title: Laparoscopic liver resection and the learning curve: a 14-year, single-center experience.
abstract: BACKGROUND
  Laparoscopic liver resection has not been widely used because of intraoperative bleeding. This problem should be solved with instruments and techniques that require a short learning curve.
  
  
  METHODS
  The aim of this work was to present the technique used in our center to perform laparoscopic liver resection using the 'curettage and aspiration' technique with laparoscopic Peng's multifunctional operational dissectors and regional occlusion of inflow and outflow. We retrospectively analyzed patients who underwent a laparoscopic liver resection from August 1998 to August 2012, and collected the conversion rate, operating time, blood loss, hospitalization, bile leakage rate, bleeding rate, and other complications on a yearly basis and in total. We used SPSS software to analyze whether there was a significant difference, and summarized the learning curve of laparoscopic liver resection with various procedures.
  
  
  RESULTS
  We performed 365 cases of laparoscopic liver resection, including left hemihepatectomy, left lateral lobectomy, segmental hepatectomy, non-anatomic liver resection, right hemihepatectomy, and caudate lobectomy. The diseases included liver cancer, hepatolithiasis, liver hemangioma, focal nodular hyperplasia, liver abscess, and metastatic hepatic carcinoma. In total, 63 cases (17.20 %) were converted to open surgery because of severe adhesions, bleeding, or anatomical limitation. Mean blood loss was 370.6 ± 404.0 ml; mean operating time was 150.8 ± 73.0 min; and mean postoperation hospitalization was 9.2 ± 5.3 days. There were four cases (1.32 %) with the complication of bile leakage and two cases of hemorrhage (0.66 %). No intraoperative or postoperative deaths occurred. After finishing 15-30, 43, 35, and 28 cases of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy, respectively, the average operating time, blood loss, and hospitalization were almost the same as the overall mean results.
  
  
  CONCLUSIONS
  The technique used in our center is a safe, fast, and effective approach to laparoscopic liver resection. Our 14 years of experience demonstrates that this technique can prevent postoperative bleeding and bile leakage. A surgeon can master the skill of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy after ∼15-30, 43, 35, and 28 case procedures, respectively.
authors.affiliation: Key Laboratory of Laparoscopic Technique of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Institute of Minimally Invasive Surgery of Zhejiang University, Zhejiang University, No. 3, Qingchun Road East, Hangzhou, 310016, China, cxjzju@gmail.com.
authors.forename: Xiujun
authors.initials: X
authors.lastname: Cai
authors.forename: Zheyong
authors.initials: Z
authors.lastname: Li
authors.forename: Yale
authors.initials: Y
authors.lastname: Zhang
authors.forename: Hong
authors.initials: H
authors.lastname: Yu
authors.forename: Xiao
authors.initials: X
authors.lastname: Liang
authors.forename: Renan
authors.initials: R
authors.lastname: Jin
authors.forename: Feng
authors.initials: F
authors.lastname: Luo
mesh_terms: D002983:Clinical Competence; D004502:Education, Medical, Continuing / Q000379:methods*; D006498:Hepatectomy / Q000193:education* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D008107:Liver Diseases / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome