单术者机器人辅助腹腔镜肾部分切除术的学习曲线

Learning curve for robotic assisted laparoscopic partial nephrectomy:a single operator experience

目的探讨单术者机器人辅助腹腔镜肾部分切除术的学习曲线。方法回顾性分析2016年2月至2018年4月北京协和医院100例行机器人辅助腹腔镜肾部分切除术治疗的肾肿瘤患者的病例资料。男64例,女36例。平均年龄51.5(18~79)岁。平均体质指数24.9(19~31)kg/m^(2)。TNM分期均为T1N0M0期,具有肾部分切除术指征。肿瘤位于左侧38例,右侧62例。肿瘤平均最大径3.9(1.0~6.7)cm.平均R.E.N.A.L.评分6.7(4~11)分。手术均由单一术者完成,术者拥有10年以上腹腔镜主刀经验,已完成传统腹腔镜手术>1000台。本组手术为术者开展机器人手术后的前100例。手术平均装机时间14(10~30)min,平均手术时间119.2(60~240)min,平均热缺血时间16.7(0~45)min,平均术中估计出血量105.2(30~500)ml。无中转根治性肾切除术,无中转开腹或普通腹腔镜手术。术后未发生严重并发症(Dindo-Calvein分级≥Ⅲ级)。术后出现下肢肌间静脉血栓、尿瘘、肺部感染、肾周血肿各1例,保守治疗后均痊愈,无需进一步手术或介入治疗。术后病理结果无切缘阳性情况。使用累积和检验(CUSUM)方法对装机时间和手术时间的学习曲线进行拟合,根据曲线的拐点(累积和停止上升、累积和开始下降)判断术者机器人手术的3个不同学习阶段,并比较术者不同学习阶段的手术患者特征和围手术期数据。结果根据CUSUM法拟合的手术时间学习曲线显示,机器人手术的学习曲线为19例。根据手术时间学习曲线的拐点,将100例手术分为3个阶段:1~19例为学习阶段,20~43例为掌握阶段,44~100例为熟练阶段。3个阶段的患者年龄、性别、肿瘤侧别、术中估计出血量、术后病理类型、住院总费用、并发症发生率比较差异均无统计学意义(P>0.05)。学习阶段的患者中位体质指数明显低于掌握阶段和熟练阶段(23kg/m^(2)与26kg/m^(2)、25kg/m^(2),P=0.02)。学习阶段、掌握阶段、熟练阶段的中位装机时间(20 min与12 min与12 min)、中位手术时间(150 min与120 min与100 min)、中位热缺血时间(21 min与18 min与15 min)均呈逐渐缩短趋势(P<0.001)。学习阶段术后中位住院时间明显长于掌握阶段和熟练阶段(7d与6d和6d,P=0.011)。学习阶段、掌握阶段、熟练阶段的中位肿瘤最大径(3.7 cm与3.9 cm与4.0 cm,P=0.75)和中位R.E.N.A.L.评分(6分与7分与7分,P=0.16)呈逐渐增加的趋势,但差异无统计学意义。结论对于腹腔镜手术经验丰富的术者,机器人辅助腹腔镜肾部分切除术的学习曲线为19例左右。完成学习曲线后,装机时间、手术时间、热缺血时间和患者术后住院时间可较初期明显缩短。

Objective To present the learning curve of robotic assisted laparoscopic partial nephrectomy by a single surgeon.Methods The clinical data of 100 patients with renal tumor who underwent robot assisted laparoscopic partial nephrectomy in Peking Union Medical College Hospital from February 2016 to April 2018 were retrospectively analyzed.There were 64 males and 36 females.The average age was 51.5(18-79)years.The average body mass index(BMI)was 24.9(19-31)kg/m^(2).TNM stage was T1N0M0,which indicated partial nephrectomy.The tumors were located on the left in 38 cases and on the right in 62 cases.The average maximum diameter of tumor was 3.9(1.0-6.7)cm,and the average R.E.N.A.L.score was 6.7(4-11).All operations were performed by a single surgeon.This group of operations were the first 100 robot cases for this surgeon.The mean machines docking time was 14(10-30)min,the mean operation time was 119.2(60-240)min,the mean warm ischemia time was 16.7(0-45)min,and the estimated mean blood loss was 105.2(30-500)ml.There was no conversion to open surgery or laparoscopic radical nephrectomy.No serious complications occurred(Dindo calvein grade≥gradeⅢ).There were 1 case of lower extremity intramuscular venous thrombosis,1 case of urinary fistula,1 case of pulmonary infection and 1 case of peri-kidney hematoma after operation.All patients were cured after conservative treatment without further operation or intervention.Cumulative Sum(CUSUM)test was used to fit the learning curve of docking time and operation time,and to judge the three different learning stages of robot surgery according to the inflection of the curve(CUSUM stop rising,and CUSUM begin to decline).The characteristics of patients and perioperative data of different learning stages were compared.Result According to the CUSUM,the learning curve of robot assisted laparoscopic partial nephrectomy was 19 cases.According to the inflection point of operation time learning curve,100 cases could be divided into three stages,1st-19th cases were learning stage,20th-43rd cases were mastering stage and 44th-100th cases are proficient stage.There were no significant differences in age,gender,tumor side,intraoperative bleeding volume,postoperative pathological type,total cost of hospitalization and incidence of complications among the three stages(P>0.05).The median BMI in the learning stage was significantly lower than that in the mastery stage and the proficiency stage(23 kg/m^(2),26 kg/m^(2),25 kg/m^(2),P=0.02).The median docking time(20 min,12 min,12 min),median operation time(150 min,120 min,100 min)and median warm ischemia time(21 min,18 min,15 min)were gradually shortened in the learning stage,mastering stage and proficient stage(P<0.001).The median length of postoperative hospital stay in mastering stage and proficient stage was shorter than that in learning stage(7 d,6 d,6 d,P=0.011).The median maximum diameter of tumor(3.7 cm,3.9 cm,4.0 cm)and median R.E.N.A.L.score(6,7,7)increased gradually in learning stage,mastering stage and proficient stage,but the difference was not statistically significant(P=0.75,P=0.16).Conclusions The learning curve of robotic assisted laparoscopic partial nephrectomy for an experienced surgeon is about 19 cases.After the completion of the learning curve,the docking time,operation time,warm ischemia time and postoperative hospital stay of patients can be significantly shortened than the initial period,and more difficult renal tumor operations can be accomplished.