Learning Curve and Outcomes of Pure Laparoscopic Donor Major Hepatectomy Performed by Fellowship-Trained Surgeons: Cumulative Sum and Propensity Score Matching Analysis.

BACKGROUND Pure laparoscopic donor major hepatectomy (PLDMH) offers important advantages for donors but has largely been restricted to expert surgeons. Evidence on fellowship-trained surgeons (FTSs) performing PLDMH after structured training is limited. This study evaluated donor safety and operative efficiency of FTSs using propensity score matching (PSM) and cumulative sum (CUSUM) analysis. MATERIAL AND METHODS We retrospectively reviewed 517 consecutive PLDMHs from 3 centers, including 1 expert surgeon (n = 462) and 3 FTSs (n = 55). FTSs underwent a structured, phase-task-based training program; 2 received short-term on-site proctorship for initial cases. To reduce baseline differences, we applied 1: 3 propensity score matching (PSM) between FTS and expert cases. Donor and recipient characteristics were balanced. Learning curves were assessed using risk-adjusted CUSUM for major donor complications and residual CUSUM for operative time. RESULTS After PSM, 55 FTS cases were matched to 165 expert cases. Major donor complications were comparable (5.5% vs 4.2%, P=0.714) and no case required conversion to open surgery. Donor operative time was longer in the FTS group (338±102 vs 220±44 minutes, P<0.001). Recipient biliary leakage was more frequent in the FTS group (18.2% vs 8.5%, P=0.046), whereas other outcomes were similar after matching. Risk-adjusted CUSUM demonstrated stabilization of donor safety within 8 to 10 cases per FTS, while operative efficiency stabilized after 6 to 15 cases. CONCLUSIONS FTSs demonstrated acceptable donor safety outcomes under structured training conditions, with operative performance showing a trend toward improvement after approximately 10 to 15 cases.