Altgassen C, Michels W, Schneider A
Department of Obstetrics and Gynecology, Campus Luebeck, University of Schleswig-Holstein, Kiel, Germany.
Obstet Gynecol. 2004 Aug;104(2):308-13. doi: 10.1097/01.AOG.0000132806.46344.05.
The aim of this study was to evaluate the factors considered for proficiency and to estimate the number of procedures needed to achieve competence in laparoscopic-assisted vaginal hysterectomy in a teaching hospital.
The length of the learning curve, duration of surgery, change of hemoglobin (in grams per liter), conversion rate, and intra- and postoperative complications were evaluated. Cases were analyzed according to the order for the individual surgeon.
Thirty-three surgeons performed 929 laparoscopic-assisted vaginal hysterectomies during the study period. Analyzing the duration of surgery and rate of complications, we decided on a cutoff of 30 cases. Eight surgeons with more than 30 cases performed 668 laparoscopic-assisted vaginal hysterectomies. Their initial 30 cases (group A, the first 30 cases) were compared with their subsequent cases (group B, cases 31 and after). Patient age, body mass index, and uterine weight did not differ between the groups. The intraoperative complication rate dropped from 4.2% to 0.5% (P =.001), hemoglobin drop decreased from -0.8 +/- 0.9 g/L to -0.5 +/- 1.0 g/L (P =.002), and postoperative complications dropped from 12.9% to 7.0% (P =.017). The duration of surgery was also shorter (148.8 +/- 45.4 minutes versus 125.1 +/- 46.5 minutes), but this difference was taken from the results of 1 surgeon.
A learning experience of 30 laparoscopic-assisted vaginal hysterectomies was necessary in our institution to reach a low level of complications. Duration of the surgical procedure was not an adequate study endpoint to assess a learning effect.
本研究旨在评估腹腔镜辅助阴式子宫切除术熟练程度的相关影响因素，并估算在教学医院达到胜任该手术所需的手术例数。
评估学习曲线长度、手术时长、血红蛋白变化（克/升）、中转率以及术中和术后并发症情况。根据每位外科医生的手术顺序对病例进行分析。
在研究期间，33位外科医生共实施了929例腹腔镜辅助阴式子宫切除术。通过分析手术时长和并发症发生率，我们确定了30例为一个分界点。8位实施超过30例手术的外科医生共完成了668例腹腔镜辅助阴式子宫切除术。将他们的最初30例手术（A组，前30例）与后续手术（B组，第31例及以后）进行比较。两组患者的年龄、体重指数和子宫重量无差异。术中并发症发生率从4.2%降至0.5%（P = 0.001），血红蛋白下降幅度从-0.8±0.9克/升降至-0.5±1.0克/升（P = 0.002），术后并发症发生率从12.9%降至7.0%（P = 0.017）。手术时长也更短（148.8±45.4分钟对125.1±46.5分钟），但该差异仅来自1位外科医生的结果。
在我们机构，进行30例腹腔镜辅助阴式子宫切除术的学习经历对于降低并发症发生率是必要的。手术时长并非评估学习效果的充分研究终点。
