Dinçler Selim, Koller Michael T, Steurer Johann, Bachmann Lucas M, Christen Daniel, Buchmann Peter
Department of Surgery, City Hospital Waid, University of Zurich, Zurich, Switzerland.
Dis Colon Rectum. 2003 Oct;46(10):1371-8; discussion 1378-9. doi: 10.1007/s10350-004-6752-5.
The number of operations to reach a plateau phase in colorectal laparoscopic surgery is still under debate. There are few publications reporting on multidimensional assessment of the learning curve, including operation time and complication and conversion rates. The purpose of this study was to define a multidimensional learning curve for sigmoid resection performed by two surgeons with experience in laparoscopic surgery.
Between 1993 and 2001 from a total of 715 laparoscopic colorectal procedures, two surgeons performed self-educated 338 sigmoid resections. Demographic data, indications for surgery, procedure performed, operation time, frequency and kind of complications, conversion rate, and days to discharge were recorded. The moving average method was used to demonstrate the change of the operation time. The cumulative sum technique was used to chart the changes in the conversion and complication rates.
Surgeon A performed 199 and Surgeon B 139 sigmoid resections. The operation time decreased from 225 minutes to 169 minutes after approximately 90 operations for Surgeon A and from 270 minutes to 223 minutes after 110 operations for Surgeon B. Based on a decline in intraoperative complications and conversion rate, the steady state was reached after approximately 70 to 80 interventions for both surgeons.
The assessment of a learning curve should not be limited to measurement of a decrease in operation time but should also include the conversion and complication rates. The cumulative sum technique and moving average method as proposed in this study seem appropriate to evaluate the learning curve in this clinical domain. Our findings might be especially useful for those planning training programs in laparoscopic surgery.
结直肠腹腔镜手术达到平台期所需的手术例数仍存在争议。很少有出版物报道对学习曲线进行多维度评估，包括手术时间、并发症发生率及中转开腹率。本研究的目的是为两位有腹腔镜手术经验的外科医生实施的乙状结肠切除术定义一条多维度学习曲线。
1993年至2001年期间，在总共715例腹腔镜结直肠手术中，两位外科医生自主完成了338例乙状结肠切除术。记录了人口统计学数据、手术指征、实施的手术、手术时间、并发症的频率和种类、中转开腹率以及出院天数。采用移动平均法展示手术时间的变化。采用累积和技术绘制中转开腹率和并发症发生率的变化情况。
外科医生A实施了199例乙状结肠切除术，外科医生B实施了139例。外科医生A在大约90例手术后，手术时间从225分钟降至169分钟；外科医生B在110例手术后，手术时间从270分钟降至223分钟。基于术中并发症和中转开腹率的下降，两位外科医生在大约70至80例手术后达到稳定状态。
对学习曲线的评估不应局限于测量手术时间的减少，还应包括中转开腹率和并发症发生率。本研究中提出的累积和技术及移动平均法似乎适用于评估该临床领域的学习曲线。我们的研究结果可能对那些规划腹腔镜手术培训项目的人特别有用。
