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Background. Laparoscopic Right Hepatectomy (LRH) is a technically challenging operation. Complex surgical procedures can be improved by standardization of operative technique and uniformity of operating room (OR) practice, and accomplished by implementation of manufacturing productivity tools such as Six Sigma (SS) and Lean Management (LM). Using these strategies allow us to measure performance efficiency, detect unwanted variances, and implement process improvement.
Methods. We performed formal LRH beginning in 2008 in the same way we performed the open approach. The procedure was deconstructed into seven major step-wise components (right hepatic artery ligation/transection, right portal vein ligation/transection, retrohepatic IVC dissection, triangular ligament takedown, right hepatic vein ligation/transection, parenchyma transection, hemostasis-bile leak check) established by two surgeons. All LRHs followed the same surgical sequence, device use, and OR protocol. A non-participating surgeon reviewed the video recordings of the procedures to determine total operative time and the time for each component step. The variances (standard deviation) of each operation were calculated (average time in minutes ± SD).
Results. After implementation of LM for our LRH, 30 randomly selected video recordings of the procedure (excluding biliary reconstruction) were reviewed. The mean total operative time was 114 ± 25 min. The most efficient steps of the procedure were IVC dissection (mean 8 ± 3 min) and right hepatic vein ligation (mean 9 ± 5). The longest and also the step with the highest standard deviation was parenchyma transection (35 ± 12). The other steps were performed with minimal variations (Table 1). There were no intraoperative complications or conversions to open technique.
Conclusion. Standardization of complex procedures begins with breaking down the process into measureable components. LRH can be performed consistently and reproducibly using the same approach of a step-wise technique. Parenchyma transection had the most variation, and this could be explained by intrinsic liver factors (organ thickness, fat content, cirrhosis, etc). The identification of ways to narrow the variance in parenchyma transection, when possible, became our first focus. Using SS and LM manufacturing quality tools in surgery allows the surgeon to critically analyze performance and implement specific improvement goals.
Table 1. LRH Total operative time and steps times (n=30)*

Step	Mean	Standard deviation	Median	Range
Total operative time	114	± 25	114	78 - 177
Right hepatic artery ligation	18	± 8	17	6 - 37
Right portal vein ligation	15	± 4	15	7 - 25
Right lobe mobilization	12	± 4	11	7 - 28
IVC dissection	8	± 3	7	3 - 15
Right hepatic vein ligation	9	± 5	8	4 - 22
Parenchyma transection	35	± 12	32	21 - 65
Hemostasis/Bile leak checking	16	± 11	14	4 - 52

* Time in minutes