Cleveland Clinic Lerner College of Medicine and Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
Surg Endosc. 2022 Aug;36(8):6144-6152. doi: 10.1007/s00464-022-09182-1. Epub 2022 Mar 11.
Although interest in expanding the application of minimally invasive liver resection (MILR) is high the world over, most of the extensive experience in MILR has been reported from Far East Asia and Europe and its adoption in North America is limited. The aim of this study was to review the experience of MILR in a single North American institute over a 15-year period, highlighting both the obstacles encountered and strategies adopted to overcome the stagnation in its uptake.
This study included 500 MILR cases between 2006 and 2020. Patient demographics, disease characteristics, surgical technique, and perioperative outcomes are summarized. The major hepatectomy rate and conversion rate were assessed according to case numbers (first 100, 101-300, and 301-500 cases) to assess chronological trends.
Of 500, 402 MILRs were done by pure laparoscopic (80.4%), 67 were hand assisted (13.4%), and 31 were robotic (6.2%). The majority (64%) of cases were performed for malignancy (n = 320; 100 Hepatocellular carcinoma, 153 Colorectal metastases, 27 Intrahepatic cholangiocarcinoma, and others, 40, 64%). A total of 71 cases were converted to open (14.2%). The annual case number gradually increased over the first few years; however, case numbers stayed around 30 between 2009 and 2017. In this period, despite accumulating MILR experience, open conversion rates increased despite no change in major hepatectomy rate. After this period of long-term stagnation, we introduced crucial changes in team composition and laparoscopic instrumentation. Our MILR case number and major hepatectomy rate thereafter increased significantly without increasing conversion or complication rates.
Our recovery from long-term stagnation by instituting key changes as detailed in this study could be used as a guidepost for programs that are contemplating transitioning their MILR program from minor to advanced resections. Establishing a formal MILR training model through proper mentorship/proctorship and building a dedicated MILR team would be imperative to this strategy.
尽管全世界都对扩大微创肝切除术（MILR）的应用很感兴趣，但大多数关于 MILR 的广泛经验都来自远东和欧洲，而北美对其的应用则很有限。本研究旨在回顾一家北美机构在 15 年内的 MILR 经验，重点介绍在采用 MILR 中遇到的障碍和采用的策略，以克服其采用率的停滞不前。
本研究纳入了 2006 年至 2020 年间的 500 例 MILR 病例。总结了患者人口统计学、疾病特征、手术技术和围手术期结果。根据病例数（前 100 例、第 101-300 例和第 301-500 例）评估主要肝切除术率和转化率，以评估时间趋势。
500 例 MILR 中，402 例采用纯腹腔镜（80.4%），67 例采用手辅助（13.4%），31 例采用机器人（6.2%）。大多数（64%）病例为恶性肿瘤（n=320；100 例肝细胞癌，153 例结直肠转移瘤，27 例肝内胆管细胞癌和其他肿瘤 40 例）。共有 71 例转为开放性手术（14.2%）。最初几年，每年的病例数逐渐增加；然而，2009 年至 2017 年，病例数一直维持在 30 例左右。在此期间，尽管积累了 MILR 经验，但尽管主要肝切除术率没有变化，开放性转化率却有所增加。在这段长期停滞不前的时期之后，我们在团队组成和腹腔镜器械方面进行了关键的改变。此后，我们的 MILR 病例数和主要肝切除术率显著增加，而转化率和并发症率没有增加。
通过实施本研究中详细介绍的关键改变，我们从长期停滞中恢复过来，这可以作为考虑将其 MILR 计划从低风险向高风险转变的计划的指导方针。通过适当的指导/监督建立正式的 MILR 培训模式，并建立专门的 MILR 团队对于该策略至关重要。
