Role of mentorship in the learning curve of robotic right lobe donor hepatectomy

摘要

The starting of minimally invasive donor hepatectomy (MIDH) is a consequence of the success of minimally invasive techniques in liver surgery, which came about mainly as a response to the prolonged postoperative pain and risk of incisional hernias that can worsen the quality of life in living liver donors. Although characterized by modest expansion and criticized for possible increased risks to donors, it originated in Europe but has expanded to Asian countries.1 More recently, laparoscopic donation has been joined by robotic approaches introduced in experienced, high-volume centers in Asia and in the Middle East to overcome the disadvantages of laparoscopy (eg, steep learning curve).2,3 In the current issue of Liver Transplantation, Cheah et al4 reviewed a series of 116 robotic right donor hepatectomy cases from 2 specialized centers with the aim of quantifying the expected learning curve and the role of mentorship in this setting. The results of the comparative analysis showed that only 7 robotic right hepatectomy procedures (CUSUM [cumulative sum] method) are required to stabilize operating times and that the learning curve can be reduced to 9 procedures. All this was accomplished without jeopardizing donor safety as the complications recorded were comparable (22.8% center 1 vs. 27.6% center 2) and mostly classified as minor. Furthermore, a decreasing trend of complications at the end of the learning curve was also recorded. This report is further proof that the most complex skills and knowledge can be transferred with a mentorship program in the field of living liver donation. The reason for this stems from the fact that donor hepatectomy is an operation that can be standardized very well: the anatomy of the donor is known down to the smallest detail, as are all the details of the operation, its stages, and the logistics of the teams involved. Video techniques and knowledge can be discussed and transferred by a mentor. Obviously, teams must be experienced in this field with a sufficient background in conventional procedures; it is generally agreed that some experience with minimally invasive methods is also necessary. According to the Houston experience, mentorship made it possible to even select donors with anatomical biliary variants or larger right lobes in a shorter time in combination with a significant reduction in surgical resection times. These possibilities have already been demonstrated in the past and, above all, are made easier by the use of robotic platforms.3 The reproducibility of not only laparoscopic but also robotic MIDH makes it possible to allow safe donor hepatectomy in different specialized centers in different continents with optimal results in a very short timeframe and without substantial additive risks.5 Furthermore, the possibility of minimizing complications in the donor may also improve the outcomes of the recipients, although this will need to be proven.5 In specialized, high-volume living donor liver transplantation centers, robotics has enabled the further development of MIDH by offering its benefits to many more donors regardless of whether they have anatomical variants. This is also the case in some centers that have developed laparoscopic techniques to a very high level, but laparoscopic donation appears more difficult to implement than the robotic approach. The learning curve of robotic surgery has proven to be much shorter, overcoming many shortcomings of laparoscopy: the ability to perform a “copy-and-paste” of conventional surgical gestures democratizes minimally invasive approaches by offering these benefits to more patients from surgeons who have not fully mastered the laparoscopic learning curve.6,7 The operative time of right lobe donation can be significantly decreased with <35 cases in a linear progression, while for laparoscopy, the learning curve may require at least 60 cases to complete.3,8 A very recent worldwide survey of 4607 (50.8%) of the 9061 living donor liver transpla