胸乳径路腔镜甲状腺切除术中应用神经监测的学习曲线分析

Learning curve analysis of intraoperative nerve monitoring in endoscopic thyroidectomy via sternomastoid pathway

目的探讨胸乳径路腔镜甲状腺切除术中应用神经监测的学习曲线特点。方法回顾性分析42例行胸乳径路腔镜甲状腺切除术患者的资料,所有手术均由同一组术者实施。采用累积总和法计算每例患者的喉返神经识别时间,获得该组术者胸乳径路甲状腺切除术中应用神经监测的学习曲线。比较学习曲线不同阶段的喉返神经识别时间、喉返神经识别率、喉返神经损伤发生率、术中出血量、术后引流量、住院时间及并发症发生情况。结果手术例数在20例时喉返神经识别时间达到最大值,据此将曲线分为A、B两个阶段,A阶段(前20例)为早期学习阶段,B阶段(20例以后)为后期熟练阶段。B阶段患者喉返神经识别时间、术中出血量、术后引流量、住院时间均短于或少于A阶段患者,差异均有统计学意义(均P<0.05);B阶段患者喉返神经识别率、喉返神经损伤发生率和并发症发生率与A阶段差异均无统计学意义(均P>0.05)。结论术者能够熟练掌握胸乳径路腔镜甲状腺切除术须累积的最少手术例数为20例。后期熟练的手术操作可缩短腔镜甲状腺切除术中喉返神经识别时间、住院时间,减少术中出血量、术后引流量。

Objective To investigate the characteristics of learning curve of intraoperative nerve monitoring in endoscopic thyroidectomy via sternomastoid pathway.Methods The data of 42 patients who underwent endoscopic thyroidectomy via sternomastoid pathway were retrospectively analyzed.All the operations were performed by the same group of operators.The cumulative sum method was used to calculate the recognition time of the recurrent laryngeal nerve for each patient,and the learning curve of intraoperative nerve monitoring in endoscopic thyroidectomy via sternomastoid pathway was obtained for this group of patients.The recurrent laryngeal nerve recognition time,recurrent laryngeal nerve recognition rate,incidence of recurrent laryngeal nerve injury,intraoperative blood loss,postoperative drainage volume,hospitalization time and occurrence of complications were compared at different stages of the learning curve.Results The recognition time of recurrent laryngeal nerve reached the maximum when the number of surgical cases reached 20.According to this,the curve was divided into two stages:stage A(top 20 cases)was the early learning stage,and stage B(after 20 cases)was the late proficiency stage.The recognition time of the recurrent laryngeal nerve,intraoperative blood loss,postoperative drainage volume and hospitalization time of stage B patients were shorter or less than those of stage A patients,with no statistically significant difference(all P<0.05).There were no statistically significant difference in the recurrent laryngeal nerve recognition rate,incidence of recurrent laryngeal nerve injury,and incidence of complications between stage A and stage B(all P>0.05).Conclusion The minimum number of surgical cases in which the operator could master the endoscopic thyroidectomy via sternomastoid pathway was 20.And proficient surgical operations in the later stage can shorten the recognition time and hospitalization time of the recurrent laryngeal nerve during laparoscopic thyroidectomy,reduce intraoperative bleeding and postoperative drainage volume.