title: Assessing the learning curve for totally laparoscopic major-complex liver resections: a single hepatobiliary surgeon experience.
abstract: BACKGROUND
  Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (≥ 3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon.
  
  
  METHODS
  From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared.
  
  
  RESULTS
  Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P=0.017), blood loss (P=0.004), number of cases requiring a Pringle maneuver (P=0.006), and blood transfusion (P=0.001) from case number ten onward.
  
  
  CONCLUSIONS
  This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale.
authors.affiliation: *HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico of Abano Terme, Abano Terme ‡HPB Unit, La Maddalena Cancer Center, Palermo §Medical Oncology Unit, Gallipoli General Hospital, Gallipoli, Italy †Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium.
authors.forename: Marcello G
authors.initials: MG
authors.lastname: Spampinato
authors.forename: Marianna
authors.initials: M
authors.lastname: Arvanitakis
authors.forename: Francesco
authors.initials: F
authors.lastname: Puleo
authors.forename: Lucio
authors.initials: L
authors.lastname: Mandala
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Quarta
authors.forename: Gianandrea
authors.initials: G
authors.lastname: Baldazzi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000193:education* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D066231:Surgeons / Q000592:standards*