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What is the Learning Curve for Laparoscopic Major Hepatectomy?

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50–65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC).

Methods

We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments.

Results

Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45–60 cases is evident for laparoscopic hepatic resection.

Conclusion

Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45–60 cases.

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References

  1. Nguyen, K.T., T.C. Gamblin, and D.A. Geller, World review of laparoscopic liver resection-2,804 patients. Ann Surg, 2009. 250(5): p. 831–41.

    Article  PubMed  Google Scholar 

  2. Geller, D.A. and A. Tsung, Longterm outcomes and safety of laparoscopic liver resection surgery for hepatocellular carcinoma and metastatic colorectal cancer. J Hepatobiliary Pancreat Sci, 2015.

  3. Nguyen, K.T., T.C. Gamblin, and D.A. Geller, Laparoscopic liver resection for cancer. Future Oncol, 2008. 4(5): p. 661–70.

    Article  PubMed  Google Scholar 

  4. Nguyen, K.T. and D.A. Geller, Is laparoscopic liver resection safe and comparable to open liver resection for hepatocellular carcinoma? Ann Surg Oncol, 2009. 16(7): p. 1765–7.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Nguyen, K.T., et al., Minimally invasive liver resection for metastatic colorectal cancer: a multi-institutional, international report of safety, feasibility, and early outcomes. Ann Surg, 2009. 250(5): p. 842–8.

    Article  PubMed  Google Scholar 

  6. Nguyen, K.T. and D.A. Geller, Outcomes of laparoscopic hepatic resection for colorectal cancer metastases. J Surg Oncol, 2010. 102(8): p. 975–7.

    Article  PubMed  Google Scholar 

  7. Reddy, S.K., A. Tsung, and D.A. Geller, Laparoscopic liver resection. World J Surg, 2011. 35(7): p. 1478–86.

    Article  PubMed  Google Scholar 

  8. Sasaki, A., et al., Ten-year experience of totally laparoscopic liver resection in a single institution. Br J Surg, 2009. 96(3): p. 274–9.

    Article  CAS  PubMed  Google Scholar 

  9. Vigano, L., et al., Laparoscopic liver resection: a systematic review. J Hepatobiliary Pancreat Surg, 2009. 16(4): p. 410–21.

    Article  PubMed  Google Scholar 

  10. Buell, J.F., et al., The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg, 2009. 250(5): p. 825–30.

    Article  PubMed  Google Scholar 

  11. Wakabayashi, G., et al., Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg, 2015. 261(4): p. 619–29.

    PubMed  Google Scholar 

  12. Ciria, R., et al., Comparative short term benefits of laparoscopic liver resection: 9,000 cases and climbing. Ann Surg, 2015.

  13. Nguyen, K.T., et al., Comparative benefits of laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg, 2011. 146(3): p. 348–56.

    Article  PubMed  Google Scholar 

  14. Castaing, D., et al., Oncologic results of laparoscopic versus open hepatectomy for colorectal liver metastases in two specialized centers. Ann Surg, 2009. 250(5): p. 849–55.

    Article  PubMed  Google Scholar 

  15. Kazaryan, A.M., et al., Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome. Ann Surg, 2010. 252(6): p. 1005–12.

    Article  PubMed  Google Scholar 

  16. Kazaryan, A.M., B.I. Rosok, and B. Edwin, Laparoscopic and open liver resection for colorectal metastases: different indications? HPB (Oxford), 2010. 12(6): p. 434; author reply 435.

    Article  Google Scholar 

  17. Topal, H., et al., Outcome of laparoscopic major liver resection for colorectal metastases. Surg Endosc, 2012. 26(9): p. 2451–5.

    Article  PubMed  Google Scholar 

  18. Schiffman, S.C., et al., Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients. Surgery, 2015. 157(2): p. 211–22.

    Article  PubMed  Google Scholar 

  19. Beppu, T., et al., Long-term and perioperative outcomes of laparoscopic versus open liver resection for colorectal liver metastases with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci, 2015.

  20. Takahara, T., et al., Minimally invasive donor hepatectomy: evolution from hybrid to pure laparoscopic techniques. Ann Surg, 2015. 261(1): p. e3-4.

    Article  PubMed  Google Scholar 

  21. Hasegawa, Y., et al., Approaches to laparoscopic liver resection: a meta-analysis of the role of hand-assisted laparoscopic surgery and the hybrid technique. J Hepatobiliary Pancreat Sci, 2015. 22(5): p. 335–41.

