0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Outcome and Learning Curve in 159 Consecutive Patients Undergoing Total Laparoscopic Hemihepatectomy ONLINE FIRST

Marcel J. van der Poel, BSc1; Marc G. Besselink, MD, MSc, PhD1; Federica Cipriani, MD1; Thomas Armstrong, MD, PhD1; Arjun S. Takhar, MD, PhD1; Susan van Dieren, PhD2; John N. Primrose, MD, PhD, FRCS3; Neil W. Pearce, MD, FRCS1; Mohammad Abu Hilal, MD, PhD, FRCS1
[+] Author Affiliations
1Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, England
2Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
3University Surgery, University of Southampton, Southampton, England
JAMA Surg. Published online July 06, 2016. doi:10.1001/jamasurg.2016.1655
Text Size: A A A
Published online

Importance  Widespread implementation of laparoscopic hemihepatectomy is currently limited by its technical difficulty, paucity of training opportunities, and perceived long and harmful learning curve. Studies confirming the possibility of a short and safe learning curve for laparoscopic hemihepatectomy could potentially benefit the further implementation of the technique.

Objective  To evaluate the extent and safety of the learning curve for laparoscopic hemihepatectomy.

Design, Setting, and Participants  A prospectively collected single-center database containing all laparoscopic liver resections performed in our unit at the University Hospital Southampton National Health Service Foundation Trust between August 2003 and March 2015 was retrospectively reviewed; analyses were performed in December 2015. The study included 159 patients in whom a total laparoscopic right or left hemihepatectomy procedure was started (intention-to-treat analysis), including laparoscopic extended hemihepatectomies and hemihepatectomies with additional wedge resections, at a tertiary referral center specialized in laparoscopic hepato-pancreato-biliary surgery.

Main Outcomes and Measures  Primary end points were clinically relevant complications (Clavien-Dindo grade ≥III). The presence of a learning curve effect was assessed with a risk-adjusted cumulative sum analysis.

Results  Of a total of 531 consecutive laparoscopic liver resections, 159 patients underwent total laparoscopic hemihepatectomy (105 right and 54 left). In a cohort with 67 men (42%), median age of 64 years (interquartile range [IQR], 51-73 years), and 110 resections (69%) for malignant lesions, the overall median operation time was 330 minutes (IQR, 270-391 minutes) and the median blood loss was 500 mL (IQR, 250-925 mL). Conversion to an open procedure occurred in 17 patients (11%). Clinically relevant complications occurred in 17 patients (11%), with 1% mortality (death within 90 days of surgery, n = 2). Comparison of outcomes over time showed a nonsignificant decrease in conversions (right: 14 [13%] and left: 3 [6%]), blood loss (right: 550 mL [IQR, 350-1150 mL] and left: 300 mL [IQR, 200-638 mL]), complications (right: 15 [14%] and left: 4 [7%]), and hospital stay (right: 5 days [IQR, 4-7 days] and left: 4 days [IQR, 3-5 days]). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 55 laparoscopic hemihepatectomies for conversions.

Conclusions and Relevance  Total laparoscopic hemihepatectomy is a feasible and safe procedure with an acceptable learning curve for conversions. Focus should now shift to providing adequate training opportunities for centers interested in implementing this technique.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1.
Risk-Adjusted Cumulative Sum Analysis of Conversions of Laparoscopic Right and Left Hemihepatectomies

A risk-adjusted cumulative sum analysis of conversions for the difference between the cumulative expected outcome and the actual observed outcome of 159 consecutive laparoscopic right and left hemihepatectomies. A multivariable logistic regression model for conversion from laparoscopic to open hemihepatectomy was constructed using backward selection to calculate the expected outcome. Every operation is plotted from left to right and the line goes up for laparoscopically performed surgery and down for procedures that were converted to the open approach. Visual inspection shows a learning curve of 55 procedures.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Risk-Adjusted Cumulative Sum Analysis of Conversions of Laparoscopic Right Hemihepatectomies

A risk-adjusted cumulative sum analysis of conversion for the difference between the cumulative expected outcome and the actual observed outcome of 105 consecutive laparoscopic right hemihepatectomies. Visual inspection demonstrated a learning curve of 45 procedures.

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

150 Views
0 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
Jobs
brightcove.createExperiences();