The single surgeon learning curve of laparoscopic liver resection: A continuous evolving process through stepwise...

Area of Science:

• Hepatobiliary Surgery
• Surgical Education
• Minimally Invasive Surgery

Background:

• Laparoscopic liver resection (LLR) is technically demanding, with limited data on defining the single-surgeon learning curve (SSLC).
• Establishing reproducibility and feasibility of the SSLC requires analysis of consecutive caseload volume over time.

Purpose of the Study:

• To evaluate the single-surgeon learning curve (SSLC) for laparoscopic liver resection (LLR) over an 11-year period.
• To define the number of cases required to achieve proficiency in LLR using risk-adjusted cumulative sum (RA-CUSUM) analysis.

Main Methods:

• Retrospective analysis of 319 LLR performed by a single surgeon (June 2003-May 2014).
• Development of a difficulty scale (DS) from 1 to 10 for each procedure.
• Application of risk-adjusted cumulative sum (RA-CUSUM) analysis to conversion rate (CR), operative time (OT), blood loss (BL), morbidity, and mortality.

Main Results:

• RA-CUSUM analysis identified three periods: P1 (91 cases, mean DS 3.8), P2 (92-159 cases, mean DS 5.3), and P3 (160-319 cases, mean DS 4.7).
• Period P2 showed the highest CR and morbidity rates with longer OT; Period P3 demonstrated significantly improved outcomes (P < 0.001).
• A minimum of 50 cases led to a significant decrease in BL, while 160 cases were needed to complete the SSLC for safe LLR.

Conclusions:

• At least 160 laparoscopic liver resections are necessary to complete the single-surgeon learning curve for safe performance of various LLR types.
• A minimum of 50 cases can significantly reduce blood loss, indicating early benefits.
• A longer learning curve should be anticipated to safely broaden the indications for laparoscopic liver resection.