    Article  PubMed  Google Scholar 

  22. Cardinal, J.S., et al., Laparoscopic major hepatectomy: pure laparoscopic approach versus hand-assisted technique. J Hepatobiliary Pancreat Sci, 2013. 20(2): p. 114–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Koffron, A.J., et al., Laparoscopic liver surgery for everyone: the hybrid method. Surgery, 2007. 142(4): p. 463–8; discussion 468 e1-2.

    Article  Google Scholar 

  24. Nitta, H., et al., Laparoscopy-assisted major liver resections employing a hanging technique: the original procedure. Ann Surg, 2010. 251(3): p. 450–3.

    Article  PubMed  Google Scholar 

  25. Tsung, A., et al., Robotic versus laparoscopic hepatectomy: a matched comparison. Ann Surg, 2014. 259(3): p. 549–55.

    Article  PubMed  Google Scholar 

  26. Nguyen, K.T. and D.A. Geller, Laparoscopic liver resection--current update. Surg Clin North Am, 2010. 90(4): p. 749–60.

    Article  PubMed  Google Scholar 

  27. Cherqui, D., et al., Laparoscopic living donor hepatectomy for liver transplantation in children. Lancet, 2002. 359(9304): p. 392–6.

    Article  PubMed  Google Scholar 

  28. Soubrane, O., et al., Laparoscopic left lateral sectionectomy in living donors: safety and reproducibility of the technique in a single center. Ann Surg, 2006. 244(5): p. 815–20.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ban, D., et al., A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci, 2014. 21(10): p. 745–53.

    Article  PubMed  Google Scholar 

  30. Giuliante, F. and F. Ardito, Minimally invasive liver surgery in a hepato-biliary unit: learning curve and indications. Updates Surg, 2015. 67(2): p. 201–6.

    Article  PubMed  Google Scholar 

  31. Nomi, T., et al., Learning curve for laparoscopic major hepatectomy. Br J Surg, 2015. 102(7): p. 796–804.

    Article  CAS  PubMed  Google Scholar 

  32. Hunter, J.G., J.M. Sackier, and G. Berci, Training in laparoscopic cholecystectomy. Quantifying the learning curve. Surg Endosc, 1994. 8(1): p. 28–31.

    Article  CAS  PubMed  Google Scholar 

  33. Andrew, C.G., et al., Early results after laparoscopic Roux-en-Y gastric bypass: effect of the learning curve. Can J Surg, 2006. 49(6): p. 417–21.

    PubMed  PubMed Central  Google Scholar 

  34. Bencini, L. and L.J. Sanchez, Learning curve for laparoscopic ventral hernia repair. Am J Surg, 2004. 187(3): p. 378–82.

    Article  PubMed  Google Scholar 

  35. Jaffer, U. and A.E. Cameron, Laparoscopic appendectomy: a junior trainee’s learning curve. JSLS, 2008. 12(3): p. 288–91.

    PubMed  PubMed Central  Google Scholar 

  36. Lal, P., et al., Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve. Surg Endosc, 2004. 18(4): p. 642–5.

    Article  PubMed  Google Scholar 

  37. Schlachta, C.M., et al., Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum, 2001. 44(2): p. 217–22.

    Article  CAS  PubMed  Google Scholar 

  38. Vigano, L., et al., The learning curve in laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg, 2009. 250(5): p. 772–82.

    Article  PubMed  Google Scholar 

  39. Kluger, M.D., et al., The learning curve in laparoscopic major liver resection. J Hepatobiliary Pancreat Sci, 2013. 20(2): p. 131–6.

    Article  PubMed  Google Scholar 

  40. Abu Hilal, M., et al., Single-centre comparative study of laparoscopic versus open right hepatectomy. J Gastrointest Surg, 2011. 15(5): p. 818–23.

    Article  PubMed  Google Scholar 

  41. Dagher, I., et al., Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg, 2009. 250(5): p. 856–60.

    Article  PubMed  Google Scholar 

  42. Lin, N.C., H. Nitta, and G. Wakabayashi, Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg, 2013. 257(2): p. 205–13.

    Article  PubMed  Google Scholar 

  43. Tzanis, D., et al., European experience of laparoscopic major hepatectomy. J Hepatobiliary Pancreat Sci, 2013. 20(2): p. 120–4.

