Updates in Surgery

, Volume 67, Issue 2, pp 207–213 | Cite as

MILS in a general surgery unit: learning curve, indications, and limitations

  • Alberto Patriti
  • Luigi Marano
  • Luciano Casciola
Original Article
Part of the following topical collections:
  1. Minimally Invasive Liver Surgery: An Update


Minimally invasive liver surgery (MILS) is going to be a method with a wide diffusion even in general surgery units. Organization, learning curve effect, and the environment are crucial issues to evaluate before starting a program of minimally invasive liver resections. Analysis of a consecutive series of 70 patients has been used to define advantages and limits of starting a program of MILS in a general surgery unit. Seventeen MILS have been calculated with the cumulative sum method as the number of cases to complete the learning curve. Operative times [270 (60–480) vs. 180 (15–550) min; p 0.01] and rate of conversion (6/17 vs. 5/53; p 0.018) decrease after this number of cases. More complex cases can be managed after a proper optimization of all steps of liver resection. When a high confidence of the medical and nurse staff with MILS is reached, economical and strategic issues should be evaluated in order to establish a multidisciplinary hepatobiliary unit independent from the general surgery unit to manage more complex cases.


Liver Laparoscopy Learning curve Robot-assisted surgery Hepatectomy General surgery 


Compliance with ethical standards

Conflict of interest


Ethical Standard

I declare that in the study were respected the ethical standards conformed to the guidelines of the Helsinki Declaration (as revised in Tokyo 2004). No study advertising was made and no remuneration was offered.

Research involving human participants and/or animals

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Veldkamp R, Kuhry E, Hop WCJ, Jeekel J, Kazemier G, Bonjer HJ et al (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6(7):477–484PubMedCrossRefGoogle Scholar
  2. 2.
    Dixon E, Vollmerjr C, Bathe O, Sutherland F (2005) Training, practice, and referral patterns in hepatobiliary and pancreatic surgery: survey of general surgeons. J Gastrointest Surg 9(1):109–114PubMedCrossRefGoogle Scholar
  3. 3.
    Cunningham SC, Farooqui S (2013) Subspecialty radiology and surgery. Hepatobiliary Pancreat Dis Int 12:122–124PubMedCrossRefGoogle Scholar
  4. 4.
    Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I et al (2009) The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 250(5):825–830PubMedCrossRefGoogle Scholar
  5. 5.
    Medbery RL, Chadid TS, Sweeney JF, Knechtle SJ, Kooby DA, Maithel SK, Lin E, Sarmiento JM (2014) Laparoscopic vs open right hepatectomy: a value-based analysis. J Am Coll Surg 218(5):929–939. doi: 10.1016/j.jamcollsurg.2014.01.045 PubMedCrossRefGoogle Scholar
  6. 6.
    Torzilli G, Procopio F, Cimino M, Del Fabbro D, Palmisano A, Donadon M et al (2010) Anatomical segmental and subsegmental resection of the liver for hepatocellular carcinoma: a new approach by means of ultrasound-guided vessel compression. Ann Surg 251(2):229–235PubMedCrossRefGoogle Scholar
  7. 7.
    Gurusamy KS, Pamecha V, Sharma D, Davidson BR (2009) Techniques for liver parenchymal transection in liver resection. Cochrane Database Syst Rev (1):CD006880. doi: 10.1002/14651858.CD006880.pub2
  8. 8.
    Casciola L, Patriti A, Ceccarelli G, Bartoli A, Ceribelli C, Spaziani A (2011) Robot-assisted parenchymal-sparing liver surgery including lesions located in the posterosuperior segments. Surg Endosc 25:3815–38248PubMedCrossRefGoogle Scholar
  9. 9.
    Patriti A, Ceccarelli G, Bartoli A, Casciola L (2011) Extracorporeal pringle maneuver in robot-assisted liver surgery. Surg Laparosc Endosc Percutan Tech 21(5):e242–e244PubMedCrossRefGoogle Scholar
  10. 10.
    Bolsin S, Colson M (2000) The use of the Cusum Technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 12:433–438PubMedCrossRefGoogle Scholar
  11. 11.
    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240(2):205–213PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Cherqui D (2003) Laparoscopic liver resection. Br J Surg 90(6):644–646PubMedCrossRefGoogle Scholar
  13. 13.
    Viganò L, Tayar C, Laurent A, Cherqui D (2009) Laparoscopic liver resection: a systematic review. J Hepatobiliary Pancreat Surg 16(4):410–421PubMedCrossRefGoogle Scholar
  14. 14.
    Giulianotti PC, Sbrana F, Coratti A, Bianco FM, Addeo P, Buchs N et al (2011) Totally robotic right hepatectomy: surgical technique and outcomes. Arch Surg 146(7):844–850PubMedCrossRefGoogle Scholar
  15. 15.
    Ceccarelli G, Patriti A, Bellochi R, Spaziani A, Casciola L (2013) Costs and benefits. A triad in comparison: open, laparoscopic, and robotic surgery. Updates in Surgery. Springer Milan, Milano, pp 57–64Google Scholar
  16. 16.
    Dagher I, Gayet B, Tzanis D, Tranchart H, Fuks D, Soubrane O et al (2014) International experience for laparoscopic major liver resection. J Hepatobiliary Pancreat Sci 21(10):732–736PubMedCrossRefGoogle Scholar
  17. 17.
    Simillis C, Constantinides VA, Tekkis PP, Darzi A, Lovegrove R, Jiao L et al (2007) Laparoscopic versus open hepatic resections for benign and malignant neoplasms—a meta-analysis. Surgery 141(2):203–211PubMedCrossRefGoogle Scholar
  18. 18.
    Descottes B, Glineur D, Lachachi F, Valleix D, Paineau J, Hamy A et al (2003) Laparoscopic liver resection of benign liver tumors. Surg Endosc 17(1):23–30PubMedCrossRefGoogle Scholar
  19. 19.
    Vigano L, Laurent A, Tayar C, Tomatis M, Ponti A, Cherqui D (2009) The learning curve in laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg 250(5):772–782PubMedCrossRefGoogle Scholar
  20. 20.
    Wakabayashi G, Cherqui D, Geller DA, Han H-S, Kaneko H, Buell JF (2014) Laparoscopic hepatectomy is theoretically better than open hepatectomy: preparing for the 2nd International Consensus Conference on Laparoscopic Liver Resection. J Hepatobiliary Pancreat Sci 21:723–731PubMedCrossRefGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2015

Authors and Affiliations

  • Alberto Patriti
    • 1
  • Luigi Marano
    • 1
  • Luciano Casciola
    • 2
  1. 1.Division of General, Minimally Invasive and Robotic Surgery, Department of SurgeryASL Umbria 2, Ospedale San Matteo degli InfermiSpoletoItaly
  2. 2.Division of Minimally Invasive SurgeryEuropean HospitalRomeItaly

Personalised recommendations