无充气腋窝入路完全腔镜下甲状腺癌根治术的学习曲线分析

背景与目的：甲状腺癌是临床上常见的恶性肿瘤，外科手术是其主要的治疗手段。无充气腋窝入路完全腔镜下甲状腺手术是一种可行、安全、美观的腔镜手术术式，目前正在国内逐步推广开展。本研究旨在探讨无充气腋窝入路完全腔镜下甲状腺癌根治术的学习曲线，总结外科医师对这门新术式的逐渐熟悉掌握的过程，以期为该术式的推广发展提供一定的参考。 方法：回顾性分析2019年1月—2020年6月连续收治的40例行无充气腋窝入路完全腔镜下甲状腺切除术的甲状腺癌患者临床资料，构建并分析手术时间变化趋势图与CUSUM学习曲线，并寻找学习曲线的截点值。以CUSUM学习曲线的截点值作为分界，将学习曲线分为两个阶段，比较两个阶段患者的一般资料与相关临床指标。 结果：40例患者的手术时间为65~150 min，平均（107.50±26.38）min。手术时间变化趋势图显示，随着手术例数的不断增加，手术时间整体呈下降的趋势。拟合的CUSUM曲线在手术例数累积至22例时达顶点，以第22例手术患者为分界，将学习曲线划分为学习提高与熟练掌握两个阶段，学习提高阶段组（22例）和熟练掌握阶段组（18例）患者的一般临床资料进行比较差异均无统计学意义（均P>0.05）；学习提高阶段组的手术时间明显长于熟练掌握阶段组（129.09 min vs. 81.11 min，P<0.001）；两组在术中出血量、术后切口疼痛评分、术后住院时间、术后并发症发生率等方面的比较，差异均无统计学意义（均P>0.05）。 结论：学习无充气腋窝入路完全腔镜下甲状腺癌根治术具有显著的学习曲线，掌握该项术式至少需要累积22例手术，希望该研究的结果能为普外科医师顺利平稳的达到学习曲线的平台（由学习提高阶段过渡到熟练掌握阶段），并逐渐熟悉掌握这一术式提供一定的理论依据与帮助。

Analysis of learning curve of complete endoscopic radical thyroidectomy via a gasless axillary approach

Background and Aims: Thyroid cancer is a common malignant tumor in clinical practice, for which surgery is the main treatment method. Endoscopic radical thyroidectomy via a gasless axillary approach is a feasible, safe and cosmetic surgical option, and is being increasingly carried out in our country. The purpose of this study was to investigate the learning curve of endoscopic radical thyroidectomy via a gasless axillary approach, and summarize the course of familiarizing and mastering this new procedure for surgeons, so as to provide a reference for the promotion and development of this procedure.  Methods: The clinical data of 40 patients with thyroid cancer undergoing total endoscopic radical thyroidectomy via a gasless axillary approach consecutively admitted from January 2019 to June 2020 were retrospectively analyzed. The changing trend graph of operative time and the CUSUM learning curve were modeled and analyzed, and the cut-off value of the learning curve was identified. Taking the cut-off value of the CUSUM learning curve as the threshold, the learning curve was divided into two stages, and then the general information and relevant clinical variables of patients in the two stages were compared. Results: In the 40 patients, the operative time ranged from 65 to 150 min, with an average operative time of (107.50±26.38) min. The changing trend graph of operative time demonstrated that the operative time displayed an overall descending trend as the number of cases of operation increased. The fitting CUSUM curve reached a maximum value at the cumulative number of cases of operation up to 22. Taking the 22nd operated patient as the demarcation, the learning curve was divided into learning improvement stage and proficient mastery stage. There were no significant differences in terms of the general data between patients in learning improvement stage group (22 cases) and proficient mastery stage group (18 cases) (all P>0.05). The operative time of learning improvement stage group was significantly longer than that in proficient mastery stage group (129.09 min vs. 81.11 min, P<0.001). There were no significant differences with regard to the intraoperative blood loss, postoperative incision pain score, length of postoperative hospital stay and incidence of postoperative complications between the two groups (all P>0.05). Conclusion: There is a significant learning curve for learning total endoscopic radical thyroidectomy via a gasless axillary approach. Mastering this procedure requires the accumulation of at least 22 operations. It is hoped that the results of this study can provide certain theoretical basis and help for general surgeons to uneventfully go through the plateau of the learning curve (transition from the learning improvement stage to the proficient mastery stage), and then familiarize and master this procedure.