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Original Investigation
October 2016

Outcome and Learning Curve in 159 Consecutive Patients Undergoing Total Laparoscopic Hemihepatectomy

Author Affiliations
  • 1Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, England
  • 2Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
  • 3University Surgery, University of Southampton, Southampton, England
JAMA Surg. 2016;151(10):923-928. doi:10.1001/jamasurg.2016.1655
Key Points

Question  What is the learning curve of total laparoscopic hemihepatectomy and can such a complex technique be implemented safely within a liver unit?

Findings  In this review of 159 patients undergoing total laparoscopic hemihepatectomy, a learning curve of 19 procedures was found. Overall outcomes were satisfactory and remained unchanged after the introduction of this technique to third and fourth surgeons within the unit.

Meaning  Total laparoscopic hemihepatectomy is a feasible and safe procedure with an acceptable learning curve when performed by experienced surgeons.


Importance  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.

Objective  To evaluate the extent and safety of the learning curve for laparoscopic hemihepatectomy.

Design, Setting, and Participants  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.

Main Outcomes and Measures  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.

Results  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.

Conclusions and Relevance  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.