耻骨上辅助经脐单孔腹腔镜下肾切除术：单中心学习曲线研究

Suprapubic-assisted laparoendoscopic single-site nephrectomy： analysis of learning curve in one center

目的 探讨耻骨上辅助经脐单孔腹腔镜（suprapubic-assisted laparoendoscopic single-sitesurgery,SA-LESS）肾切除术的学习曲线.方法 收集2013年4月至2016年4月60例行SA-LESS肾切除术患者的临床资料,手术分别由两位已熟练掌握标准腹腔镜手术的副主任医师施行（B、C组）,每组各30例.B组男25例,女5例,平均年龄（48.4±9.4）岁;C组男23例,女7例,平均年龄（52.6±l2.0）岁.以另一位主任医师同期熟练操作完成的30例SA-LESS肾切除术数据为基准组（A组）,男26例,女4例,平均年龄（50.8±12.3）岁.3组患者均为单侧上尿路结石或输尿管狭窄所致重度肾积水（无功能肾）,对侧肾功能均正常.记录3组的手术时间、术中出血量、术中增加套管或中转开放手术例数、术中术后并发症等数据,计算B、C组的累积和值（cumulative summation,CUSUM）,并用Matlab软件进行多项式曲线分别拟合描绘B、C组术者的个体及总体CUSUM.结果 A组30例手术均顺利完成,手术时间85 ～ 175 min,平均（123.3 ±28.4） min;出血量65～280 ml,平均（121.7 ±43.1）ml.B组28例顺利完成手术,手术时间90～ 260 min,平均（141.7 ±49.4）min;出血量70 ～450 ml,平均（165.2 ±81.9） ml.C组29例顺利完成手术,手术时间90 ～235 min,平均（133.1±33.7）min;出血量75 ～500ml,平均（140.0 ±72.3）ml.B组术中中转标准腹腔镜和开放手术各1例,C组中转标准腹腔镜手术1例.A组术中发生Satava Ⅰ级并发症1例,术后发生Clavien-Dindo Ⅰ级并发症1例;B组术中发生Satava Ⅰ级并发症2例、SatavaⅡ级并发症1例,术后发生Clavien-Dindo Ⅰ级并发症1例;C组术中发生Satava Ⅰ级并发症1例、SatavaⅡ级并发症2例,术后发生Clavien-DindoⅡ级并发症1例.两位副主任医师个体CUSUM拟合学习曲线斜率开始为负值的手术例数分别为15、11例,总体学习曲线自第13例起开始为负值.结论 对于已经熟练掌握标准腹腔镜手术的高年资泌尿外科医生,经过13例的手术学习,可以掌握SA-LESS肾切除术.

Objective To evaluate the learning curve of Suprapubic-assisted laparoendoscopic single-site surgery （SA-LESS） nephrectomy in our center.Methods From April 2013 to April 2016,60 patients underwent SA-LESS nephrectomy performed by two associate chief physicians （group B and C,30 patients in both groups）.There were 25 males and 5 females with mean age （48.4 ±9.4）years in group B,and 23 males and 7 females with mean age （52.6 ± 12.0）years in group C.Operative time,estimated blood loss,converting to conventional laparoscopy or open surgery,intra and postoperative complications in both groups were recorded,The data from both group B and C were compared with those of group A [Standard group with 30 patients who underwent SA-LESS nephrectomy performed by a skillful chief physician,26 males and 4 females with mean age （50.8 ± 12.3） years].All the patients in the three groups were diagnosed with upper urinary tract calculus or ureteral stricture with severe ipsilateral hydronephrosis （nofunction kidney） and a normal contralateral kidney.The sum of the Cumulative Summation （CUSUM） was also cumulated.Individual learning curve and total learning curve were established.Result All the 30 procedures in group A were successfully completed with an average operative time [（123.3 ± 28.4） min （85 ～ 175 min）] and an average estimated blood loss[（121.7 ±43.1） ml（65 ～ 280 ml）].There were 28 procedures successfully finished in group B and 29 in group C,respectively.The average operative time was [（141.7 ±49.4） min（90 ～260 min）] and the average estimated blood loss was [（165.2 ±81.9） ml（70 ～450 ml）] in group B,and the average operative time was [（133.1 ± 33.7）min （90 ～235 min）]and the avcragccstimatcd blood loss was [（140.0±72.3）m1（75 ～500 ml）] in group C.There was 1 case converted to conventional laparoscopy and 1 case converted to open surgery in group B with 4 （13.3%） complications （Satava Ⅰ 2 cases,Satava Ⅱ 1 case,Clavien-Dindo Ⅰ 1 case） in all.There was 1 case converted to conventional laparoscopy in group C with 4 （13.3%） complications （Satava Ⅰ 1 case,Satava Ⅱ 2 cases,Clavien-Dindo Ⅱ 1 case） in all.Statistical analysis showed that the number corresponding to the slope changed into negative was 15 and 11 for group B and C,respectively,and 13 was confirmed in the total learning curve.Conclusions SA-LESS nephrectomy could be feasible and safe for an experienced laparoscopic surgeon,who may master it after he finished 13 cases of SA-LESS nephrectomy.