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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

Halls, Mark Christopher, MBBS*; Alseidi, Adnan, MD; Berardi, Giammauro, MD; Cipriani, Federica, MD§; Van der Poel, Marcel, MD; Davila, Diego, MD||; Ciria, Ruben, PhD**; Besselink, Marc, PhD; D’Hondt, Mathieu, MD††; Dagher, Ibrahim, PhD‡‡; Alrdrighetti, Luca, PhD§; Troisi, Roberto Ivan, PhD‡,§§; Abu Hilal, Mohammad, MD, PhD, DocEur, FRCS, FACS*

doi: 10.1097/SLA.0000000000002996

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.

*Department of Hepatopancreatobiliary Surgery, University Hospital Southampton, Southampton, UK

Digestive Disease Institute, Virginia Mason Medical Centre, Seattle, WA

Department of General, Hepatobiliary and Transplant Surgery, Ghent University Hospital Medical School, Ghent, Belgium

§Department of Hepatobiliary Surgery, San Raffaele Hospital, Milan, Italy

Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

||Department of Hepatopancreatobiliary Surgery, Clinica CES, Medellin, Colombia

**Department of Liver Transplantation and Hepatobiliary Surgery, University Hospital Reina Sofia, Cordoba, Spain

††Department of Digestive and Hepatobiliary Surgery, AZ Groeninge, Kortrijk, Belgium

‡‡Department of Minimally Invasive Surgery, Assistance Publique – Hopitaux de Paris, Paris, France

§§Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.

Reprints: Professor Mohammad Abu Hilal, MD, PhD, DocEur, FRCS, FACS, Department of Hepato-Biliary and Pancreatic Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 2YD, UK. E-mail:; Mark Christopher Halls, MBBS, University Hospital Southampton, Southampton SO16 2YD, UK. E-mail:

The authors declare no conflict of interests.

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