结合术前三维重建的腹腔镜肝切除术学习曲线研究

目的 分析结合术前三维重建的腹腔镜肝切除术的学习曲线。方法 回顾性分析2019年3月至2020年12月华西医院上锦分院普外一科单中心行腹腔镜肝切除术患者64例的临床资料，使用累计分析法分析成功实施手术患者的手术时间与手术难度评分的比值，并绘制学习曲线。结果 64例患者中3例中转开腹，61例完成腹腔镜肝切除术。所有患者术前行三维重建辅助手术。中位手术时间为185(100～150)min，中位难度评分为4(4～6)分。以手术时间与手术难度评分的比值绘制学习曲线，显示1～26例为上升期，27～41例为波动期，42例以后进入成熟期。成熟期手术难度评分明显高于上升期及波动期(P<0.05)。患者围手术期病死率1.6%(1/61)，术后并发症总发生率为14.8%(9/61)，其中出血发生率为4.9%(3/61)，胆漏发生率为4.9%(3/61)，肝功能不全发生率11.5%(7/61)；术后中位住院时间6 d。结论 结合术前三维重建开展腹腔镜肝切除术安全可行，施行约40例以后可以渡过学习曲线，达到较稳定和熟练的程度。

Learning curve of preoperative 3D reconstruction-assisted laparoscopic hepatectomy

Objective To analyze the learning curve of laparoscopic hepatectomy combined with preoperative three-dimensional (3D) image reconstruction. Methods The clinical data of patients who underwent laparoscopic hepatectomy in Shangjin Branch of West China Hospital, from Mar. 2019 to Dec. 2020, were retrospectively analyzed. The ratio of operation time to the surgical difficulty scoring of patients who successfully underwent surgery was analyzed with cumulative analysis, and the learning curves were plotted. Results Of the 64 patients, 3 underwent conversion to open operation, and 61 underwent laparoscopic hepatectomy. All patients underwent 3D image reconstruction before operation. Drawing the learning curve with the ratio of operation time to surgical difficulty scoring, 1~26 cases were in the rising period, 27~41 cases were in the fluctuating period, and 42 cases later were in the mature period. The surgical difficulty scoring in the mature period was significantly higher than those in the rising period or in the fluctuating period (P<0.05). The perioperative mortality was 1.6% (1/61), the overall postoperative complication rate was 14.8% (9/61), of which bleeding was 4.9% (3/61), bile leakage was 4.9% (3/61), liver insufficiency was 11.5% (7/61); and the median postoperative hospitalization time was 6 d. Conclusion Approximately after 40 cases of laparoscopic hepatectomy combined with 3D image reconstruction, which can cross the learning curve to achieve greater stability and proficiency.