单术者机器人辅助腹腔镜肾部分切除术学习曲线分析

Study on learning curve of robot-assisted partial nephrectomy based on single surgeon's experience

目的:探讨机器人辅助腹腔镜肾部分切除术(RAPN)治疗肾肿瘤的学习曲线。方法:回顾性分析2012年5月~2013年8月由单一术者连续完成的40例RAPN患者的临床资料,按手术先后分为4组:第1组(1~10例)、第2组(11~20例)、第3组(21~30例)、第4组(31~40例)。分析对比4组手术时间、热缺血时间、并发症、肾功能等指标。结果:4组患者年龄、肿瘤最大径、R.E.N.A.L.评分等基线数据差异无统计学意义,而手术总时间[(202.20±18.06)min、(194.70±11.68)min、(160.30±14.28)min、(155.20±22.29)min,P<0.01]、热缺血时间[(31.80±10.73)min、(27.10±4.56)min、(16.85±7.01)min、(15.00±6.32)min,P<0.01]的差异有统计学意义,且随着例数增多,呈现逐渐下降的趋势。术中出血量虽呈现下降趋势,但各组之间差异并无统计学意义[(145.00±59.86)ml、(140.00±65.83)ml、(115.00±47.43)ml、(110.00±31.62)ml,P=0.360]。两两对比发现第1组和第2组、第3组和第4组在手术时间和热缺血时间上差异并无统计学意义(P>0.05),而第2组和第3组之间差异有统计学意义(P<0.01)。结论:对于一位有着丰富腹腔镜手术经验的术者,实现普通腹腔镜到RAPN的过渡是一个顺利、快速的过程,学习曲线为15~20例。学习曲线存在个体差异性,术者应根据自身经验选择合适患者,实现手术效果的最优化。

Objective：To investigate the learning curve of robot-assisted partial nephrectomy（RAPN）.Method：We retrospectively analyzed 40patients＇ clinical data who received RAPN continuously by a single surgeon between May 2012 and Aug.2013.The patients were sequentially divided into the first group（1-10cases）,second group（11-20cases）,third group（21-30cases）and the fourth group（31-40cases）.Clinical parameters including operative time,warm ischemia time,estimated blood loss,renal function,et al.were compared among four groups.Result：No significant difference of age,tumor diameter or R.E.N.A.L score was observed among four groups.By multiple comparison,difference of operative time（202.20±18.06 min,194.70±11.68 min,160.30±14.28 min,155.20±22.29 min,P〈0.001）and warm ischemia time（31.80±10.73 min,27.10±4.56 min,16.85±7.01 min,15.00±6.32 min,P〈0.001）was significant among four groups with descending trend.Although similar trend was observed in estimated blood loss,there was no statistical significance（145.00±59.86 ml,140.00±65.83 ml,115.00±47.43 ml,110.00±31.62 ml,P=0.360）.There was significant difference of operative time,warm ischemia time between the second and third group.Conclusion：The transition from laparoscopy to RAPN is a feasible and rapid process.The learning curve is 15-20 cases.In consideration of individualized difference,optimal patients should be chosen based on surgeon＇s experience.