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From IDEAL learning curve to team maturation: a decade of experience reducing conversion in laparoscopic liver
Juxian Song1,2, Li Cao1, Weikun Wu1,2
1Department of Hepatobiliary Surgery, The First Affiliated Hospital of Army Medical University, Gaotanyan Main Street 29, Shapingba District, Chongqing, 400038, China.
Background:
Difficulty scoring systems overlook how a surgical team learns. We examined whether a structured team-based pathway (debriefing, risk stratification, protocolized decisions) was associated with a reduction in conversion in laparoscopic liver resection (LLR) without avoiding complex cases.
Methods:
This single-center retrospective cohort study analyzed 2,051 pure LLRs (2009-2018), grouped by IDEAL phases: early, exploration, and maturation. The pathway was introduced in 2015.
Primary Endpoint:
unplanned conversion.
Results:
The overall conversion rate was 7.2% (147/2,051). Complex posterosuperior resections remained stable (15.8% to 12.3%, P = 0.120), yet conversion fell from 14.2% to 4.6% (P < 0.001). After adjustment for clinical covariates, the pathway period was associated with 53% lower odds of conversion (aOR = 0.47, 95%CI 0.33-0.65); however, when calendar year was added to the model, the pathway effect was no longer significant (aOR = 0.99, 95%CI 0.50-1.97), while year remained independently associated with lower conversion (aOR = 0.84 per year, 95%CI 0.75-0.94). CUSUM showed a biphasic learning curve crossing below zero at approximately the time of pathway introduction. Median total hospital stay shortened from 16.4 to 15.8 days (P = 0.006). Subgroup analyses suggested greater reductions in cirrhosis (45% RRR) and posterosuperior tumors (38% RRR).
Conclusion:
In this single-center experience, conversion fell substantially without simplifying case mix, but the improvement was associated with time and cumulative team experience rather than a specific pathway effect. The structured team-based approach may support, but not independently explain, this progression.