小儿经脐单部位腹腔镜肾盂输尿管成形术——单中心80例学习曲线结果分析

Analysis of individual-surgeon learning curve of 80 cases of transumbilical multi-stab laparoscopic pyeloplasty

目的总结经脐单部位腹腔镜肾盂输尿管成形术的手术经验，分析其学习曲线规律，探讨影响手术时间长短的因素。方法回顾性分析2009年6月至2013年6月由单个外科医生完成的89例经脐单部位腹腔镜下肾盂输尿管吻合术的临床资料。其中，男63例，女26例；左侧57例，右侧32例；年龄最小1个月，最大16岁，中位年龄6个月。除重复肾输尿管积水1例、异位血管3例、再次手术患儿5例外，其余常规肾积水病例80例进行学习曲线分析。所有患儿按常规步骤行经脐单部位肾盂输尿管成形术，记录并分析围手术期相关资料，以手术时间定义学习曲线。结果所有患儿均成功接受经脐单部位腹腔镜肾盂输尿管成形术。常规80例患儿中，2例患儿术中增加1个新Trocar通道，无患儿中转传统开腹手术。术后有2例出现肾周积液，1例出现反复性泌尿系统感染，1例术后积水未见缓解，拟计划再次手术。平均手术时间为（91．6±16．6）min，平均术中出血量为（8．4±3．0）ml，平均术后住院时间（8．7±4．4）d。学习曲线显示有腹腔镜手术经验的单个外科医生需要累积20例左右的手术经验才能度过学习期。12岁以上患儿、肾盂膨胀大、再次手术者、异位血管、重复输尿管畸形为手术难点因素。结论经脐单部位腹腔镜肾盂输尿管成形术手术例数的累积可以显著缩短手术时间。经过大约20例手术后，医生的手术熟练和稳定程度明显提高。经脐单部位腹腔镜肾盂输尿管成形术对于有腹腔镜经验的外科医生是一种易于上手，安全可靠的术式，值得临床推广应用。

Objective To explore the perioperative outcomes of transumbilical multi-stab laparoscopic pyeloplasty by analyzing the learning curve of individual surgeons. Methods A total of 89 cases were recruited for transumbilieal multi-stab laparoscopic pyeloplasty during June 2009 to June 2013. There were 63 males and 26 females. And the involved side was left （n = 57） and right （n = 32）. Renal duplication （n = 1）, ectopic vessels （n = 3） and reoperation （n = 5） were excluded for analysis. Routine laparoscopic pyeloplasty was performed by individual operators. The perioperative findings were recorded and the learning curve was defined. Results All patients successfully underwent transumbilical multi-stab laparoscopie pyeloplasty. And there was neither conversion into open surgery nor perinephric space effusion. Urinary tract infection oecurred postoperatively in I case. One case of hydronephrosis worsened postoperatively and required reoperation. The mean intraoperative blood loss was （8. 4± 3. 0） ml, mean operative duration （91.6 ± 16. 6） rain and mean hospital stay was （8. 7 ± 4.4） days. Significant differences in operative duration existed between initial 10 eases and more advanced groups. And significantly longer operative duration was found in juvenile group. Large anteroposterior diameter of pelvis, renal duplication, ectopie vessel and reoperation were operative bottlenecks. Conclusions For transumbilical multi-stab laparoseopic pyeloplasty, a larger case load may yield shorter operative durations. The learning eurve suggests that a laparoscopic surgeon may become proficient after eompleting approximately 20 cases.