Learning curve for laparoscopic major hepatectomy

Nomi, Takeo; Fuks, David; Kawaguchi, Yoshikuni; Mal, F.; Nakajima, Yasuaki; Gayet, Brice

doi:10.1002/bjs.9798

Cited by 203 publications

(128 citation statements)

References 28 publications

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“…Because of the steep learning curve for major LLR,14, 15 we developed a practical scoring system to assess the difficulty of LLR procedures regularly performed in clinical settings. In addition, a study by Ban and colleagues described a system to determine the difficulty of LLR techniques 16…”

Section: Evolution Of Laparoscopic Liver Resectionmentioning

confidence: 99%

“…Experienced liver surgery units must help standardize the techniques required for each LLR procedure25 and share their experience of the technical challenges of LLR. Major LLR requires a high level of technical skill and has a steeper learning curve than minor LLR 15. One study found that 60 laparoscopic minor liver resections was adequate experience before attempting major LLR 69.…”

Section: Technical Considerationsmentioning

confidence: 99%

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Evolution and revolution of laparoscopic liver resection in Japan

Kaneko

Otsuka

Kubota

et al. 2017

Annals of Gastroent Surgery

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Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta‐analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high‐volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi‐hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

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Section: Evolution Of Laparoscopic Liver Resectionmentioning

confidence: 99%

Section: Technical Considerationsmentioning

confidence: 99%

Evolution and revolution of laparoscopic liver resection in Japan

Kaneko

Otsuka

Kubota

et al. 2017

Annals of Gastroent Surgery

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“…In HCC patients with underlying liver cirrhosis, laparoscopic liver resection is difficult because of the presence of portal hypertension and thus a high bleeding tendency which renders parenchymal transection difficult [15,28,33]. Safe performance of the operation calls for ample experience [34][35][36].…”

Section: Introductionmentioning

confidence: 99%

The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong

et al. 2017

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Background: Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC. Summary: The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need. Key Message: The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

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“…Hasegawa et al11 demonstrated that a major LLR could be safely introduced for a surgeon with an experience level of at least 60 minor LLR. Nomi et al12 reported that 45 major LLR were required before operating times were reduced. Thus, several studies have described the learning curve for major LLR en bloc; however, it is clear that the number of segments alone does not convey the complexity of a resection.…”

Section: Discussionmentioning

confidence: 99%

“…In several previous studies, various procedures were assessed and discussed, particularly the learning curve, en bloc as a major LLR 3, 10, 11, 12, 13, 14, 15. The complexity of each major hepatectomy procedure differs widely, and the number of segments alone does not convey the complexity of a resection.…”

Section: Introductionmentioning

confidence: 99%

Laparoscopic left hemihepatectomy is suitable as a first step in pure laparoscopic major hepatectomy

Hasegawa

Nitta

Takahara

et al. 2018

Annals of Gastroent Surgery

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AimAs a procedure, major laparoscopic liver resection (LLR) remains in the exploration phase. Previous studies have assessed major LLR en bloc, including hepatectomies of varying complexities; however, the number of segments alone does not convey the complexity of a resection. This study aimed to assess operative outcomes of LLR procedures with more than one sectionectomy, and to identify the best procedure as a first step when learning to carry out major LLR in order to make LLR a safer, more widely used procedure.MethodsWe carried out a retrospective review of the operative outcomes of 120 consecutive patients who underwent pure LLR with more than one sectionectomy. Operative outcomes were compared according to the complexity classification recently published, and the learning curve for each LLR procedure was assessed and compared.ResultsOperative outcomes, including operative time, blood loss, and the comprehensive complication index, were significantly stratified according to complexity. There were significant differences in operative outcomes among the medium complexity procedures. The operative time for left hemihepatectomy was the shortest, and the amount of blood loss was the lowest among the medium complexity LLR. Operative times for left hemihepatectomy shortened significantly with time and experience (r = −0.639), and the slope of the learning curve was steeper than for right hemihepatectomy and right posterior sectionectomy.ConclusionLeft hemihepatectomy is suitable as a first step in pure laparoscopic major hepatectomy and, given its safety and rapid learning curve for surgeons, it could become the gold standard procedure.

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Learning curve for laparoscopic major hepatectomy

Abstract: The learning curve for LMH consisted of three characteristic phases identified by CUSUM analysis. The data suggest that the learning phase of LMH included 45 to 75 patients.

Cited by 203 publications

References 28 publications

Evolution and revolution of laparoscopic liver resection in Japan

Evolution and revolution of laparoscopic liver resection in Japan

The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong

Laparoscopic left hemihepatectomy is suitable as a first step in pure laparoscopic major hepatectomy

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