腹腔镜联合杯状举宫器下全子宫切除术的学习曲线

Learning curve of total laparoscopic hysterectomy with cup-type uterine manipulator

目的探索腹腔镜联合杯状举宫器下全子宫切除术的学习曲线。方法回顾分析2011年3月至2013年3月我院完成的102例腹腔镜联合杯状举宫器全子宫切除术患者的临床资料,以简单正弦拟合两周期点将其按手术日期分为3个阶段,比较各阶段平均手术时间、术中出血量、中转开腹率、并发症发生率及平均住院时间。结果各阶段手术时间、术中出血量均呈下降趋势,各阶段病例在年龄、子宫大小、BMI、疾病类型等一般资料上无显著差别(P>0.05)。I阶段手术时间(163.3±94.2)min,显著长于II、III阶段(P<0.05);I阶段术中出血量(304.3±169.8)mL,显著长于II、III阶段(P<0.05);进一步两两比较,II、III阶段的手术时间和出血量差异均无显著性意义。中转开腹I阶段1例;术中并发症I、II阶段各1例;术后并发症II阶段1例;术后平均住院时间、术后病率各阶段比较均无统计学意义(P>0.05)。以简单的振荡正弦曲线Y=sinx-π/2拟合移动平均线,手术时间的拐点为31例,术中出血量的拐点为36例。结论腹腔镜联合杯状举宫器下全子宫切除术对已熟练掌握腹腔镜技术的妇科医生是安全可行的随着手术例数增加,手术时间和术中出血量逐渐减少,学习曲线大约为34例,可达到较熟练程度。

Objective To explore the learning curve of Total laparoscopic hysterectomy with Cup-type uterine manipulator .Methods We analyzed the clinical data of 102 cases of total laparoscopic hysterectomy with Cup-type uterine manipulator performed by a single surgi-cal team between June 2011 and June 2013 retrospectively .With a simple sine fitting learning curve ,the patients were divided into stage Ⅰ,Ⅱ,Ⅲwith 34 cases in each stage Ⅱbased on the surgery date ,and the operation time ,intraoperative blood loss ,conversion rate to open sur-gery,complications,postoperative morbidity and postoperative hospitalization time were compared in different stages .Results Each stage of operation time ,intraoperative blood loss are declining ,the three stages were similar with regard to baseline characteristics .The mean operating time (mean ±sd) of stageⅠ(163.3 ±94.2 min) was significantly longer than stage ⅡandⅢ(P<0.05).Significant more blood loss was observed in stage Ⅰ(304.3 ±169.8 mL) than in stageⅡandⅢ(P<0.05).The operating time and intraoperative blood loss did not bary significantly between stage ⅡandⅢ(P>0.05).Conversion to open surgery occurred in one cases of stage Ⅰ,1 patient in stage Ⅰand 1 in stage Ⅱdeveloped intraoperative complications ,1 patient in stage Ⅱhad postoperative complication .There were no significant differences be-tween the three stages with respect to the rate of postoperative morbidity and postoperative hospitalization time (P>0.05).With simple oscil-lation sine curve Y=sinx-π/2 fitting moving averages ,operation time of a turning point for 31 cases,inflection point for 36 cases of intraop-erative blood loss .Conclusion Total laparoscopic hysterectomy with Cup-type uterine manipulator is safe and feasible for well-trained laparo-scopic hepatobliliary surgeon .Opreative time and intraoperative blood loss decrease significantly with the accumulation of cases .The learning curve is about 34 cases to reach proficiency .