Stepwise introduction of laparoscopic liver surgery: validation of guideline recommendations

Safety of laparoscopic compared to open right hepatectomy after portal vein occlusion: results from a multicenter study

BACKGROUND

Concerns have been expressed about the feasibility of laparoscopic right hepatectomy (Lap-RH) after portal vein occlusion (PVO), because of its technical difficulty. The aim of this study is to assess the safety and feasibility of lap-RH after PVO.

METHODS

Retrospective analysis of prospectively collected data from high-volume HPB centers was performed. The peri-operative outcomes of lap-RH were compared to open-RH. Propensity score matching (PSM) was used to mitigate the influence of selection bias. Both one-stage and two-stage procedures were considered.

RESULTS

Between 01/2010 and 12/2020, 284 patients underwent RH or extended RH after PVO. The laparoscopic approach was used in 63 (22%) cases. Overall, surgeries were mainly performed for colorectal metastases (68.6%). Two-stage procedures were required in one-third of the cases for both groups. After PSM, 126 patients of the open-RH group were matched with 63 patients of the lap-RH group. In the lap-RH group, compared to open-RH, median FLR% post-PVO was larger (39.4% vs 38.5%, p = 0.037), median operation time was longer (360 vs 264 min, p < 0.001), pedicle clamping was used more frequently (79.4% vs 38.9%, p > 0.001), and median blood loss was higher (250 cc vs 200 cc, p = 0.024). Severe intraoperative incidents seldom occurred in both groups (6.3% lap-RH vs 1.6% open-RH, p = 0.208). The overall and severe complication rates were comparable. ISGLS liver failure grade B/C was rare in both groups (3.2% lap-RH vs 4.8% open-RH, p = 0.721). 90-day mortality was 1.6% following either lap-RH or open-RH. Lap-RH allowed a shorter median hospital stay (6 vs 8 days, p = 0.001). R1 resection rate was lower after lap-RH (3.2% vs 16%, p = 0.008).

CONCLUSION

Lap-RH after PVO is safe, although it is technically more demanding than open-RH. This study also suggests some potential benefits of the laparoscopic approach, in terms of a shorter hospital stay and increased rate of radical resections.

Risk factors and outcomes of conversions in robotic and laparoscopic liver resections: A nationwide analysis

BACKGROUND

Unfavorable intraoperative findings or incidents during minimally invasive liver surgery may necessitate conversion to open surgery. This study aimed to identify predictors for conversion in minimally invasive liver surgery and gain insight into outcomes following conversions.

METHODS

This nationwide, retrospective cohort study compared converted and non-converted minimally invasive liver surgery procedures using data from 20 centers in the Dutch Hepatobiliary Audit (2014-2022). Propensity score matching was applied. Subgroup analyses of converted robotic liver resection versus laparoscopic liver resection and emergency versus non-emergency conversions were performed. Predictors for conversions were identified using backward stepwise multivariable logistic regression.

RESULTS

Of 3,530 patients undergoing minimally invasive liver surgery (792 robotic liver resection, 2,738 laparoscopic liver resection), 408 (11.6%) were converted (4.9% robotic liver resection, 13.5% laparoscopic liver resection). Conversion was associated with increased blood loss (580 mL [interquartile range 250-1,200] vs 200 mL [interquartile range 50-500], P < .001), major blood loss (≥500 mL, 58.8% vs 26.7%, P < .001), intensive care admission (19.0% vs 8.4%, P = .005), overall morbidity (38.9% vs 21.0%, P < .001), severe morbidity (17.9% vs 9.6%, P = .002), and a longer hospital stay (6 days [interquartile range 5-8] vs 4 days [interquartile range 2-5], P < .001) but not mortality (2.2% vs 1.2%, P = .387). Emergency conversions had increased intraoperative blood loss (1,500 mL [interquartile range 700-2,800] vs 525 mL [interquartile range 208-1,000], P < .001), major blood loss (87.5% vs 59.3%, P = .005), and intensive care admission (27.9% vs 10.6%, P = .029), compared with non-emergency conversions. Robotic liver resection was linked to lower conversion risk, whereas American Society of Anesthesiologists grade ≥3, larger lesion size, concurrent ablation, technically major, and anatomically major resections were risk factors.

CONCLUSION

Both emergency and non-emergency conversions negatively impact perioperative outcomes in minimally invasive liver surgery. Robotic liver resection reduces conversion risk compared to laparoscopic liver resection.

Towards a Standardization of Learning Curve Assessment in Minimally Invasive Liver Surgery

OBJECTIVE

The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting.

SUMMARY BACKGROUND DATA

MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization.

METHODS

A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery).

RESULTS

60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%).

