改良后腹腔镜解剖性肾上腺切除术学习曲线分析
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摘要
目的:分析改良后腹腔镜下解剖性肾上腺切除术(MARA)的学习曲线,探讨MARA手术入路的优势。方法:回顾性分析2016年3月～2018年6月我科收治时间连续、同一术者行MARA的48例肾上腺肿瘤患者的临床资料。根据手术时间顺序分为A、B、C三组,每组16例。分析手术例数与手术时间、术中出血量、术后24h腹膜后引流量、术后住院天数的相关性。结果:手术例数增加,手术时间显著缩短(r_s=0.82,P<0.01),术中出血量(r_s=0.95,P<0.01)、术后24h腹膜后引流量(r_s=0.94,P<0.01)显著减少,术后住院天数(r_s=0.16,P>0.05)无明显变化。A组平均手术时间为(59.37±3.98)min,显著长于B组(46.75±5.63)min、C组(32.69±8.85)min(P<0.01);A组术中出血量为(56.88±3.40)ml,显著多于B组(40.81±0.75)ml、C组(25.19±4.04)ml(P<0.01);A组平均术后24h腹膜后引流量为(40.75±5.98)ml,显著多于B组(25.75±2.75)ml和C组(12.87±1.50)ml,三组比较差异均有统计学意义(P<0.01)。三组患者术后住院天数与手术例数增加无显著相关性(P>0.05)。结论:MARA安全、有效,随着手术例数的增加,手术时间明显缩短、术中出血量及术后引流量显著减少,初学者完成16例手术后可初步掌握该方法,完成32例手术后,手术熟练和稳定程度进一步提升。
Objective:To evaluate and discuss the learning curve and advantage of modified anatomical retroperitoneoscopic adrenalectomy(MARA).Method:From March 2016 to June 2018,the data from 48 consecutive patients who had undergone MARA were retrospectively analyzed.According to the number of procedures performed by the surgeon,all patients were classified into three chronological groups,16 cases in each group.The operative outcomes analyzed were operative time,intraoperative blood loss,drainage quantity 24 hours after operation and hospital stay.Result:Group A(59.37±3.98)min had longer operative time than that of Group B(46.75±5.63)min and Group C(32.69±8.85)min(P<0.01).Group A(56.88±3.40)ml had more intraoperative blood loss than that of group B(40.81±0.75)ml and group C(25.19±4.04)ml(P<0.01).Group A(40.75±5.98)ml had more drainage quantity than that of group B(25.75±2.75)ml and group C(12.87±1.50)ml(P<0.01).However,hospital stay was not strongly correlated with additional experience among each group(P>0.05).Conclusion:MARA is safe and effective.With the increase of the number of surgical procedures,the operation time significantly shortened,the intraoperative blood loss and drainage quantity 24 hours after operation significantly reduced.Beginners can master the method after completing 16 cases of surgery.After 32 cases of surgery,the proficiency and stability of the surgery further improved.
Objective:To evaluate and discuss the learning curve and advantage of modified anatomical retroperitoneoscopic adrenalectomy(MARA).Method:From March 2016 to June 2018,the data from 48 consecutive patients who had undergone MARA were retrospectively analyzed.According to the number of procedures performed by the surgeon,all patients were classified into three chronological groups,16 cases in each group.The operative outcomes analyzed were operative time,intraoperative blood loss,drainage quantity 24 hours after operation and hospital stay.Result:Group A(59.37±3.98)min had longer operative time than that of Group B(46.75±5.63)min and Group C(32.69±8.85)min(P<0.01).Group A(56.88±3.40)ml had more intraoperative blood loss than that of group B(40.81±0.75)ml and group C(25.19±4.04)ml(P<0.01).Group A(40.75±5.98)ml had more drainage quantity than that of group B(25.75±2.75)ml and group C(12.87±1.50)ml(P<0.01).However,hospital stay was not strongly correlated with additional experience among each group(P>0.05).Conclusion:MARA is safe and effective.With the increase of the number of surgical procedures,the operation time significantly shortened,the intraoperative blood loss and drainage quantity 24 hours after operation significantly reduced.Beginners can master the method after completing 16 cases of surgery.After 32 cases of surgery,the proficiency and stability of the surgery further improved.
引文
1 van Uitert A,d'Ancona F C H,Deinum J,et al.Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery[J].Surg Endosc,2017,31(7):2771-2775.
