中国经肛全直肠系膜切除结构化培训尸体手术训练中学员表现分析

Performance analysis on trainees in hands-on cadaveric dissection course of Chinese transanal total mesorectal excision structured training

目的分析参加经肛全直肠系膜切除(taTME)结构化培训尸体手术训练中学员表现。方法针对2018年4月至2019年7月参加taTME结构化培训研讨会的学员,通过问卷调查获取数据,分析学员在尸体手术训练过程中各步骤的技术表现、术中困难及并发症以及术后标本直肠系膜完整度等结果。结果共45名学员参加taTME结构化培训研讨会,其中39名学员返回问卷。荷包缝合方面,5名(12.8%)学员未能独立完成,7名(17.9%)学员需要经过两次或以上尝试来完成荷包缝合。在各方向直肠系膜间隙的切开分离过程中,85%~90%学员能在教员不同程度上的口头指导下亲自完成。最终标本直肠系膜完整性的评价中,系膜不完整的标本共5例(12.8%),系膜近乎完整的标本共18例(46.2%),系膜完整的标本共16例(41.0%)。术中并发症及遇到困难方面,18名(46.2%)学员进入错误间隙,1名(2.6%)学员出现直肠穿孔,4名(10.3%)学员出现荷包失败,2名(5.1%)学员出现尿道损伤。单因素分析发现只有学员培训前独立完成taTME手术的例数≥1例为术中不出现并发症的影响因素。结论参加培训的学员在荷包缝合、直肠全层切开以及直肠系膜间隙的分离等各重要手术步骤中获得较为充足的亲自上手练习机会,较丰富的工作经验以及腹腔镜全直肠系膜切除术(TME),经肛门内镜微创手术(TEM)、经肛门微创手术(TAMIS)的手术经验并不能降低taTME手术经肛操作部分的术中并发症发生率。参加包含尸体手术训练的taTME结构化培训有助于降低术中并发症发生率并提高手术安全性。

Objective To analyze trainees’ performance in hands-on cadaveric dissection course of Chinese transanal total mesorectal excision(taTME) structured training.Methods Questionnaires were sent to all the trainees who participated in Chinese taTME structured training from April 2018 to July 2019,with the purpose to analyze the performance of the trainees,to record intraoperative difficulties and complications,and to evaluate the mesorectal completeness of the specimens.Results From April 2018 to July 2019,45 trainees in total participated in taTME structured training,39 of them had completed and returned the questionnaires.Regarding purse-string suturing,5(12.8%) trainees did not accomplish it independently,7(17.9%) trainees accomplished it with more than one attempt.Eighty-five to ninety percent of the trainees could accomplish the dissection of the mesorectal plane on each side with only verbal support from trainers.The evaluation of the specimen completeness showed that 5(12.8%) specimenswere incomplete,18(46.2%)specimens were near complete and 16(41.0%)specimens were complete.About intraoperative difficulties and complications,18(46.2%)traineesentered into the wrong dissection planes,1(2.6%) trainee encountered rectal perforation,4(10.3%) trainees failed in purse-string suturing,2(5.1%) trainees encountered urethral injury.Univariate analysis showed that only the experience of performing one or more taTME surgeries before training was an influencing factor for not encountering intraoperative complication in cadaveric handson training.Conclusion Trainees could gain plenty of hands-on operating experience in important steps of taTME surgery including purse-string suturing,full thickness rectotomy,mesorectal plane dissection.Extensive experience of laparoscopic total mesorectal excision,transanal endoscopic microsurgery or transanal micro-invasive surgery will not decrease the intraoperative complication rate for transanal part of taTME procedure on cadaver.Participating taTME structured training with hands-on cadaveric dissection course is helpful before applying taTME procedure on patients.