ORIGINAL ARTICLE
Assessing the Learning Curve for Totally Laparoscopic Major-Complex Liver Resections: A Single Hepatobiliary Surgeon Experience Marcello G. Spampinato, MD, PhD, FEBS,* Marianna Arvanitakis, MD, PhD,w Francesco Puleo, MD,w Lucio Mandala, MD, PhD,z Giuseppe Quarta, MD,y and Gianandrea Baldazzi, MD*
Background: Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (Z3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon. Materials and Methods: From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared. Results: Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P = 0.017), blood loss (P = 0.004), number of cases requiring a Pringle maneuver (P = 0.006), and blood transfusion (P = 0.001) from case number ten onward. Conclusions: This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale. Key Words: laparoscopic major liver resection, laparoscopic complex liver resections, learning curve, laparoscopic hepatectomy
(Surg Laparosc Endosc Percutan Tech 2015;25:e45–e50)
T
he first laparoscopic liver resection (LLR) was performed by Reich et al.1 Since then, this approach has been increasingly used to treat both benign and malignant neoplasm of the liver requiring resection, with comparable outcomes to open hepatectomies.2–4 In many centers, the Received for publication July 19, 2013; accepted November 1, 2013. From the *HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico of Abano Terme, Abano Terme; zHPB Unit, La Maddalena Cancer Center, Palermo; yMedical Oncology Unit, Gallipoli General Hospital, Gallipoli, Italy; and wDepartment of Gastroenterology, Erasme University Hospital, Brussels, Belgium. F.P. receives grants by Fonds Erasme, Brussels, Belgium. The remaining authors declare no conflicts of interest. Reprints: Marcello G. Spampinato, MD, PhD, FEBS, HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico di Abano Terme, Piazza C. Colombo 1, Abano Terne (PD) 35031, Italy (e-mail: marcello. [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
laparoscopic approach has become the gold standard to perform minor liver resections for lesions located in the anteroinferior segments of the liver,5,6 whereas only few highly specialized centers all around the world routinely perform major (Z3 segments) or complex (right superoposterior segments) hepatectomies, owing to technical challenging issues and advanced laparoscopic skills required to perform it.7 Recently, encouraging results have been reported in terms of feasibility and safety for laparoscopic major-complex liver surgery,8,9 although many doubts still remain on reproducibility, type of surgical training, and minimum number of cases required to achieve an adequate experience to perform it safely. The aim of our study was to evaluate the learning curve of a single hepatobiliary surgeon (M.G.S.) on majorcomplex totally laparoscopic liver resections (TLLR) performed over a short period of 3 years.
MATERIALS AND METHODS This is a retrospective comparative study analyzing prospectively recorded data of consecutive elective TLLR performed by a single hepatobiliary surgeon (M.G.S.) for both benign and malignant liver neoplasm over a period of 40 months. A major hepatectomy was defined as the removal of Z3 liver segments according to the Brisbane 2000 Terminology of Liver Anatomy and Resections.10 A complex laparoscopic hepatectomy was defined as the removal of the right superoposterior segments of the liver (segments VII and VIII) as stated by the Louisville position on LLR.7 With the respect to the liver location, patients with large lesions considered difficult to obtain an R0 resection because of central location and intimate contact to major hepatic veins, or requiring a locoregional lymph-node dissection, were excluded. Previous abdominal surgery was not considered a contraindication for a laparoscopic approach. Perioperative mortality was defined as death during the same hospital admission or within 90 days of hepatic resection. Postoperative complications were classified as per Dindo-Clavien classification.11 Margin status was defined as microscopically negative for tumor (R0) or microscopically positive for tumor (R1). Readmission rate for any reason was recorded.
Surgical Technique Operation was carried out with the patient in a lithotomy position using 4 to 5 operative ports. In the event of complex hepatectomies, a left semisupine decubitus was used to facilitate the access to the right posterior segments. Liver resectability was always confirmed by an
Volume 25, Number 2, April 2015
www.surgical-laparoscopy.com |
e45
Surg Laparosc Endosc Percutan Tech
Spampinato et al
intraoperative staging ultrasound. A 90 cm cotton sling along with an 8 cm silicon intracorporeal tourniquet was always placed around the hepatoduodenal ligament and brought extracorporeal through the paraumbilical port to be used if an intermittent Pringle Maneuver (IPM) was required. In the event of a right/left hemihepatectomy, an extrahepatic intraglissonian approach was used to control hepatic inflow with division of the arterial and portal branch with the aid of Hem-o-lok clips (Weck Closure System, Durham, NC), whereas attempt to control the outflow extraparenchymally was never done. A combination of cavitations-aspiration system, harmonic scalpel, and bipolar forceps were used to divide the parenchyma; vascular staplers were applied to divide the hepatic veins as well as the bile duct within the glissonian pedicles intraparenchymally. Specimen was retrieved by an endobag through a Pfannestiel incision.
