以累积和法分析胸乳入路腔镜甲状腺切除术的学习曲线

The learning curve of endoscopic thyroidectomy via breast by cumulative sum analysis

目的:探讨经胸乳入路行腔镜甲状腺切除术的学习曲线。方法:回顾分析2016年2月至2020年12月由同一组术者为95例患者经胸乳入路行腔镜甲状腺切除术的临床资料,采用累积和法及最佳拟合曲线分析其学习曲线,比较学习曲线不同阶段的一般资料、手术时间、术中出血量、术后引流量、引流时间、住院时间、止痛药使用量、并发症等指标。结果:95例患者均顺利完成手术,无中转开放及围手术期死亡病例。累积和法得出拟合曲线最大转折点在28例,此例后可认为已度过学习曲线,以此为分界将学习曲线分为学习提高、熟练掌握两个阶段。两阶段患者的一般资料、住院时间差异无统计学意义(P>0.05),手术时间由(167.6±50.1)min降至(113.2±21.4)min(P<0.01);术中出血量由(31.6±10.0)mL降至(15.7±6.0)mL(P<0.01);术后引流量由(145.3±75.6)mL降至(80.4±40.6)mL(P<0.01);术后引流时间由(2.5±0.9)d降至(2.0±0.6)d(P<0.05),差异有统计学意义。学习提高阶段的止痛药使用率、并发症发生率均高于熟练掌握阶段(P<0.05)。结论:胸乳入路腔镜甲状腺切除术学习过程安全,经过约28例的手术后可达到熟练掌握阶段,适合具有腔镜手术与开放甲状腺手术经验的团队开展。

Objective:To explore the learning curve of endoscopic thyroidectomy via breast approach.Methods:From Feb.2016 to Dec.2020,the clinical data of 95 patients who underwent endoscopic thyroidectomy by breast approach were analyzed retrospectively.The learning curve was evaluated by the cumulative sum method and the best fitting curve.General information,average operative time,intraoperative blood loss,postoperative drainage volume,postoperative drainage time,postoperative hospital stay,dosage of analgesics and complication rate were compared between different stages of learning curve.Results:All the 95 patients completed the operation successfully,and there was no case of conversion to open surgery or perioperative death.According to cumulativesum and best fitting curve,the maximum turning point of the curve was 28 cases,which was considered to have passed the learning curve.The learning curve divided into two stages:learning improvement and mastery.There was no significant difference in the general data and hospital stay between the two stages(P>0.05).The average operation time decreased from(167.6±50.1)min to(113.2±21.4)min(P<0.01),intraoperative blood loss decreased from(31.6±10.0)mL to(15.7±6.0)mL(P<0.01),postoperative drainage volume decreased from(145.3±75.6)mL to(80.4±40.6)mL(P<0.01),postoperative drainage time decreased from(2.5±0.9)d to(2.0±0.6)d(P<0.05).The analgesics usage rate and postoperative complication rate in improvement stage were higher than those in mastery stage(P<0.05).Conclusions:It is safe to study endoscopic thyroidectomy via breast approach,surgeons can master the technique after about 28 cases.More surgical teams which have experience of laparoscopic surgery and traditional thyroidectomy can carry out this technique.