腹腔镜直肠癌切除术的学习曲线

Learning curve of laparoscopic resection for rectal cancer

目的评估腹腔镜直肠癌切除手术不同阶段的手术效果,探讨无腹腔镜胆囊切除术经验的外科医师如何尽快掌握腹腔镜直肠癌手术。方法分析2002年11月至2005年6由同一组无腹腔镜胆囊切除经验医师完成的105例腹腔镜直肠癌切除术。按手术先后次序分3组(A、B、C),每组35例,比较各组手术时间、术中出血量、淋巴结清扫总数、标本长度、中转开腹率、并发症及住院天数,分析不同阶段的手术效果。结果三组病例在年龄、性别、病理分期和手术方式等方面无显著差别(P>0．05)。A组手术时间(196．1±30．3min),显著长于B组(164．8±22．7min)和C组(158．7±20．9min)(P均< 0．001);A组出血量(72．4±21．5ml)明显多于B组(48．2±16．3 ml)和C组(46．6±15．4 ml)(P<0．001);B、C两组的手术时间和出血量差异均无显著性意义(P均>0．05);中转开腹率由A组的11．4％降至B组和C组的2．9％,术中并发症发生率由A组的17．1％降至B组和C两组的5．7％,但差异没有显著意义;三组住院时间逐渐缩短,各组比较差异有显著性意义;各组淋巴结清扫个数、标本长度、术后并发症比较,差异均无显著性意义(P>0．05)。A组手术35例在17个月内完成,平均每月2．1例,B组和C组各用时7个月,平均每月5例。结论无腹腔镜胆囊手术经验的外科医师行腹腔镜直肠癌切除术的学习曲线大约为35例,手术频度为平均每月2．1例。

Objective To evaluate the surgical outcomes of laparoscopic resection for rectal cancer and to investigate how surgeons without previous training of laparoscopic cholecystectomy （LC） can quickly learn laparoseopic resection for rectal cancer. Methods Clinical data of 105 cases of laparoscopic rectal resection performed by a group of surgeons without previous training of LC were reviewed. The cases were divided equally into 3 groups （groups A, B and C） according to the sequence of the operations. The operating time, blood loss, lymph node harvest, length of specimen, conversion rate to open surgery, intra- and postoperative complications and hospital stay were compared between the 3 groups. Results There were no significant differences between the 3 groups with respect to age, gender, Dukes＇stage or surgical approach （P〉0.05）. The operating time in group A was 196.1±30.3 min, significantly longer than that in group B （164.8±22.7min） and group C （158.7±20.9min） （P〈0.001）, but the operating time did not vary significantly between groups B and C （P〉0.05）. The blood loss was significantly greater in group A than in groups B and C （72.4±91.5, 48.2±16.3, and 46.6±15.4 ml, respectively, P〈0.001）, but showed no significant difference between the latter two groups （P〉0.05）. The rate ofcoversion to open surgery decreased from 11.4% in group A to 2.9% in group B and group C, but the difference was not statistically significant （P〉0.05）. The rate of intraoperative complications declined from 17.1% in group A to 5.7% in group B and group C, showing no significant difference either. The lymph node harvest, length of specimen, and postoperative complications showed no significant variation between the 3 groups （P〉0.05）, but group C had significantly shorter mean hospital stay in comparison with groups A and B （P〈0.001）. The 35 patients in group A received the operation within a time period of 17 months （2.1 cases per month）, and operations in groups B and C were done in 7 months （5 cases per month）. Conclusion The learning curve of laparoscopic rectal resections is approximately 35 cases, and the surgeons without previous experience of laparoscopic cholecystectomy can learn the surgical skills after performing 35 laparoseopic resections for rectal cancer at the monthly frequency of 2.1 cases.