title: Learning curve of self-taught laparoscopic liver surgeons in left lateral sectionectomy: results from an international multi-institutional analysis on 245 cases.
abstract: Laparoscopy was suggested as gold standard for left lateral sectionectomy (LLS), thanks to recognized benefits compared to open approach. Aim of this study was to define learning curve (LC) of laparoscopic LLS (LLLS) using operative time (OT) as tool to analyze outcome of procedures performed by four experienced surgeons. Reproducibility and safety of LC in LLLS among independent surgeons were also analyzed as essential features of "standard procedure" concept.
  
  
  
  LLLS performed by four experienced surgeons was collected. Multivariate analysis was carried out to screen factors affecting OT. A cumulative LC was created calculating median OT. Skewness of OT was analyzed, and ROC curve was carried out to identify the cutoff for LC. The impact of LC on outcomes (morbidity and mortality, blood loss, conversions, surgical margins and length of stay) was determined.
  
  
  
  A total of 245 LLLSs were collected. Conversion rate was 1.2 %. Median OT was 141 min, blood loss 100 mL, morbidity 11.4 % and mortality 0.4 %. "Associated procedures" was the only independent factor affecting OT. The skewness of the OT was calculated, and the cutoff point for LC was determined after 15 LLLSs. LLLS performed during and after LC period had similar outcomes.
  
  
  
  LLLS is feasible with low morbidity, mortality and conversion rate. LC in LLLS is shorter compared to minor liver resections. Furthermore, it is reproducible and safe since it does not negatively affect clinical outcome. A reproducible, safe and short LC contributes to considering laparoscopy as the gold standard approach to perform LLS.
authors.affiliation: Hepatobiliary Surgery Unit, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy. ratti.francesca@hsr.it.
authors.forename: Francesca
authors.initials: F
authors.lastname: Ratti
authors.affiliation: Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway.|Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
authors.forename: Leonid I
authors.initials: LI
authors.lastname: Barkhatov
authors.affiliation: Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent, Belgium.
authors.forename: Federico
authors.initials: F
authors.lastname: Tomassini
authors.affiliation: Hepatobiliary Surgery Unit, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.|University Surgical Unit, Southampton General Hospital, NHS Foundation Trust, Southampton, UK.
authors.forename: Federica
authors.initials: F
authors.lastname: Cipriani
authors.affiliation: Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway.|Department of Surgery, Finnmark Hospital, Kirkenes, Norway.
authors.forename: Airazat M
authors.initials: AM
authors.lastname: Kazaryan
authors.affiliation: Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway.|Department of Hepatopancreatobiliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.|Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
authors.forename: Bjǿrn
authors.initials: B
authors.lastname: Edwin
authors.affiliation: University Surgical Unit, Southampton General Hospital, NHS Foundation Trust, Southampton, UK.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Abu Hilal
authors.affiliation: Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent, Belgium.
authors.forename: Roberto I
authors.initials: RI
authors.lastname: Troisi
authors.affiliation: Hepatobiliary Surgery Unit, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000706:statistics & numerical data; D005260:Female; D006498:Hepatectomy / Q000193:education / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000193:education / Q000379:methods*; D059032:Learning Curve; D007902:Length of Stay / Q000706:statistics & numerical data; D008099:Liver / Q000601:surgery; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D015203:Reproducibility of Results; D012189:Retrospective Studies; D066231:Surgeons / Q000193:education*; D055815:Young Adult
keywords: Laparoscopy; Learning curve; Left lateral sectionectomy; Liver surgery; Standard