基于静脉解剖基础的标准化手术流程对机器人辅助肾部分切除学习曲线的影响

Venous anatomy based standard operating procedure to improve the learning curve of robotic-assisted laparoscopic partial nephrectomy PDF(PC)87

目的探讨以静脉解剖理论为基础制定机器人辅助腹腔镜肾部分切除术的标准化手术流程对手术者学习曲线的指导作用和临床价值。方法2021年1月~2022年3月间单一术者连续完成的机器人辅助腹腔镜肾部分切除术病人40例。40例连续病例依手术时间先后顺序分为A、B、C、D四组,每组各10例。手术均由同一位主刀医生完成。术者和第一助手在开始实施首例手术前,对我单位制定的基于静脉解剖基础的机器人辅助腹腔镜肾部分切除术标准化手术流程进行系统学习考核。术中通过对生殖静脉、下腔静脉、肾静脉和腰静脉的解剖辨认,引导整个手术流程。对比四组病人在总手术时间、肾脏热缺血时间、术中出血量、引流管拔除时间、病理切缘阳性率和术中及围术期并发症等指标之间的差异。结果40例病人均顺利完成手术,平均手术时间(114.25±30.65)分钟,平均热缺血时间(22.5±7.42)分钟,术中平均出血量(290±314.44)ml。随着手术例数的积累,A、B、C、D组病人的总手术时间逐渐缩短,分别为142分钟,122分钟,107分钟和87分钟。肾脏热缺血时间逐渐缩短,分别为30分钟,23分钟,22分钟和18分钟。D组病人术中出血量明显少于前三组,分别为335 ml,330 ml,335 ml和160 ml。引流管拔除时间分别为5.9天,6.1天,5.6天和5.1天;病人总的并发症发生率为17.5%,四组病人并发症的数量分别为2例、2例、2例和1例;差异无统计学意义。结论在积累10例手术后,术者已能独立完成机器人辅助腹腔镜肾部分切除术。完成20例手术后,术者能逐渐熟练掌握该手术方式。完成30例手术后,术者的技术水平达到并维持稳定状态。建立以静脉解剖理论为基础的标准化手术流程,能帮助术者缩短总手术时间和肾脏热缺血时间,减少术中出血量,提高手术的安全性,缩短术者的学习曲线。

Objective To evaluate the value of establishing a standard operating procedure(SOP)based on the venous anatomy system to improve the learning curve of robotic-assisted laparoscopic partial nephrectomy(VAB-RAPN).Methods The clinicopathological data of 40 consecutive patients who underwent RAPN were collected.Patients were divided into Group A,B,C,and D,with 10 cases in each group.All procedures were completed by a single surgeon.Our procedure is to perform the operation by identifying the landmark of the gonadal vein,inferior vena cava,renal vein,and lumbar vein.The differences in operation time(OT),renal warm ischemia time(WIT),estimated blood loss(EBL),time of drainage removed,positive surgical margins(PSM)and operative complications were compared.And the significance of the groups was statistically analyzed.Results All the patients successfully underwent the operation.The average OT of the 40 patients was 114.25±30.65 min.The average renal WIT was 22.5±7.42 min.And the average EBL was 290±314.44 ml.With the accumulation of surgical cases,the OT of groups A,B,C,and D gradually shortened,which were 142 min,122 min,107 min,and 87 min.The WIT gradually shortened,which were 30 min,23 min,22 min,and 18 min.The time of drainage removed was 5.9 d,6.1 d,5.6 d,and 5.1 d.The EBLs in group D were 335 ml,330 ml,335 ml,and 160 ml.No significant difference had been found in drainage removal and post-operative complications.Conclusion By conducting the standard operating procedures,the junior surgeon can manipulate the RAPN in 10 cases.After 20 cases,the surgeon has mastered the core skills of RAPN.After 30 cases,the surgeon can manage the procedure skillfully.The learning curve shows a significant decline after 30 cases.And it can help to save the OT and WIT,and reduce intraoperative EBL.The VAB-RAPN standard procedure in our center is worth being recommended.