Effective stepwise training and procedure-standardization for young surgeons to perform laparoscopic left hepatectomy

Mitsuo Shimada, MD, Satoru Imura, MD, Yuji Morine, MD, Tetsuya Ikemoto, MD, Yu Saito, MD, Shinichiro Yamada, MD, Hiroki Teraoku, MD, Masato Yoshikawa, MD, Chie Takasu, MD. Tokushima University

Introduction: Laparoscopic hepatectomy remains to be one of the most difficult procedures for young surgeons. We have recently developed a new training method and procedure-standardization for young surgeons to perform laparoscopic left hepatectomy (Lap-LHx). The aim of this study is to clarify the effect of our method for young surgeons to perform Lap-LHx.

Methods: Standardization of Lap-LHx: After mobilization of left lobe, left 1st Glissonean pedicle is encircled using the Arantius’ ligament approach by Cho et al. (Asian J Endosc Surg. 2012). Briefly, after division of the Arantius’ ligament, a space between the left Glissonean pedicle and the liver parenchyma made by retracting the caudal stump of the ligament was used to encircle the left Glissonean pedicle. After marking a demarcation line, parenchymal dissection is performed under the Pringle maneuver, principally using CUSA. The common trunk of middle and left hepatic vein is encircled in case of hybrid method.

Training method: 1st step, training of fundamental procedures using a dry box ; 2nd step, detailed preoperative simulation using a Vincent 3-D software for each patients; 3rd step, practices in OR and self-assessment including understanding anatomies and completion grade of each procedure using a original score sheet, and feedback by both mentors and Professor.

23 patients who underwent Lap-LHx included in this study were divided into 2 groups, young (non-board certified) surgeons (n=9) and senior (board certified) surgeons (n=14).

Results: As for short-term outcome of all Lap-LHx, mean blood loss and operative time were 203g and 327 min., respectively. Only one patient suffered from a superficial SSI. Regarding the comparison between young and senior surgeons, blood loss and operative time in young surgeon group (336 min. and 194g) were similar to those in senior surgeon group (322 min. and 208g).

Conclusion: Our procedure standardization of Lap-LHx and stepwise training could enable young surgeons to perform Lap-LHx surely and safely.

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