具有开放手术经验外科医师腹腔镜直肠癌根治术学习曲线研究

Learning curve of laparscopic resection in rectal cancer for experienced surgeon

目的探讨具有丰富开放手术经验的外科医师（〉200例次/年）尽快掌握腹腔镜直肠癌根治术的方法。方法回顾性分析2009年8月至2015年4月第二军医大学附属长海医院肛肠外科同一团队完成的120例腹腔镜辅助直肠癌根治术病例资料。按手术日期先后分为A、B、C 3组,每组40例,时间跨度分别为36、19、11个月。比较各组的手术时间、术中出血量、中转开放发生率、清扫淋巴结数、直肠系膜完整性、术后通气时间、术后住院时间及术后并发症发生率,并应用移动平均法绘制手术时间曲线。结果 A组手术时间明显长于B、C组[（162.9±36.7）min vs.（147.0±36.8）min vs.（132.7±31.9）min,P〈0.05],B、C组间差异无统计学意义（P〉0.05）;A组在术中出血量、中转开放发生率和术后住院时间方面与B、C组差异无统计学意义（P〉0.05）;其余指标包括淋巴结清扫数、直肠标本系膜完整性、术后通气时间和术后并发症发生率,3组差异均无统计学意义（P〉0.05）。手术时间曲线显示,在手术开展至41~51例后,手术时间逐渐稳定。结论具有丰富开放手术经验的外科医师腹腔镜直肠癌根治术的学习曲线约为40例。

Objective To investigate how experienced surgeons in open surgery can quickly learn laparscopic resection for rectal cancer. Methods The clinical data of 120 cases of laparscopic resection for rectal cancer performed by the same team of surgeons from August 2009 to April 2015 in Changhai Hospital of the Second Military Medical University were analyzed retrospectively. The cases were divided into three groups （40 cases in each group） by operative sequence. The time span was 36, 19, 11 months respectively. The operating time, blood loss, the rate of conversion to open operation, number of lymph nodes, the integrityof mesorectum, postoperative aerofluxus time, postoperative hospital stay and the rate of postoperative complications were compared among the 3 groups. Results The operating time in group A was （162.9±36.7）min,which as much higher than that in group B （147.0±36.8）min and group C （132.7±31.9） min （P〈0.05）. However, there was no significant difference between group B and C （P〉0.05）. Intraoperative blood loss, the rate of conversion to open operation and postoperative hospital stay in group A had no significant difference compared with those in group B and C （P 〉 0.05）. Also, there was no significant difference in the integrity of mesorectum, number of lymph nodes, postoperative aerofluxus time and the rate of postoperative complications among 3 gourps （P〉0.05）. Conclusion From the learning curve, surgeons with rich experience in open surgery can learn laparscopic skills for rectal cancer after performing 40 cases.