CONCLUSIONS

This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Transatlantic registries for minimally invasive liver surgery: towards harmonization

BACKGROUND

Several registries focus on patients undergoing minimally invasive liver surgery (MILS). This study compared transatlantic registries focusing on the variables collected and differences in baseline characteristics, indications, and treatment in patients undergoing MILS. Furthermore, key variables were identified.

METHODS

The five registries for liver surgery from North America (ACS-NSQIP), Italy, Norway, the Netherlands, and Europe were compared. A set of key variables were established by consensus expert opinion and compared between the registries. Anonymized data of all MILS procedures were collected (January 2014-December 2019). To summarize differences for all patient characteristics, treatment, and outcome, the relative and absolute largest differences (RLD, ALD) between the smallest and largest outcome per variable among the registries are presented.

RESULTS

In total, 13,571 patients after MILS were included. Both 30- and 90-day mortality after MILS were below 1.1% in all registries. The largest differences in baseline characteristics were seen in ASA grade 3-4 (RLD 3.0, ALD 46.1%) and the presence of liver cirrhosis (RLD 6.4, ALD 21.2%). The largest difference in treatment was the use of neoadjuvant chemotherapy (RLD 4.3, ALD 20.6%). The number of variables collected per registry varied from 28 to 303. From the 46 key variables, 34 were missing in at least one of the registries.

CONCLUSION

Despite considerable variation in baseline characteristics, indications, and treatment of patients undergoing MILS in the five transatlantic registries, overall mortality after MILS was consistently below 1.1%. The registries should be harmonized to facilitate future collaborative research on MILS for which the identified 46 key variables will be instrumental.

Association between achieving textbook outcomes and better survival after laparoscopic liver resection in the anterolateral segments in patients with hepatocellular carcinoma

BACKGROUND

The quality of surgical procedures are assessed by textbook outcomes (TO). LLR is considered a standard treatment for HCC in the anterolateral segments of the liver. The main objective of this study was to evaluate the factors affecting achievement of TO for laparoscopic liver resection (LLR) and its impact on survival.

METHODS

We conducted a retrospective cohort study of patients who underwent LLR for lesions located in the anterolateral segments (n=309). Patients were divided into TO and non-TO group.

RESULTS

A TO was achieved in 55.0% of patients (n=170). In multivariable analysis, Model for End-stage Liver Disease (MELD) score >10 (odds ratio[OR] 3.076; 95% confidence interval[CI] 1.134-8.342), absence of diabetes mellitus (OR 2.325; 95% CI 1.227-4.407) and thrombocytopenia (OR 2.115; 95% CI 1.134-8.342) were independently associated with not achieving TO. The 5-year overall (82.9% vs. 72.8%, P=0.017) and recurrence-free (48.8% vs. 35.4%; P=0.036) survival rates were significantly greater in the TO group than in the non-TO group.

CONCLUSION

The MELD score, thrombocytopenia, and hypoalbuminemia were independent risk factors influencing the achievement of TO. TO influences the short- and long-term outcomes after LLR for HCC.

Learning curves in minimally invasive hepatectomy: systematic review and meta-regression analysis

BACKGROUND

Minimally invasive hepatectomy (MIH) has become an important option for the treatment of various liver tumours. A major concern is the learning curve required. The aim of this study was to perform a systematic review and summarize current literature analysing the learning curve for MIH.

METHODS

A systematic review of the literature pertaining to learning curves in MIH to July 2019 was performed using PubMed and Scopus databases. All original full-text articles published in English relating to learning curves for both laparoscopic liver resection (LLR), robotic liver resection (RLR), or a combination of these, were included. To explore quantitatively the learning curve for MIH, a meta-regression analysis was performed.

RESULTS

Forty studies relating to learning curves in MIH were included. The median overall number of procedures required in studies utilizing cumulative summative (CUSUM) methodology for LLR was 50 (range 25-58) and for RLR was 25 (16-50). After adjustment for year of adoption of MIH, the CUSUM-derived caseload to surmount the learning curve for RLR was 47.1 (95 per cent c.i. 1.2 to 71.6) per cent; P = 0.046) less than that required for LLR. A year-on-year reduction in the number of procedures needed for MIH was observed, commencing at 48.3 cases in 1995 and decreasing to 23.8 cases in 2015.

CONCLUSION

The overall learning curve for MIH decreased steadily over time, and appeared less steep for RLR compared with LLR.

Learning process of laparoscopic liver resection and postoperative outcomes: chronological analysis of single-center 15-years' experience

BACKGROUND

Limited studies have reported the actual learning process of laparoscopic liver resection (LLR). This study aimed to chronologically evaluate our 15 years' experience of LLR.

