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/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.