    Article  PubMed  Google Scholar 

  44. Pearce, N.W., et al., Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure. Am J Surg, 2011. 202(5): p. e52-8.

    Article  PubMed  Google Scholar 

  45. Alrasheed, T., et al., Robotic microsurgery: validating an assessment tool and plotting the learning curve. Plast Reconstr Surg, 2014. 134(4): p. 794–803.

    Article  CAS  PubMed  Google Scholar 

  46. Boone, B.A., et al., Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve. JAMA Surg, 2015. 150(5): p. 416–22.

    Article  PubMed  Google Scholar 

  47. Napoli, N., et al., The learning curve in robotic distal pancreatectomy. Updates Surg, 2015.

  48. Park, E.J., et al., Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer?: a comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries. Medicine (Baltimore), 2014. 93(25): p. e109.

    Article  Google Scholar 

  49. Shakir, M., et al., The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre. HPB (Oxford), 2015. 17(7): p. 580–6.

    Article  Google Scholar 

  50. Starnes, C.C., et al., The economy of motion of the totally robotic gastric bypass: technique, learning curve, and outcomes of a fellowship-trained, robotic bariatric surgeon. J Laparoendosc Adv Surg Tech A, 2015. 25(5): p. 411–8.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA

    Kimberly M. Brown

  2. Liver Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA

    David A. Geller

  3. UPMC Liver Cancer Center, UPMC Montefiore, 3459 Fifth Ave, 7 South, Pittsburgh, PA, 15213-2582, USA

    David A. Geller

Authors
  1. Kimberly M. Brown
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  2. David A. Geller
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Corresponding author

Correspondence to David A. Geller.

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Conflict of Interest

The authors declare that they have no competing interests.

Additional information

Learning Objectives

1) To discuss indications, techniques, benefits, and pitfalls of laparoscopic liver resection.

2) To define the learning curve for laparoscopic liver resection, including laparoscopic major hepatectomy

3) To summarize the outcomes of laparoscopic liver resection for HCC and metastatic colorectal cancer (mCRC).

CME Questions

1) The learning curve for laparoscopic liver resection has been reported to be:

A) 5 cases

B) 10 cases

C) 60 cases

D) 100 cases

2) With greater operative experience in laparoscopic liver resection, all of the following improve except:

A) ICU stay

B) OR time

C) Conversion rate

D) Blood loss

3) For surgical approach in laparoscopic liver resection, all of the following techniques are commonly used except:

A) Pure laparoscopic

B) Hand-assisted

C) Hybrid approach

D) Gasless laparoscopic approach

4) The number of laparoscopic liver resection cases reported worldwide is approximately:

A) 500 cases

B) 2,000 cases

C) 9,500 cases

D) 22,000 cases

5) The percentage of laparoscopic liver resection cases being done for malignancy is:

A) 10-20 %

B) 20-30 %

C) 50-60 %

D) 80-90 %

6) Peri-operative mortality for laparoscopic liver resection has been reported at:

A) <1 %

B) 3 %

C) 5 %

D) 10 %

7) The number of International Laparoscopic Liver Consensus Conference convened is:

A) 1

B) 2

C) 3

D) 5

8) The ideal case for a surgeon just starting his/her laparoscopic learning curve would be:

A) 2 cm HCC in segment VII in a patient with minimal fibrosis

B) 6 cm symptomatic hemangioma peripheral in segment VI in a patient with normal parenchyma

C) 3 cm CRC metastasis in segment II in a patient with fatty liver

D) 3 cm CRC metastasis in segment II in a patient with normal parenchyma

E) 2 cm peripheral HCC in segment V in a patient with cirrhosis

CME questions for this article available to SSAT members at http://ssat.com/jogscme/

Disclosure Information: Authors: Kimberly M. Brown, M.D., has nothing to disclose. David A. Geller, M.D. has nothing to disclose. Editors-in-Chief: Jeffrey B. Matthews, M.D., has nothing to disclose; Charles Yeo, M.D., has nothing to disclose. CME Overseers: Arbiter: Jeffrey B. Matthews, M.D., has nothing to disclose; Vice-Arbiter: Ranjan Sudan, M.D., has nothing to disclose; Question Reviewers: I. Michael Leitman, M.D. has nothing to disclose; Ellen J. Hagopian, M.D., has nothing to disclose.

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Brown, K.M., Geller, D.A. What is the Learning Curve for Laparoscopic Major Hepatectomy?. J Gastrointest Surg 20, 1065–1071 (2016). https://doi.org/10.1007/s11605-016-3100-8

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  • DOI: https://doi.org/10.1007/s11605-016-3100-8

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