Pure Laparoscopic Living Donor Right Hepatectomy: A Multifactorial Evolutional Learning Curve Analysis From a Single‐Surgeon High‐Volume Series

BACKGROUND: Pure laparoscopic donor right hepatectomy (PLDRH) is a safe technique, but its learning curve is often oversimplified. This study evaluates variables contributing to evolutional patterns for mastering PLDRH. METHODS: Consecutive donors undergoing PLDRH at a single center (2014-2021) were collected. A cumulative sum (CUSUM) method assessed a composite score derived from graft weight (GW), bile duct (BD) anatomy, operative time (OT), and warm ischemia time (WIT). Segmented regression identified the statistical breakpoint in the composite learning curve. RESULTS: Among 215 donors, no conversion occurred. Major post-operative complications (Clavien-Dindo ≥ 3) were reported in 2 (0.9%) cases with no mortality. CUSUM analysis identified a significant technical breakpoint at case 180 (p < 0.001). While OT and WIT improved after 60 cases (p < 0.001), surgical complexity, specifically GW and multiple BD, simultaneously increased between 60 and 180 cases. This demonstrates a multiphasic learning process where technical maturity was achieved by case 180, maintaining high safety standards despite progressive inclusion of larger grafts and more complex anatomy. CONCLUSION: The PLDRH learning curve is multifactorial and non-linear. While approximately 60 cases suffice for technical standardization, achieving full mastery over complex donors requires further caution. This multifactorial "evolutional" approach provides a comprehensive understanding for targeted improvement and surgical coaching.