Learning curve for laparoscopic major hepatectomy

BackgroundLaparoscopic major hepatectomy (LMH) is evolving as an important surgical approach in hepatopancreatobiliary surgery. The present study aimed to evaluate the learning curve for LMH at a single centre. MethodsData for all patients undergoing LMH between January 1998 and September 2013 were recorded in a prospective database and analysed. The learning curve for operating time (OT) was evaluated using the cumulative sum (CUSUM) method. ResultsOf 173 patients undergoing major hepatectomy, left hepatectomy was performed in 28 (162 per cent), left trisectionectomy in nine (52 per cent), right hepatectomy in 115 (665 per cent), right trisectionectomy in 13 (75 per cent) and central hepatectomy in eight (46 per cent). Median duration of surgery was 270 (range 100-540) min and median blood loss was 300 (10-4500) ml. There were 20 conversions to an open procedure (116 per cent). Vascular clamping was independently associated with conversion on multivariable analysis (hazard ratio 595, 95 per cent c.i. 124 to 2856; P=0026). The CUSUMOT learning curve was modelled as a parabola (CUSUMOT=02149xpatient number(2)-30586xpatient number-11183; R-2=07356). The learning curve comprised three phases: phase 1 (45 initial patients), phase 2 (30 intermediate patients) and phase 3 (the subsequent 98 patients). Although right hepatectomy was most common in phase 1, a significant decrease was observed from phase 1 to 3 (P=0007) in favour of more complex procedures. ConclusionThe 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. Safe in experienced hands