腹腔镜保留肾单位术三级培训模式初探

Three-stage training model for laparoscopic nephron-sparing nephrectomy

目的介绍腹腔镜保留肾单位术的三级培训模式。方法三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作。以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式。临床实践操作又细分为三步进行，包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS。结果4名学员均成功完成全部三级培训内容。其中体外模拟培训累计时间平均为70h。经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能。4名学员均完成动物模型LNSS20例，其中半肾切除术6例。肾上极或下极平均手术时间由最初的（120．0±10．9）min降低到在完成12台LNSS时的（69．0±5．2）min，差异有统计学意义（P〈0．01）。学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7—9例后，各自成功地完成LNSS手术3例，均未出现术中并发症。LNSS平均手术时间为87min，肾脏热缺血时间平均为25min。结论“三级培训模式”能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术，显著地降低手术并发症的发生，提高手术疗效，有利于腹腔镜手术的推广应用。

Objective To introduce the three-stage model designed for urologists without laparoscopic experience to master laparoscopic nephron-sparing surgery （LNSS）. Methods The first stage was initiated on the box simulator. The second stage was scheduled to perform on pig model developed according to the standard method of LNSS. The third stage was proceeded in operating room, including assisting the laparoscopic surgeries, then 7-9 simple laparoscopic procedures performed by trainees, LNSS. Mentorinitiated model was applied during the operations. Results Four trainees finished all three stages training successfully. The mean cumulative time spend on the box trainer was 70 h, and they mastered the basic laparoscopic skills including sewing and knotting after the first stage training. Every trainee performed 20 LNSSs on pig model which consisted of 6 cases of semi-nephrectomy. The operative time for LNSS located on the renal poles was decreased from the initial （ 120.0 ± 10.9） min to （69.0 ± 5.2） min for the 14th LNSS （P 〈0.01 ）. When the 4 trainees successfully performed 7-9 simple laparoscopic operations including retroperitoneoscopic renal cyst unroofing and upper ureterolithotomy and anatomic adrenalectomy, they were evaluated objectively and subjectively by the mentor, and then were permitted to perform 3 LNSSs under the supervision of mentors. No complications occurred. The mean operative time for LNSS was 87 min, and the mean warm-ischemia time was 25 min. Conclusion The three-stage model is effective and feasible for the surgeons to master the advanced LNSS, which can reduce the complications and improve the curative effects remarkably.