Reaching proficiency in robotic liver surgery in two high-volume European HPB centers.

Robotic liver surgery is increasingly used in hepatobiliary surgery. University Medical Center Utrecht and the Karolinska University Hospital are both tertiary centers that have adopted robotic surgery with distinct implementation strategies. Analysis of these strategies may benefit surgeons starting up a robotic liver surgery program. A natural experiment comparing an unguided early adopter versus a guided majority adopter was performed. Rolling averages per block of 20 patients were used to find the required number of cases to proficiency, defined as < 10% severe complications (Clavien-Dindo ≥3 A) and < 10% conversion rate. 431 patients were included. The moving average analysis shows that the proficiency threshold of < 10% conversion rate and < 10% severe complication rate in a block of 20 cases was reached at patient 124 at UMCU and 133 at KUH. Guidance leads to a safe and rapid expansion of a surgical team with varying experience levels of surgeons. To increase complexity an intentional institutional focus is required with more limited team size. Early definition of institutional goals and alignment of training pathways is vital for efficient and sustainable program development.