihepatectomies and hemihepatectomies with additional wedge resections. 44 Main Outcome and Measures 45Primary endpoints were clinically relevant complications (Clavien-Dindo grade ≥III). Presence 46 of a learning curve effect was assessed with a risk adjusted cumulative sum analysis. 47 Results 48Out of a total of 531 consecutive laparoscopic liver resections, 159 patients underwent total 49 laparoscopic hemihepatectomy, 105 right and 54 left. In a cohort with 67 (42%) males, 50 median age of 64 years (IQR 51-73)) and 110 (72%) resections for malignant lesions, the 51 overall median operation time was 330 minutes (270-391) and median blood loss 500 ml 52 conversions. 58 Conclusions and Relevance 59Total laparoscopic hemihepatectomy is a feasible and safe procedure with an acceptable 60 learning curve for conversions. Focus should now shift to providing adequate training 61 opportunities for centers interested in implementing this technique.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery

“…With experience both operative time and blood loss decreases (79,80) and experience gained during minor resections may shorten the learning curve for major resections (81) . The learning curve for minor resections is suggested to be 60 cases (79) and that for major resections is 55 (having already developed experience on minor resections) (82) . See R24.1, 24.2, 24.3…”

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation

“…This did not change the main perioperative outcomes. Multiple studies have assessed the learning curve in LLS [23][24][25]. Whereas for minor laparoscopic liver resections the learning curve was 22 procedures [23], for major hepatectomy this was 45-55 procedure [24,25].…”

“…Multiple studies have assessed the learning curve in LLS [23][24][25]. Whereas for minor laparoscopic liver resections the learning curve was 22 procedures [23], for major hepatectomy this was 45-55 procedure [24,25]. A recent study specifically assessing the learning curve for the posterosuperior segments concluded that the learning curve was estimated to be a total of 65 procedures for anatomical resections [26].…”

Robotic vs. laparoscopic major hepatectomy

“…The learning curve is "the improvement in performance over time or the change in the ability to complete a task until failure is decreased to a constant acceptable rate" [110] . Data suggest that the learning curve for LMH is around 45-60 cases [93,[111][112][113] . van der Poel et al [93] reported that 55 is the "golden" number for LMH; however, all surgical operations were performed by two experienced hepatobiliary surgeons with at least three years of additional experience on minor laparoscopic hepatectomy.…”