Statistical Analysis Descriptive statistics were expressed as median and interquartile range for continuous variables. Differences between groups were calculated by using the Mann-Whitney test for continuous variables. The Pearson w2 test or the Fisher exact tests, if appropriate, were used for categorical variables. Learning curves concerning operation time, blood loss, time of vascular clamping, and transfusional needs were expressed with linear regression and R2 values. Statistical analysis was performed by appropriate tests using the SPSS software package version (SPSS, Chicago, IL). All P-values
Assessing the Learning Curve for Totally Laparoscopic Major-Complex Liver Resections: A Single Hepatobiliary Surgeon Experience Marcello G. Spampinato, MD, PhD, FEBS,* Marianna Arvanitakis, MD, PhD,w Francesco Puleo, MD,w Lucio Mandala, MD, PhD,z Giuseppe Quarta, MD,y and Gianandrea Baldazzi, MD*
Background: Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (Z3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon. Materials and Methods: From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared. Results: Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P = 0.017), blood loss (P = 0.004), number of cases requiring a Pringle maneuver (P = 0.006), and blood transfusion (P = 0.001) from case number ten onward. Conclusions: This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale. Key Words: laparoscopic major liver resection, laparoscopic complex liver resections, learning curve, laparoscopic hepatectomy
(Surg Laparosc Endosc Percutan Tech 2015;25:e45–e50)
T
he first laparoscopic liver resection (LLR) was performed by Reich et al.1 Since then, this approach has been increasingly used to treat both benign and malignant neoplasm of the liver requiring resection, with comparable outcomes to open hepatectomies.2–4 In many centers, the Received for publication July 19, 2013; accepted November 1, 2013. From the *HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico of Abano Terme, Abano Terme; zHPB Unit, La Maddalena Cancer Center, Palermo; yMedical Oncology Unit, Gallipoli General Hospital, Gallipoli, Italy; and wDepartment of Gastroenterology, Erasme University Hospital, Brussels, Belgium. F.P. receives grants by Fonds Erasme, Brussels, Belgium. The remaining authors declare no conflicts of interest. Reprints: Marcello G. Spampinato, MD, PhD, FEBS, HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico di Abano Terme, Piazza C. Colombo 1, Abano Terne (PD) 35031, Italy (e-mail: marcello. [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
laparoscopic approach has become the gold standard to perform minor liver resections for lesions located in the anteroinferior segments of the liver,5,6 whereas only few highly specialized centers all around the world routinely perform major (Z3 segments) or complex (right superoposterior segments) hepatectomies, owing to technical challenging issues and advanced laparoscopic skills required to perform it.7 Recently, encouraging results have been reported in terms of feasibility and safety for laparoscopic major-complex liver surgery,8,9 although many doubts still remain on reproducibility, type of surgical training, and minimum number of cases required to achieve an adequate experience to perform it safely. The aim of our study was to evaluate the learning curve of a single hepatobiliary surgeon (M.G.S.) on majorcomplex totally laparoscopic liver resections (TLLR) performed over a short period of 3 years.
MATERIALS AND METHODS This is a retrospective comparative study analyzing prospectively recorded data of consecutive elective TLLR performed by a single hepatobiliary surgeon (M.G.S.) for both benign and malignant liver neoplasm over a period of 40 months. A major hepatectomy was defined as the removal of Z3 liver segments according to the Brisbane 2000 Terminology of Liver Anatomy and Resections.10 A complex laparoscopic hepatectomy was defined as the removal of the right superoposterior segments of the liver (segments VII and VIII) as stated by the Louisville position on LLR.7 With the respect to the liver location, patients with large lesions considered difficult to obtain an R0 resection because of central location and intimate contact to major hepatic veins, or requiring a locoregional lymph-node dissection, were excluded. Previous abdominal surgery was not considered a contraindication for a laparoscopic approach. Perioperative mortality was defined as death during the same hospital admission or within 90 days of hepatic resection. Postoperative complications were classified as per Dindo-Clavien classification.11 Margin status was defined as microscopically negative for tumor (R0) or microscopically positive for tumor (R1). Readmission rate for any reason was recorded.
Surgical Technique Operation was carried out with the patient in a lithotomy position using 4 to 5 operative ports. In the event of complex hepatectomies, a left semisupine decubitus was used to facilitate the access to the right posterior segments. Liver resectability was always confirmed by an
Volume 25, Number 2, April 2015
www.surgical-laparoscopy.com |
e45
Surg Laparosc Endosc Percutan Tech
Spampinato et al
intraoperative staging ultrasound. A 90 cm cotton sling along with an 8 cm silicon intracorporeal tourniquet was always placed around the hepatoduodenal ligament and brought extracorporeal through the paraumbilical port to be used if an intermittent Pringle Maneuver (IPM) was required. In the event of a right/left hemihepatectomy, an extrahepatic intraglissonian approach was used to control hepatic inflow with division of the arterial and portal branch with the aid of Hem-o-lok clips (Weck Closure System, Durham, NC), whereas attempt to control the outflow extraparenchymally was never done. A combination of cavitations-aspiration system, harmonic scalpel, and bipolar forceps were used to divide the parenchyma; vascular staplers were applied to divide the hepatic veins as well as the bile duct within the glissonian pedicles intraparenchymally. Specimen was retrieved by an endobag through a Pfannestiel incision.
Statistical Analysis Descriptive statistics were expressed as median and interquartile range for continuous variables. Differences between groups were calculated by using the Mann-Whitney test for continuous variables. The Pearson w2 test or the Fisher exact tests, if appropriate, were used for categorical variables. Learning curves concerning operation time, blood loss, time of vascular clamping, and transfusional needs were expressed with linear regression and R2 values. Statistical analysis was performed by appropriate tests using the SPSS software package version (SPSS, Chicago, IL). All P-values
