从腹腔镜到机器人辅助肾部分切除术的过渡:一个资深腹腔镜外科医生的学习曲线

背景腹腔镜肾部分切除术的高难度和挑战性使许多腹腔镜外科医生采用机器人辅助肾部分切除术治疗肾脏小肿瘤。从腹腔镜肾部分切除术到机器人辅助肾部分切除术的过渡期我们评估一个资深腹腔镜外科医生的学习曲线。方法我们比较同一外科医生施行的早期20例机器人辅助肾部分切除术和最近18例腹腔镜肾部分切除术的围术期结果。所有手术是在2005年4月～2009年7月间完成的。既往该医生成功施行100余例腹腔镜肾部分切除术和100余例机器人辅助手术。2组手术步骤相同,在镜下充分游离肾动静脉后,完整游离肿瘤表面,利用术中超声来界定肿瘤边界,哈巴狗血管阻断钳控制肾动脉,在热缺血状态下切除肿瘤,2-0可吸收线连续缝合肾实质,如果集合系统切开后也予以缝合。学习曲线的定义指能熟练地在较短的手术时间和热缺血时间内完成机器人辅助肾部分切除术的例数。利用散点图显示机器人辅助肾部分切除术的学习曲线,用以比较2种术式的手术时间和热缺血时间。结果 2组患者术前临床资料和肿瘤病理学结果的比较无统计学差异。2组均无切缘阳性病例。2组手术并发症也无统计学差异。在机器人辅助肾部分切除术的学习曲线(图1)中,手术时间和热缺血时间均呈下降趋势。经过早期5例手术后,机器人辅助肾部分切除术的平均手术时间即可接近最近18例腹腔镜肾部分切除术的平均手术时间。前5例机器人辅助肾部分切除术的平均手术时间是242.8 min,远远长于后15例机器人辅助肾部分切除术平均手术时间171.3 min(P=0.011)。结论 一个资深腹腔镜外科医生从腹腔镜到机器人辅助肾部分切除术过渡是一个非常迅速的过程。2组热缺血时间、术中估计出血量和住院时间均无统计学差异。经过前5例机器人辅助肾部分切除术后,一个资深腔镜外科医生行机器人辅助和腹腔镜肾部分切除术的手术时间大致相同。

Transition From Laparoscopic to Robotic Partial Nephrectomy: the Learning Curve for an Experienced Laparoscopic Surgeon

Background The complexity of laparoscopic partial nephrectomy(LPN) has prompted many laparoscopic surgeons to adopt robotic partial nephrectomy(RPN) for the treatment of small renal masses.We assessed the learning curve for an experienced laparoscopic surgeon during the transition from LPN to RPN.Methods We compared perioperative outcomes of the first 20 patients who underwent RPN to the last 18 patients who underwent LPN by the same surgeon(MAP).Surgical technique was consistent across platforms.The learning curve was defined as the number of cases required to consistently perform RPN with shorter average operative times(OT) and warm ischemia times(WIT),as compared to the last 18 LPN.A line of best fit aided graphical interpretation of the learning curve on a scatter diagram of OT versus procedure date. Results The 2 groups had comparable preoperative demographics and tumor histopathology.No patients in either group had a positive surgical margin.There was a downward trend in both OT and WIT during the RPN learning curve.After the first 5 RPN cases,the average OT reached the average OT of the last 18 LPN cases.The average OT of the first 5 RPN patients was 242.8 minutes,compared with the average OT of the last 15 RPN patients of 171.3 minutes(P=0.011).Conclusion The transition from LPN to RPN is rapid in an experienced laparoscopic surgeon.There were no significant differences in WIT,estimated blood loss,or length of hospital stay between LPN and RPN.RPN achieved a similar OT as LPN after 5 procedures.