Multimodal analysis of the learning curve for pure laparoscopic donor right hepatectomy in a low-volume transplant...

The adoption of pure laparoscopic donor right hepatectomy (PLDRH) has been limited by a perceived steep learning curve, traditionally estimated at 60-70 cases. This study evaluates whether "second-generation" laparoscopic surgeons can achieve proficiency more rapidly in a low-volume transplant center using structured training and standardized techniques.

We analyzed 29 consecutive, non-selective PLDRH cases performed by a single surgeon. A multimodal CUSUM analysis, incorporating operative time, estimated blood loss, and the Comprehensive Complication Index, was used to define the learning curve, alongside a donor complexity score. Outcomes were compared with a cohort of 21 conventional open donor right hepatectomies.

A three-phase learning progression was identified. Competency and proficiency were reached at cases 10 and 20, respectively. Phase 2 (cases 11-20) was characterized by a "second learning curve" as the team encountered more complex anatomical variations within the consecutive cohort. By Phase 3 (cases 21-29), surgical metrics stabilized with zero complications, even as case complexity increased. Compared to CODRH, the PLDRH group achieved similar safety profiles but significantly shorter hospital stays (p < 0.05).

PLDRH can be safely implemented in low-volume centers with an accelerated learning curve. For surgeons with prior advanced laparoscopic expertise, institutional proficiency may be achieved within 20 cases. These findings suggest that standardized "second-generation" approaches may broaden the accessibility of laparoscopic donor surgery without compromising safety.