Comparison of the results of mastering laparoscopic liver resection technology through self-learning and a mentoring program

Aim. To compare the learning curve of laparoscopic liver resection under a mentoring program with that of an expert-level surgeon who mastered the procedure independently.

Materials and methods. A retrospective analysis was conducted on the outcomes of laparoscopic liver resections performed from 2015 to 2020 by an expert-level surgeon (referred to as Surgeon 1) and a surgeon trained under a mentoring program (Surgeon 2). The CUSUM method was employed to assess changes in the difficulty score and perioperative outcomes during the surgeon training. The resection difficulty was evaluated using IWATE criteria.

Results. Surgeon 1 performed 174 operations, while Surgeon 2 performed 37 operations. The initial learning period consisted of 20 resections for Surgeon 1 and 16 for Surgeon 2, while the period of expansion of indications included resections 21 to 40 for Surgeon 1 and 17 to 37 for Surgeon 2. The two surgeons revealed no significant differences in the resection difficulty scores (p = 0.131), the intraoperative blood loss (p = 0.505), and the incidence of postoperative complications (p = 0.552) during the initial period. However, the operative time for Surgeon 1 was significantly longer than that for Surgeon 2 (p = 0.007). In the comparative analysis of the second period of learning, Surgeon 1 had a significantly higher difficulty score (p = 0.008). No differences were observed in the incidence of postoperative complications: 4 cases (20%) for Surgeon 1 and 3 cases (15%) for Surgeon 2 (p = 0.507). During the period of expansion of indications, Surgeon 2 demonstrated significantly less blood loss (p = 0.033) and a shorter average operative time (p = 0.002).

Conclusion. Learning laparoscopic liver resection occurs faster under mentoring. Learning under a mentoring program reveals a tendency towards reduced operative time and blood loss. The transfer of experience from a mentor allows for the possibility of lacking expert-level proficiency in open liver resection surgery but implies the necessity for skills in performing open resections of low and moderate complexity.

1. Abu Hilal M., Aldrighetti L., Dagher I., Edwin B., Troisi R.I., Alikhanov R., Aroori S., Belli G., Besselink M., Briceno J., Gayet B., D'Hondt M., Lesurtel M., Menon K., Lodge P., Rotellar F., Santoyo J., Scatton O., Soubrane O., Sutcliffe R., Van Dam R., White S., Halls M.C., Cipriani F., Van der Poel M., Ciria R., Barkhatov L., Gomez-Luque Y., Ocana-Garcia S., Cook A., Buell J., Clavien P.A., Dervenis C., Fusai G., Geller D., Lang H., Primrose J., Taylor M., Van Gulik T., Wakabayashi G., Asbun H., Cherqui D. The Southampton Consensus Guidelines for laparoscopic liver surgery: from indication to implementation. Ann. Surg. 2018; 268 (1): 11–18. https://doi.org/10.1097/SLA.0000000000002524

2. Vigano L., Laurent A., Tayar C., Tomatis M., Ponti A., Cherqui D. The learning curve in laparoscopic liver resection. Ann. Surg. 2009; 250 (5): 772–782. https://doi.org/10.1097/SLA.0b013e3181bd93b2

3. Lin C.W., Tsai T.J., Cheng T.Y., Wei H.K., Hung C.F., Chen Y.Y., Chen C.M. The learning curve of laparoscopic liver resection after the Louisville statement 2008: will it be more effective and smooth? Surg. Endosc. 2016; 30 (7): 2895–2903. https://doi.org/10.1007/s00464-015-4575-1

4. Van der Poel M.J., Besselink M.G., Cipriani F., Armstrong T., Takhar A.S., van Dieren S., Primrose J.N., Pearce N.W., Abu Hilal M. Outcome and learning curve in 159 consecutive patients undergoing total laparoscopic hemihepatectomy. JAMA Surg. 2016; 151 (10): 923. https://doi.org/0.1001/jamasurg.2016.1655

5. Aghayan D.L., Kazaryan A.M., Dagenborg V.J., Røsok B.I., Fagerland M.W., Waaler Bjørnelv G.M., Kristiansen R., Flatmark K., Fretland Å.A., Edwin B. OSLO-COMET Survival Study Collaborators. Long-Term oncologic outcomes after laparoscopic versus open resection for colorectal liver metastases: a randomized trial. Ann. Intern. Med. 2021; 174 (2): 175–182. https://doi.org/10.7326/M20-4011

6. Halls M.C., Alseidi A., Berardi G., Cipriani F., Van der Poel M., Davila D., Ciria R., Besselink M., D'Hondt M., Dagher I., Alrdrighetti L., Troisi R.I., Abu Hilal M. A comparison of the learning curves of laparoscopic liver surgeons in differing stages of the IDEAL paradigm of surgical innovation. Ann. Surg. 2019; 269 (2): 221–228. https://doi.org/10.1097/SLA.0000000000002996

7. Ban D., Tanabe М., Ito Н., Otsuka Y., Nitta Н., Abe Y., Hasegawa Y., Katagiri Т., Takagi С., Itano О., Kaneko Н., Wakabayashi G. A novel difficulty scoring system for laparoscopic liver resection. J. Hepatobiliary Pancreat. Sci. 2014; 21 (10): 745–753. https://doi.org/10.1002/jhbp.166

8. Khan N., Abboudi H., Khan M.S., Dasgupta P., Ahmed K. Measuring the surgical 'learning curve': methods, variables and competency. BJU Int. 2014; 113 (3): 504–508. https://doi.org/10.1111/bju.12197

9. Bagante F., Spolverato G., Strasberg S.M., Gani F., Thompson V., Hall B.L., Bentrem D.J., Pitt H.A., Pawlik T.M. Open hepatectomy: a comparative analysis of the National Surgical Quality Improvement Program Database. J. Gastrointest. Surg. 2016; 20 (9): 1608–1617. https://doi.org/10.1007/s11605-016-3202-3

10. Nomi T., Fuks D., Kawaguchi Y., Mal F., Nakajima Y., Gayet B. Learning curve for laparoscopic major hepatectomy. Br. J. Surg. 2015; 102 (7): 796–804. https://doi.org/10.1002/bjs.9798

11. Van der Poel M.J., Besselink M.G., Cipriani F., Armstrong T., Takhar A.S., van Dieren S., Primrose J.N., Pearce N.W., Abu Hilal M. Outcome and learning curve in 159 consecutive patients undergoing total laparoscopic hemihepatectomy. JAMA Surg. 2016; 151 (10): 923. https://doi.org/0.1001/jamasurg.2016.1655