尽管全世界对扩大微创肝切除术（MILR）应用的兴趣很高，据报道，MILR的大部分丰富经验来自远东亚洲和欧洲，其在北美的应用有限。这项研究的目的是回顾MILR在一个北美研究所15年的经验，强调遇到的障碍和为克服吸收停滞而采取的战略。
这项研究包括2006年至2020年间的500例MILR病例。患者人口统计学，疾病特征，外科技术,总结围手术期结局。根据病例数（前100、101-300和301-500例）评估主要肝切除术率和转化率，以评估时间趋势。
500，402例MILRs是通过纯腹腔镜（80.4%）完成的，67人是手辅助（13.4%），31人是机器人(6.2%)。大多数（64％）病例为恶性肿瘤（n=320；100肝细胞癌，153结直肠转移瘤,27肝内胆管癌,和其他人,40，64%）。共有71例转为开放(14.2%)。在最初的几年中，每年的病例数逐渐增加；然而，在2009年至2017年期间，病例数保持在30左右。在这个时期,尽管积累了MILR经验，尽管大肝切除术率没有变化，但开放转换率增加。在这个长期停滞期之后,我们介绍了团队组成和腹腔镜器械的关键变化。此后，我们的MILR病例数和主要肝切除术率显着增加，而没有增加转换或并发症发生率。
我们通过制定本研究中详述的关键变化从长期停滞中恢复过来，可以作为正在考虑将MILR计划从次要切除过渡到高级切除的计划的指南。通过适当的指导/监督建立正式的MILR培训模型，并建立专门的MILR团队对于此策略至关重要。
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.
