A falciform ligament flap surface sealing technique for laparoscopic and robotic-assisted liver surgery

Learning curve analysis of 100 consecutive robotic liver resections

BACKGROUND

Robotic liver surgery, as part of minimally invasive liver surgery (MILS), offers advantages like enhanced dexterity and stable camera and instrument control. However, the learning curve - particularly the number of cases required for proficiency - remains underexplored. This study analyzes 100 consecutive robotic liver resections performed by a single surgeon to assess the learning curve and outcomes.

PATIENTS AND METHODS

This retrospective analysis reviewed data from the Magdeburg registry of minimally invasive liver surgery (MD-MILS) from June 2013 to July 2024, to identify surgeons who performed at least 100 robotic liver resections. Operation time and Iwate difficulty score were used as indicators of surgical proficiency and learning progression.

RESULTS

One surgeon fulfilled the inclusion criteria of performing 100 robotic liver resections. Of these, 41 (41%) were major and 59 (59%) were minor liver resections. A significant reduction in average operation time was observed across the series, decreasing from an initial average of 450 min to approximately 300 min by the 100th operation. Similarly, the Iwate difficulty score showed a significant upward trend, reflecting the increasing technical challenges of the procedures. The learning curve was divided into four distinct phases: Competency (Cases 1-20), Proficiency (Cases 21-30), Early Mastery (Cases 31-65), and Full Mastery (Cases 66-100), highlighting the progression in skill acquisition and case complexity. Major complications (21%), such as bile leak, bilioma, and pulmonary embolism, were observed during the study period.

CONCLUSION

Over 100 robotic liver resections, significant learning curve progression was evident, with marked improvements in operation time and handling of complex cases. The results suggest that approximately 65 cases are needed for a surgeon experienced in open and laparoscopic liver surgery to achieve consistent proficiency in robotic liver resections. These findings underscore the importance of standardized training protocols to support the learning curve in robotic liver surgery.

Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review

OBJECTIVE

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

BACKGROUND

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

METHODS

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

RESULTS

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

CONCLUSION

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.