全乳晕入路腔镜甲状腺切除术十步法学习曲线

Study on the learning curve of the ten-step method of endoscopic thyroidectomy by complete areola approach

目的探讨全乳晕入路腔镜甲状腺切除术(areola approach endoscopic thyroidectomy,AET)的学习曲线,探索影响手术熟练度的关键步骤,指导训练重点。方法回顾性分析开展AET技术初期95例因甲状腺乳头状癌行全乳晕入路腔镜单侧甲状腺切除术的患者资料,术中全程录像。按照AET十步法进行操作:切口定位、穿刺建腔、寻找喉返神经、入喉点解剖、喉上神经外支保护、甲状旁腺原位保留、颈中央区清扫、标本取出、甲状旁腺自体移植、缝合引流。记录手术总时间,依据手术步骤时间上的重叠进一步分为6个时间段进行计时。结果手术总时间拟合曲线在前20例即有明显下降,在20例以后曲线趋于平稳。按手术日期分为5组,第1~4组20例、第5组15例;第1组手术总时间(121.25±24.32)min,明显长于第2~5组(P<0.05);十步法的前3步操作时间在第1、2组间降低(P<0.05),在第2组以后相邻各组间无降低(P>0.05);十步法的后7步操作时间在相邻两组间均无降低(P>0.05)。各组间低钙血症、喉返神经损伤等并发症比较无差异(P>0.05)。结论对于具有熟练开放甲状腺手术和腹腔镜手术基础的医师,按照AET十步法进行操作,经过20例的积累后手术总时间明显下降并趋于稳定,其中关键步骤是前3步:切口定位、穿刺建腔、寻找喉返神经。

Objective To investigate the learning curve of endoscopic thyroidectomy by complete areola approach, explore the key steps that affect the proficiency of surgery, and guide the way of training. Methods Retrospective analysis of 95 patients who underwent unilateral endoscopic thyroidectomy by complete areola approach for papillary thyroid carcinoma at the initial stage of this technique, and the whole operation was recorded. The ten-step method of endoscopic thyroidectomy by complete areola approach was divided into incision positioning, puncture and cavity construction, searching for recurrent laryngeal nerve, throat entry dissection, protection of the superior laryngeal nerve branch, parathyroid preservation, neck central area dissection, specimen removal, parathyroid autotransplantation, suture and drainage. The total operation time is recorded, and it is further divided into six time periods according to the overlapping of operation steps. Results The total operation time fitting curve decreased significantly in the first 20 cases, and the curve tended to be stable after 20 cases. The participants were divided into 5 groups according to the operation date(n=20, 15 cases in group 5). The total operation time of group 1(121.25 ± 24.32) min was significantly longer than other groups(P<0.05);The time of the first steps decreased between group 1 and 2(P<0.05), and there was no decrease between the adjacent groups after group 2(P> 0.05);The time of the last seven steps has no decrease between the adjacent two groups(P>0.05). There were no differences in complications such as hypocalcemia and recurrent laryngeal nerve injury among the groups(P>0.05). Conclusions A well-trained thyroid open surgery and laparoscopic surgery surgeon can significantly reduce the total operation time and after 20 cases by using the ten-steps method. The key steps are the first three steps of the ten-step method, including incision positioning, puncture and cavity construction and searching for recurrent laryngeal nerve.