机器人肾移植术学习曲线分析

Analysis of learning curve of robot-assisted kidney transplantation

目的:本研究旨在分析机器人肾移植术操作者的学习曲线,并描述了相关手术技巧和供肾局部低温技术的优化。方法:研究共纳入自2018年3月至2021年9月在解放军总医院接受机器人肾移植术(Robotassisted kidney transplantation,RAKT)的18例终末期肾病患者,手术均由具有丰富开放性肾移植术和机器人手术经验的同一手术团队完成。绘制累积和图和休哈特控制图用以评估操作者的学习曲线和技术质量控制及患者安全性。结果:累积和分析显示,机器人手术时间、移植肾复温时间、动、静脉吻合时间均有一个显著的初始学习阶段,即在例数达到10例时进入平台期,提示该四项的学习阶段均需要至少10例,之后可获得相应稳定的能力。进一步的休哈特控制图表明,机器人手术时间和静脉吻合时间均未超过警戒线和警报线,提示上述两项技术结果稳定,未受到手术过程中个人或系统的影响。94.4%的移植肾复温时间低于警戒线,83.3%的动脉吻合时间低于警戒线,且此两项技术指标无一例超过警报线,提示虽然在最初的病例中,部分病例移植肾复温时间和动脉吻合时间在控制范围之外,但总体逐渐改善并稳定缩短。术前eGFR与术后6个月的eGFR的差值均值在67.69 ml/min,提示术后移植肾功能良好。结论:在机器人手术时间、移植肾复温时间及动、静脉吻合方面,一个经验丰富的外科团队至少需要10例经验才能达到稳定的重复性。

Objective:To analyze the operator’s learning curve for robot-assisted kidney transplantation,and report the surgical techniques and optimized technique of regional hypothermia of donor kidney.Methods:Totally,18patientswith end-stage renal disease undergoing robot-assisted kidney transplantation at the Chinese PLA General Hospital between March 2018 and September 2021 were included.All of surgeries were performed by the same surgical team with rich experience in the field of open kidney transplantation and robot-assisted surgery.The Cumulative sum analysis and Shewhart control charts were used to evaluate the operator’s learning curve,technical quality control and patients’safety.Results:The cumulative sum analysis showed that there wasa significantly initial learning stage in robotic-operation time,re-warming time,arterialanastomosis time,venous anastomosis time,all these fouritemsentered the platform stage when the number of cases reached 10.It was suggested that at least 10 cases were needed in the learning stage of the four items,and then the corresponding stable abilities could be obtained.The further Shewhart control charts showed that the robotic-operation time and venous anastomosis time did not exceed the warning line and alarm line,suggesting that the results of the above two techniques were stable and were not affected by the individual or systemicfactors during the operation.Meanwhile,94.4%of the rewarming time was shorter than the warning line,83.3%of the arterial anastomosis time was shorter than the warning line,but none of these two technical items exceeded the alarm line,suggesting that although in the initial cases,the rewarming time and arterial anastomosis time in some cases were out of control,the overall improvement and stable shortening could be obtained.The difference between eGFR before operation and at 6th month after operation was 67.69mL/min,indicating that the kidney functioned well.Conclusion:An experienced surgical team needs at least 10 cases of experience to achieve stable repeatability in terms of robotic-operation time,rewarming time and arterial/venous anastomosis.