The learning curve of laparoscopic liver resection after the Louisville statement 2008: Will it be more effective and smooth?
Laparoscopic liver resection (LLR) has been proven to be feasible and safe. However, it is a difficult and complex procedure with a steep learning curve. The aim of this study was to evaluate the learning curve of LLR at our institutions since 2008.



One hundred and twenty-six consecutive LLRs were included from May 2008 to December 2014. Patient characteristics, operative data, and surgical outcomes were collected prospectively and analyzed.



The median tumor size was 25 mm (range 5-90 mm), and 96 % of the resected tumors were malignant. 41.3 % (52/126) of patients had pathologically proven liver cirrhosis. The median operation time was 216 min (range 40-602 min) with a median blood loss of 100 ml (range 20-2300 ml). The median length of hospital stay was 4 days (range 2-10 days). Six major postoperative complications occurred in this series, and there was no 90-day postoperative mortality. Regarding the incidence of major operative events including operation time longer than 300 min, perioperative blood loss above 500 ml, and major postoperative complications, the learning curve [as evaluated by the cumulative sum (CUSUM) technique] showed its first reverse after 22 cases. The indication of laparoscopic resection in this series extended after 60 cases to include tumors located in difficult locations (segments 4a, 7, 8) and major hepatectomy. CUSUM showed that the incidence of major operative events proceeded to increase again, and the second reverse was noted after an additional 40 cases of experience. Location of the tumor in a difficult area emerged as a significant predictor of major operative events.



In carefully selected patients, CUSUM analysis showed 22 cases were needed to overcome the learning curve for minor LLR.
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan. charleslin@kfsyscc.org.|School of Medicine, National Yang-Ming University, Taipei, Taiwan. charleslin@kfsyscc.org.
Chung-Wei
CW
Lin
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan.|School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Tzu-Jung
TJ
Tsai
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan.|School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Tsung-Yen
TY
Cheng
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan.|School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Hung-Kuang
HK
Wei
Department of Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
Chen-Fang
CF
Hung
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan.|School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Yin-Yin
YY
Chen
Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei, 112, Taiwan.|School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Chii-Ming
CM
Chen
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D002983:Clinical Competence; D005260:Female; D006498:Hepatectomy / Q000193:education* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D007902:Length of Stay; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications; D015397:Program Evaluation; D013624:Taiwan
Hepatectomy; Hepatocellular carcinoma; Laparoscopic; Learning curve; Liver resection