机器人辅助冠状动脉旁路移植术的学习曲线与临床分析

Learning curves and clinical analysis of robot-assisted coronary artery bypass grafting

目的探讨达芬奇机器人辅助冠状动脉旁路移植术的学习曲线特征，分析早、中期临床结果。方法回顾性分析我院心脏外科2009年5月至2015年5月72例非体外循环使用机器人辅助下冠状动脉旁路移植手术的临床资料，按手术先后顺序分为A、B、C3组，每组24例，比较各组机器人安装时间、手术时间、出血量、并发症、监护时间、术后住院时间及随访情况等，总结机器人手术的技术学习特点和临床相关结果。结果3组患者术前资料，除左心室舒张末内径（B组显著低于c组，P=0．033）外，性别、年龄、体质量指数、左心室射血分数，合并高血压、糖尿病的比例等差异均无统计学意义（P〉0．05）。A组机器人安装时间、取乳内动脉时间、总手术时间显著长于B、C两组，B、C两组间差异无统计学意义。全组患者无手术死亡，术后ICU监护时间C组明显短于A、B两组（P=0．039）。术后随访，3组在再血管化、再发心绞痛症状、再发心肌梗死、脑梗塞方面差异均无统计学意义（P〉0．05）。随访期间死亡2例，心源性和非心源性各1例。结论达芬奇机器人辅助冠状动脉旁路移植术治疗单支或多支病变冠心病近、中期疗效满意，机器人辅助冠状动脉旁路移植术的学习曲线约为20例。

Objective To investigate the characteristics of the learning curve of off-pump robot-assisted coronary artery bypass graft surgery（RACAB） and analysis the outcomes in the short and mid-term. Methods We performed a retrospective review of 72 patients with coronary artery disease（CAD） who underwent off-pump RACAB between May 2009 and May 2015. The patients were divided into 3 groups（ group A, B and C） according to the operation sequence, 24 cases in each group. The operation time, blood loss, complications, ICU stays, hospital stays and follow-up results were analyzed, and the techniques skill and learning characteristics of RACAB were summarized. Results The preoperative data of three groups were similar ex- cept left ventricular end-diastolic diameter（ LVEDD of group B was significantly lower than that of group C, P =- 0. 033 ）. Robot installation time, time of internal mammary artery harvesting, total operation time of group A were significantly longer than group B and C, and there was no significant difference between group B and C. Postoperative ICU stay in group C was signifi- cantly shorter than A and B （ P = 0. 039 ）, with no operative mortality in the three groups. There were no differences among the three groups of revascularization, recurrent angina symptoms, recurrent myocardial infarction and cerebral infarction （ P 〉 0. 05 ）. There were 2 patients died during the follow-up of the whole group, one for cardiac reason and one for non-cardiac rea- son. Conclusion The da Vinci RACAB achieved satisfactory recent and mid-tern1 results in patients with simple multi-vessel CAD. A learning, curve of about 20 eases is reouircd to achieve adept operation.