缩短腹腔镜下腹股沟疝修补术学习曲线的因素分析

Factor analyses of learning curve for laparoscopic inguinal hernia repair

目的分析影响完成腹腔镜腹股沟疝修补术(LIHR)学习曲线的因素。方法回顾性分析2005年6月至2012年1月上海市长宁区中心医院三组医师开展LIHR的临床资料。比较医师开展LIHR前手术技能和解剖经验、培训经历、手术完成情况、手术时间、手术并发症和复发率。结果 2005年6月至2007年11月(A组)共开展12例LIHR,其中一组医师完成8例LIHR,无中转手术,手术时间(180.6±37.9)min,术后住院时间(7.8±1.3)d;另一组医师完成3例LIHR,中转开放修补术1例,手术时间(165.0±52.0)min,术后住院时间(6.5±3.3)d。术后随访1例复发,术后无严重并发症。2010年7月至2012年1月(B组)医师完成100例LIHR。手术时间(69.7±24.9)min,术后住院时间(2.5±1.1)d。中转开放修补术1例,术后复发2例,术后无严重并发症。2010年7月至2012年1月患者按时间序列分成6组,Ⅰ组和Ⅱ组各含10例患者,Ⅲ、Ⅳ、Ⅴ、Ⅵ组各含20例患者。2005年6月至2007年11月组手术时间高于2010年7月至2012年1月组中的Ⅰ组、Ⅱ组,但是差异无统计学意义(F=1.440、5.553,P=0.7664、0.1026),与后四个亚组相比差异有统计学意义(F=17.193、16.464、16.271、16.012,P=0.00001、0.00028、0.00708、0.000804)。2010年7月至2012年1月完成40例LIHR后手术时间下降并稳定在60min。结论 LIHR初学者的学习曲线需要完成约40例手术。手术者和助手术前培训有助于尽快度过学习曲线。

Objective To analyze the factors to overcome the learning curve for laparoscopic inguinal hernia repair（LIHR）. Methods The clinical data collected from June 2005 to January 2012 including three groups of surgeons was retrospectively analyzed. Compared the difference of surgeon＇s background of surgery technique and knowledge of anatomy at the beginning of LIHR,experience of training, operation performance, operation duration, complication and recurrence rate were assessed. Results In the period of June 2005 to November 2007 （ named group A）, a total of 12 cases of LIHR were performed. One group of surgeons completed 8 cases of LIHR without conversion to open repair. The mean operation duration was （ 180.6 ＋ 37.9 ） mins. The length of postoperative hospital stay was （ 7.8 ＋ 1.3 ） days. Another group of surgeons operated 3 cases of totally extraperitoneal laparoscopic repair with one case of conversion to open repair. The mean operation duration was （165.0 ＋ 52.0） mins. The length of postoperative hospital stay was （6.5 ＋ 3.3） days. There was one recurrence in follow-up and no severe complications in both groups. In the period of July 2010 to January 2012, group B performed 100 cases of LIHR, with one case of conversion to open repair and two cases of recurrences in follow-up. There was no severe complication. The mean operation duration was （69.7 ＋ 24. 9 ） mins. The length of postoperative hospital stay was （2.5 ＋ 1.1 ） days. The patients in the period of July 2010 to January 2012 were time sequentially divided into 6 groups. Ten patients each in group I to 1I and 20 patients each in groups m to vl were observed. The operation time in the period of June 2005 to November 2007 was longer than that of group [ and I1 , but without any significant difference （ F = 1. 440, 5. 553, P = 0. 766 4, 0. 102 6）, while there was significant difference compared with that of the other four groups（F= 17. 193, 16. 464, 16. 271, 16. 012, P =0. 000 01, 0. 000 28, 0. 007 08, 0. 000 804）. In the period of July 2010 to January 2012, the mean duration of surgery significantly decreased and reached a plateau of less than 60 minutes after 40 eases. Conclusions Forty eases for a beginner surgeon may be needed for the learning curve for LIHR. The preoperative training for both surgeon and assistant can be helpful for shortening the duration of learning curve.