2 Costa Almeida C E,Caroco T,Silva M A,et al.Posterior retroperitoneoscopic adrenalectomy-Case series[J].Int J Surg Case Rep,2018,51:174-177.
3 Vrielink O M,Wevers K P,Kist J W,et al.Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy:a shift to a new golden standard?[J].Langenbecks Arch Surg,2017,402(5):767-773.
4 Hashimoto T,Yoshioka K,Gondo T,et al.Learning curve and perioperative outconles of robot-assisted radical prostatectomy in 200initial Japanese cases by a single surgeon[J].J Endourol,2013,27(10):1218-1223.
5梁朝朝,邰胜.肾上腺肿瘤微创手术治疗方法的选择[J].临床泌尿外科杂志,2018,33(10):765-768.
6 Ball M W,Hemal A K,Allaf M E.International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology:laparoscopic and robotic adrenalectomy[J].BJU Int,2017,119(1):13-21.
7 Chai Y J,Yu H W,Song R Y,et al.Lateral Transperitoneal Adrenalectomy Versus Posterior Retroperitoneoscopic Adrenalectomy for Benign Adrenal Gland Disease:Randomized Controlled Trial at a Single Tertiary Medical Center[J].Ann Surg,2019,269(5):842-848.
8 Machado M T,Nunes-Silva I,da Costa E F,et al.Laparoendoscopic single-site retroperitoneoscopic adrenalectomy:bilateral step-by-step technique[J].Surg Endosc,2017,31(8):3351-3352.
9 Marek-Safiejko M,Safiejko K,ukaszewicz J,et al.AComparison of Two Approaches to Laparoscopic Adrenalectomy:Lateral Transperitoneal Versus Posterior Retroperitoneal Approach[J].Adv Clin Exp Med,2016,25(5):829-835.
10 Lairmore T C,Folek J,Govednik C M,et al.Improving Minimally Invasive Adrenalectomy:Selection of Optimal Approach and Comparison of Outcomes[J].World J Surg,2016,40(7):1625-1631.
11贾占奎,田向永,王军,等.后腹腔镜肾上腺疾病术中并发症的预防及处理[J].临床泌尿外科杂志,2017,32(2):97-99.
2 Costa Almeida C E,Caroco T,Silva M A,et al.Posterior retroperitoneoscopic adrenalectomy-Case series[J].Int J Surg Case Rep,2018,51:174-177.
3 Vrielink O M,Wevers K P,Kist J W,et al.Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy:a shift to a new golden standard?[J].Langenbecks Arch Surg,2017,402(5):767-773.
4 Hashimoto T,Yoshioka K,Gondo T,et al.Learning curve and perioperative outconles of robot-assisted radical prostatectomy in 200initial Japanese cases by a single surgeon[J].J Endourol,2013,27(10):1218-1223.
5梁朝朝,邰胜.肾上腺肿瘤微创手术治疗方法的选择[J].临床泌尿外科杂志,2018,33(10):765-768.
6 Ball M W,Hemal A K,Allaf M E.International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology:laparoscopic and robotic adrenalectomy[J].BJU Int,2017,119(1):13-21.
7 Chai Y J,Yu H W,Song R Y,et al.Lateral Transperitoneal Adrenalectomy Versus Posterior Retroperitoneoscopic Adrenalectomy for Benign Adrenal Gland Disease:Randomized Controlled Trial at a Single Tertiary Medical Center[J].Ann Surg,2019,269(5):842-848.
8 Machado M T,Nunes-Silva I,da Costa E F,et al.Laparoendoscopic single-site retroperitoneoscopic adrenalectomy:bilateral step-by-step technique[J].Surg Endosc,2017,31(8):3351-3352.
9 Marek-Safiejko M,Safiejko K,ukaszewicz J,et al.AComparison of Two Approaches to Laparoscopic Adrenalectomy:Lateral Transperitoneal Versus Posterior Retroperitoneal Approach[J].Adv Clin Exp Med,2016,25(5):829-835.
10 Lairmore T C,Folek J,Govednik C M,et al.Improving Minimally Invasive Adrenalectomy:Selection of Optimal Approach and Comparison of Outcomes[J].World J Surg,2016,40(7):1625-1631.
11贾占奎,田向永,王军,等.后腹腔镜肾上腺疾病术中并发症的预防及处理[J].临床泌尿外科杂志,2017,32(2):97-99.