title: Outcome and Learning Curve in 159 Consecutive Patients Undergoing Total Laparoscopic Hemihepatectomy.
abstract: Widespread implementation of laparoscopic hemihepatectomy is currently limited by its technical difficulty, paucity of training opportunities, and perceived long and harmful learning curve. Studies confirming the possibility of a short and safe learning curve for laparoscopic hemihepatectomy could potentially benefit the further implementation of the technique.
  
  
  
  To evaluate the extent and safety of the learning curve for laparoscopic hemihepatectomy.
  
  
  
  A prospectively collected single-center database containing all laparoscopic liver resections performed in our unit at the University Hospital Southampton National Health Service Foundation Trust between August 2003 and March 2015 was retrospectively reviewed; analyses were performed in December 2015. The study included 159 patients in whom a total laparoscopic right or left hemihepatectomy procedure was started (intention-to-treat analysis), including laparoscopic extended hemihepatectomies and hemihepatectomies with additional wedge resections, at a tertiary referral center specialized in laparoscopic hepato-pancreato-biliary surgery.
  
  
  
  Primary end points were clinically relevant complications (Clavien-Dindo grade ≥III). The presence of a learning curve effect was assessed with a risk-adjusted cumulative sum analysis.
  
  
  
  Of a total of 531 consecutive laparoscopic liver resections, 159 patients underwent total laparoscopic hemihepatectomy (105 right and 54 left). In a cohort with 67 men (42%), median age of 64 years (interquartile range [IQR], 51-73 years), and 110 resections (69%) for malignant lesions, the overall median operation time was 330 minutes (IQR, 270-391 minutes) and the median blood loss was 500 mL (IQR, 250-925 mL). Conversion to an open procedure occurred in 17 patients (11%). Clinically relevant complications occurred in 17 patients (11%), with 1% mortality (death within 90 days of surgery, n = 2). Comparison of outcomes over time showed a nonsignificant decrease in conversions (right: 14 [13%] and left: 3 [6%]), blood loss (right: 550 mL [IQR, 350-1150 mL] and left: 300 mL [IQR, 200-638 mL]), complications (right: 15 [14%] and left: 4 [7%]), and hospital stay (right: 5 days [IQR, 4-7 days] and left: 4 days [IQR, 3-5 days]). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 55 laparoscopic hemihepatectomies for conversions.
  
  
  
  Total laparoscopic hemihepatectomy is a feasible and safe procedure with an acceptable learning curve for conversions. Focus should now shift to providing adequate training opportunities for centers interested in implementing this technique.
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Marcel J
authors.initials: MJ
authors.lastname: van der Poel
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Federica
authors.initials: F
authors.lastname: Cipriani
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Thomas
authors.initials: T
authors.lastname: Armstrong
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Arjun S
authors.initials: AS
authors.lastname: Takhar
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands.
authors.forename: Susan
authors.initials: S
authors.lastname: van Dieren
authors.affiliation: University Surgery, University of Southampton, Southampton, England.
authors.forename: John N
authors.initials: JN
authors.lastname: Primrose
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Neil W
authors.initials: NW
authors.lastname: Pearce
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Abu Hilal
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D002983:Clinical Competence; D061887:Conversion to Open Surgery; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D057194:Intention to Treat Analysis; D010535:Laparoscopy / Q000009:adverse effects*; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome