Voitk A, Joffe J, Alvarez C, Rosenthal G
Department of Surgery, The Salvation Army Scarborough Grace Hospital, Ontario, Canada.
J Laparoendosc Adv Surg Tech A. 1999 Jun;9(3):243-8. doi: 10.1089/lap.1999.9.243.
This study was done to determine the factors contributing to laparoscopic failure (conversion to open surgery or early reoperation) during the learning curve for laparoscopic Nissen fundoplication in a 228-bed nonteaching community hospital. Data were gathered prospectively for the first 100 consecutive patients booked for elective laparoscopic Nissen fundoplication by the four general surgeons at the hospital. All complications were recorded contemporaneously, and particular note was taken of the factors surrounding conversion to open surgery and reoperation within 100 days of surgery. There were no deaths. The conversion rate was 20% and the early reoperation rate 6%. There were two late recurrences. The average operative time was 117 minutes and the average length of stay 1.8 days; 37 operations were performed on outpatients. The laparoscopic failure rate was 26% (18/68) during a surgeon's first 20 operations and 11% (3/28) thereafter (P < 0.09); the corresponding conversion rates were 22% and 4% (P < 0.05). During a surgeon's first 20 operations, the laparoscopic failure rate rose from 21% (12/57) to 55% (6/11) (P < 0.04) if a second surgeon did not assist. After 20 operations, this difference lost its significance. Intrathoracic herniation of the stomach was found preoperatively in 11 (44%) of 25 operations followed by laparoscopic failure and (8%) 6 of 75 without (P < 0.0002). Laparoscopic failure had no correlation with patient age, sex, ASA classification, duration of symptoms, or referring physician's specialty. The individual learning curve for laparoscopic Nissen fundoplication requires about 20 operations to surmount. Factors leading to laparoscopic failure during the learning curve are the surgeon's inexperience, absence of experienced help, and the presence of intrathoracic herniation.
本研究旨在确定在一家拥有228张床位的非教学社区医院中，腹腔镜下尼氏胃底折叠术学习曲线期间导致腹腔镜手术失败（转为开放手术或早期再次手术）的因素。前瞻性收集了该医院4位普通外科医生连续收治的前100例择期腹腔镜下尼氏胃底折叠术患者的数据。同时记录所有并发症，特别留意手术转为开放手术及术后100天内再次手术的相关因素。无死亡病例。转化率为20%，早期再次手术率为6%。有2例晚期复发。平均手术时间为117分钟，平均住院时间为1.8天；37例手术为门诊手术。在外科医生的前20例手术中，腹腔镜手术失败率为26%（18/68），此后为11%（3/28）（P<0.09）；相应的转化率分别为22%和4%（P<0.05）。在外科医生的前20例手术中，如果没有第二位外科医生协助，腹腔镜手术失败率从21%（12/57）升至55%（6/11）（P<0.04）。20例手术后，这种差异不再显著。25例腹腔镜手术失败的病例中，术前发现11例（44%）存在胃内疝，而75例未出现腹腔镜手术失败的病例中，有6例（8%）存在胃内疝（P<0.0002）。腹腔镜手术失败与患者年龄、性别、美国麻醉医师协会（ASA）分级、症状持续时间或转诊医生的专业无关。腹腔镜下尼氏胃底折叠术的个体学习曲线大约需要20例手术才能跨越。学习曲线期间导致腹腔镜手术失败的因素包括外科医生经验不足、缺乏经验丰富的助手以及存在胃内疝。