METHODS

All consecutive LLRs between 2006 to 2020 were retrospectively analyzed. The time period was divided into three groups; first (2006-2010), second (2011-2015), and third (2016-2020) period. The primary endpoint of this study was a composite of overall (Clavien-Dindo grade ≥ II) or major (grade ≥ IIIa) postoperative complications within 30 days. Using the IWATE criteria (four difficulty levels based on six indices), LLR was categorized as basic (< 7 points) and advanced (≥ 7 points) one. All analyses were performed based on the intention-to-treat principles.

RESULTS

During the study period, a total of 382 LLRs were gradually performed (first period, n = 54; second period, n = 114, and third period, n = 214). Low incidences of overall and major complications were maintained (9.3, 10.5, and 7.0%, p = 0.514, and 1.9, 2.6, and 2.3%, p = 1.000). Meanwhile, pure LLRs (i.e., LLRs without hand-assisted or hybrid approach) and advanced LLRs were increasingly performed in 25 (46.3%), 71 (62.3%), and 205 (95.8%) patients (p < 0.001) and 3 (5.6%), 18 (15.8%), and 58 (27.1%) patients (p < 0.001), respectively.

CONCLUSIONS

This study suggests that stepwise approach from basic to advanced procedures and use of hand-assisted or hybrid approach during the early phases for starting LLR practice may allow for maintaining low morbidity in specialized center.

Evaluating the Efficacy of Microsurgical Training Methods in Ophthalmology Education: A Systematic Review and Meta-analysis

Objective  The objective of our paper is to review all of the relevant literature in ophthalmology microsurgical education and identify which teaching methodologies were most effective. Methods  A systematic review and meta-analysis of the literature was conducted. Electronic databases, including Ovid MEDLINE, Cochrane CENTRAL, and EMBASE, were searched with preset terms. The search was through December 11, 2019. Eligibility criteria included studies with sufficient data for analyzing associations between surgical teaching techniques and success rates in surgical skills and the organization of the intervention as a microsurgical skills course, curriculum, or program. The articles were independently reviewed by two authors. Each included study was evaluated for quality using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach and risk of bias using the Cochrane Collaboration's tool for assessing bias. Data Extraction and Synthesis  Data extraction was performed by two reviewers and disagreements were checked by a third reviewer. A random-effects analysis was used to pool the outcomes of studies. Main Outcomes and Measures  Outcomes included time for completion of surgical task, level of preparedness, competency score, and number of surgeries with complications. Results  A total of 439 studies were reviewed and 13 studies ( n  = 8,790 surgical cases; n  = 115 trainees) were included in the meta-analysis. Excluded articles studied cataract simulation training as the primary intervention or were not related to ophthalmology. All pooled results demonstrated a positive association with surgical outcomes; however, video-based education (standardized mean difference [SMD] = 2.49 [95% confidence interval (CI): 0.36-4.63]; four effects [four studies]; n  = 69; I 2  = 90%) and stepwise teaching method (odds ratio [OR = 3.84 [95% CI: 2.66-5.55]; six effects [six studies]; n  = 6,968; I 2  = 39%) interventions were the most favorable. Conclusion and Relevance  The following five interventions evaluated in this paper were found to be effective methods of improving performance outcomes in ophthalmic microsurgery: (1) didactic lectures, (2) video-based education, (3) surgical wet-laboratory, (4) stepwise method, and (5) direct supervision and feedback. Our meta-analysis concludes that video-based education and stepwise teaching interventions are the most effective methods for a microsurgical ophthalmology training curriculum. Combining the strengths of the interventions analyzed in this study should be considered when implementing and adjusting ophthalmic surgical skills curriculums.

Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS)

BACKGROUND

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS).

METHODS

A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80.

RESULTS

A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19).

CONCLUSIONS

The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results

BACKGROUND

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results.

MATERIALS AND METHODS

Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers.

RESULTS

Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively.

CONCLUSIONS

This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

Stepwise development of laparoscopic liver resection skill using rubber traction technique

BACKGROUND

To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes.

METHODS

Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome.

RESULTS

As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed.

CONCLUSION

Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.

Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review

BACKGROUND

The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR.

METHODS

Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded.

RESULTS

Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15-20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC.

CONCLUSIONS

The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.

Comparison of functional and volumetric increase of the future remnant liver and postoperative outcomes after portal vein embolization and complete or partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

Background

Portal vein embolization (PVE) is performed to induce hypertrophy of an insufficient future remnant liver (FRL) before major liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) aims to offer a more rapid and increased hypertrophy response. The first stage can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. This study aimed to investigate the increase in FRL volume and function, as well as postoperative outcomes after PVE or complete- or partial-ALPPS1.

Methods

Patients with insufficient FRL undergoing either PVE or ALPPS underwent CT-volumetry and functional assessment using ^99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Severe complications and 90-day mortality were evaluated after liver resection.

