Learning Curve for Laparoscopic Major Hepatectomy: Use of the Cumulative Sum Method.
BACKGROUND
Laparoscopic liver resection (LLR) has now become a worldwide practice. However, the adoption of laparoscopic major hepatectomy (LMH) was slow. We report our center's experience in laparoscopic major resections.


METHODS
A total of 156 LLRs from 2002 to 2014 were studied. The clinical parameters of LMHs were compared with those of minor resections. The learning curve of LMHs was investigated using the cumulative sum (CUSUM) analysis of operative time. Subgroup analysis of right posterior sectionectomies against anterolateral hepatectomies was conducted.


RESULTS
Among the 156 LLRs, 49 (31%) were LMHs. CUSUM analysis showed that operative time improved after the 25th LMH. Beyond that proportion of pure laparoscopic LMHs increased (18/25 vs. 24/24, P=0.005); Pringle maneuver was not required (4/25 vs. 0/24, P=0.041). Blood loss (800 vs. 500 mL, P=0.034) and transfusion rate (13/25 to 3/24, P=0.003) improved in latter LMHs. Right posterior sectionectomies had significantly more blood loss than anterolateral LMHs (500 vs. 1500 mL, P=0.034).


CONCLUSIONS
Laparoscopic major resection is safe and feasible; operative outcomes improved after overcoming the learning curve. Right posterior sectionectomy, however, should be further evaluated for its cost-effectiveness.
Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong.
Fiona Ka-Man
FK
Chan
Kai-Chi
KC
Cheng
Yuk-Pang
YP
Yeung
Kit-Man
KM
Ho
D000368:Aged; D016063:Blood Loss, Surgical; D002983:Clinical Competence / Q000592:standards; D061887:Conversion to Open Surgery; D005240:Feasibility Studies; D005260:Female; D006498:Hepatectomy / Q000193:education* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time