冰冻尸体标本手术操作的经肛全直肠系膜切除术结构化培训效果分析

Analysis of the effect of transanal total mesorectai excision structured training on the operation of frozen cadaver specimens

目的：探讨冰冻尸体标本手术操作的经肛全直肠系膜切除术（TaTME）结构化培训效果。方法：采用回顾性横断面研究方法。收集2018年4月12—13日由中华医学会外科学分会结直肠外科学组、中国TaTME临床研究协作组、北京解剖学会等联合主办，首都医科大学附属北京友谊医院、北京解剖学会临床应用解剖科学技术培训中心承办的第一期TaTME结构化培训的9名学员资料。TaTME结构化培训包括理论授课、手术演示教学和冰冻尸体标本手术操作。冰冻尸体标本手术操作时9名学员分为 3组：第1组学员编号A、C、E，第2组学员编号B、D、F，第3组学员编号G、H、I，每名学员进行冰冻尸体标本手术操作问卷调查。学员培训完成3个月后进行追踪问卷调查，包括参加结构化培训前、后TaTME手术量，参加结构化培训前、后TaTME熟练度，目前尚未开展TaTME的原因，TaTME学习曲线，TaTME手术相关并发症或不良事件，将来是否会继续行TaTME，TaTME结构化培训的作用，开展TaTME前是否需要接受该结构化培训。观察指标：（1）学员参与理论授课及手术演示教学情况。（2）学员冰冻尸体标本手术操作情况。（3）学员结构化培训完成3个月后追踪调查情况。学员结构化培训前后比较采用秩和检验。结果：（1）学员参与理论授课及手术演示教学情况：9名学员均接受理论知识授课及手术演示教学。理论知识授课，加深学员对TaTME理解；现场手术演示教学使学员更加直观感受TaTME技术要领及注意事项。（2）学员冰冻尸体标本手术操作情况：9名学员在指导老师的指导下，均能顺利完成冰冻尸体标本手术操作，达到训练目的。指导老师总体评价：3组学员的标本吻合口均完整；直肠系膜完整度Quirke分级为第1、2组 2级，第3组3级；并发症及主要困难为错误间隙操作、烟雾控制不佳，其中第3组发生尿道损伤。（3）学员结构化培训完成3个月后追踪调查情况：9名学员结构化培训后，2名TaTME手术量〉10例、2名6～10例、2名1例、3名0例，结构化培训前2名TaTME手术量6～10例、2名2～5例，1名1例、4名0例，培训前后学员TaTME手术量比较，差异无统计学意义（Z=1.000，P〉0.05）；其中3名学员仍未开展TaTME，原因分别为未发现合适的患者、无TaTME手术必备的硬件设施以及仍未完全掌握TaTME。9名学员结构化培训后，1名TaTME熟练度为极为熟练、3名需要1/4程指导、3名需要1/2程指导，2名需要3/4程指导，结构化培训前1名需要1/4程指导、1名需要1/2程指导，4名需要3/4程指导、3名非常不熟悉，培训前后学员TaTME熟练度比较，差异无统计学意义（Z=1.243，P〉0.05）。9名学员中5名认为完成10例TaTME后才度过学习曲线。学员开展TaTME手术相关并发症或不良事件包括尿道损伤、出血、手术错误间隙及手术切除标本不完整。9名学员中8名表示将来会继续行TaTME。9名学员一致认为TaTME结构化培训非常必要以及开展TaTME前需要接受该结构化培训。结论：冰冻尸体标本手术操作的TaTME结构化培训，是对TaTME这一新手术方式培训的崭新尝试。结构化、规范化TaTME培训是临床开展TaTME前的必要条件，有利于提高TaTME的安全性和有效性。

Objective：To explore the effect of transanal total mesorectal excision （TaTME） structured training on the operation of frozen cadaver specimens in China's Mainland. Methods：The retrospective crosssectional study was conducted. The data of 9 trainees who participated in the 1st TaTME structured training between April 12 and 13, 2018 were collected. Chinese Society of Colorectal Surgery, Chinese Society of TaTME Surgeons and Beijing Anatomy Society were the host of TaTME structured training, Beijing Friendship Hospital of Capital Medical University and Clinical Applied Anatomy Science and Technology Training Center of Beijing Society for Anatomy Society were the undertakers. The courses included theoretical teaching, operation demonstration and frozen cadaveric specimens operation. Nine trainees were allocated into the 3 groups, including trainees A, C, E in group 1, trainees B, D, F in group 2 and trainees G, H, I in group 3. The special questionnaire survey was carried out on all the trainees at 3 months after the end of the training, contents included the number and proficiency of TaTME before and after training, reasons for not performing TaTME, learning curve of TaTME, TaTME-related complications and adverse reactions, whether or not to continue TaTME in future, effects of training, whether or not necessary to take training before TaTME. Observation indicators： （1） situations of trainees taking part in theoretical lectures and operation demonstration; （2） situations of trainees taking part in frozen cadaveric specimens operation; （3） questionnaire survey situations of trainees at 3 months after training. Comparison of trainees before and after training was done by the ranksum test. Results：（1） Situations of trainees taking part in theoretical lectures and operation demonstration： 9 trainees received theoretical lectures and operation demonstration. The theoretical lectures helped deepen understanding of the TaTME, and operation demonstration gave an intuitive feel of technical points and considerations for TaTME. （2） Situations of trainees taking part in frozen cadaveric specimens operation： 9 trainees performed successfully frozen cadaveric specimens operation under the guidance of the instructors to achieve training purposes. Overall evaluation of the instructors： anastomotic stoma was intact in 3 groups; grading 2 of Quirke grading of mesorectum was detected in group 1 and 2, and grading 3 in group 3; the main difficulty of complications was incorrect interstice operation and poor smog control, and urethral injury occurred in group 3. （3） Questionnaire survey situations of trainees at 3 months after training： 2, 2, 2 and 3 trainees after training carried respectively on more than 10, 6-10, 1 and 0 times TaTME, 2, 2, 1 and 4 trainees before training carried respectively on 6-10, 2-5, 1 and 0 in number of TaTME before and after training, with no statistically significant difference （Z=1.000, P〉0.05）. Three trainees didn′t perform TaTME due to no suitable patient, no equipment for TaTME and incompletely master operating of TaTME. After training, 1 trainee was very proficient for TaTME, 3, 3 and 2 trainees respectively needed to 1/4, 1/2 and 3/4 of guidance; before training, 1, 4 and 3 trainees needed to respectively 1/4 , 1/2 and 3/4 of guidance, and 3 trainees were very inaptitude for TaTME, with no statistically significant difference in proficiency of TaTME before and after training （Z=1.243, P〉0.05）. Five of 9 trainees thought that finishing learning curve needed 10 times TaTME. TaTMErelated complications and adverse reactions included urethral injury, bleeding, incorrect interstice operation and incomplete specimens. Eight of 9 trainees expressed that would continue to carry on TaTME. All trainees thought TaTME structured training was very necessary and training should be finished before TaTME. Conclusions：The TaTME structured training program on the operation of frozen cadaver specimens is a new attempt. The structured and standardized TaTME training is a necessary condition for clinical performing of TaTME, which is conductive to improving the safety and effectiveness of TaTME.