Results

Seventy-two patients were included; 51 underwent PVE, 12 complete-ALPPS1 and 9 partial-ALPPS1 of which 7 laparoscopic. The median increase in FRL function was 1.5-, 1.7- and 1.3-fold higher, respectively, than the increase in volume; (P<0.01, P<0.01 and P=0.44). The target hypertrophy response did not differ between the groups, but was reached earlier in both ALPPS1 groups (8 and 10 days) compared to the PVE group (23 days). Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively.

Conclusions

Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. A (laparoscopic) partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.

Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands

BACKGROUND

While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale.

METHODS

Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume.

RESULTS

Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040).

CONCLUSION

The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.

A Comparison of the Learning Curves of Laparoscopic Liver Surgeons in Differing Stages of the IDEAL Paradigm of Surgical Innovation: Standing on the Shoulders of Pioneers

OBJECTIVE

To compare the learning curves of the self-taught "pioneers" of laparoscopic liver surgery (LLS) with those of the trained "early adopters" in terms of short- and medium-term patient outcomes to establish if the learning curve can be reduced with specific training.

SUMMARY OF BACKGROUND DATA

It is expected that a wider adoption of a laparoscopic approach to liver surgery will be seen in the next few years. Current guidelines stress the need for an incremental, stepwise progression through the learning curve in order to minimize harm to patients. Previous studies have examined the learning curve in Stage 2 of the IDEAL paradigm of surgical innovation; however, LLS is now in stage 3 with specific training being provided to surgeons.

METHODS

Using risk-adjusted cumulative sum analysis, the learning curves and short- and medium-term outcomes of 4 "pioneering" surgeons from stage 2 were compared with 4 "early adapting" surgeons from stage 3 who had received specific training for LLS.

RESULTS

After 46 procedures, the short- and medium-term outcomes of the "early adopters" were comparable to those achieved by the "pioneers" following 150 procedures in similar cases.

CONCLUSIONS

With specific training, "early adapting" laparoscopic liver surgeons are able to overcome the learning curve for minor and major liver resections faster than the "pioneers" who were self-taught in LLS. The findings of this study are applicable to all surgical specialties and highlight the importance of specific training in the safe expansion of novel surgical practice.

Laparoscopic versus open liver resection in the posterosuperior segments: a sub-group analysis from the OSLO-COMET randomized controlled trial

BACKGROUND

Laparoscopic liver resection in the posterosuperior segments is technically challenging. This study aimed to compare the perioperative outcomes for laparoscopic and open resection of colorectal liver metastases located in the posterosuperior segments.

METHODS

This was a subgroup analysis of the OSLO-COMET randomized controlled trial, where 280 patients were randomly assigned to open or laparoscopic parenchyma-sparing liver resections of colorectal metastases. Patients with tumors in the posterosuperior segments were identified, and perioperative outcomes and health related quality of life (HRQoL) were compared.

RESULTS

We identified a total of 136 patients, 62 in the laparoscopic and 74 in the open group. The postoperative complication rate was 26% in the laparoscopic and 31% in the open group. The blood loss was less in the open group (500 vs. 250 ml, P = 0.006), but the perioperative transfusion rate was similar. The operative time was similar, while postoperative hospital stay was shorter in the laparoscopic group (2 vs. 4 days, P < 0.001). HRQoL was significantly better after laparoscopy at 1 month.

CONCLUSION

In patients undergoing laparoscopic or open liver resection of colorectal liver metastases in the posterosuperior segments, laparoscopic surgery was associated with shorter hospital stay and comparable perioperative outcomes.

Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases

BACKGROUND

Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting. The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection.

METHODS

A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests.

RESULTS

Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123-273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR.

CONCLUSION

LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.

Are the current difficulty scores for laparoscopic liver surgery telling the whole story? An international survey and recommendations for the future

BACKGROUND

Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections.

METHOD

Using a Visual Analogue Scale an international survey of laparoscopic liver surgeons was undertaken to assess the perceived difficulty of 26 factors previously demonstrated to affect the difficulty of a laparoscopic liver resection.

RESULTS

80 surgeons with a combined experience of over 7000 laparoscopic liver resections responded to the survey. The difficulty of laparoscopic liver surgery was suggested to be increased by a BMI > 35 by 89% of respondents; neo-adjuvant chemotherapy by 79%; repeated liver resection by 99% and concurrent procedures by 59% however these factors have not been included in the previous difficulty scoring systems.

CONCLUSION

The results suggests that the difficulty of laparoscopic liver surgery is not fully assessed by the available difficulty scoring systems and prompts the development of a new difficulty score that incorporates all factors believed to increase difficulty.