Rouach Y, Timsit M-O, Delongchamps N-B, Fontaine E, Peyromaure M, Thiounn N, Thibault P, Méjean A
Service d'urologie, hôpital Necker, 149, rue de Sèvres, 75743 Paris, cedex 15, France.
Prog Urol. 2008 Jun;18(6):344-50. doi: 10.1016/j.purol.2008.03.009. Epub 2008 May 2.
Several teams have recently confirmed the technical feasibility of laparoscopic partial nephrectomy (LPN). However, this procedure is not widely performed because it is technically difficult and associated with a high rate of bleeding complications, even for experienced teams. The authors studied the LPN learning curve for urology residents using a porcine model based on analysis of the following criteria: operating time, warm ischaemia time and intraoperative and postoperative bleeding.
Forty LPN were performed by the same operator. All operations were performed after arterial clamping and heparinisation of the animal. The renal section was always the same, removing 40% of the kidney and always comprised the excretory tract. A continuous running suture on the excretory tract and interrupted sutures on the parenchyma were performed. Operating time and warm ischaemia time were recorded. Animals were monitored for ten days. Intraoperative and postoperative bleeding via drains was recorded and retrograde urography was performed on the 10th day to confirm the absence of excretory tract leaks. Linear regression statistical tests investigated a correlation between these various criteria and the number of cases performed.
The mean total operating time, warm ischaemia time and total bleeding (intraoperative and postoperative) were 108 minutes (70-140 minutes), 38 minutes (22-50 minutes) and 95 ml (10-300 ml), respectively. Linear regression analysis revealed a direct correlation between the number of cases performed and intraoperative bleeding (p<0.001) and warm ischaemia time (p<0.001). These parameters became stable after the 10th operated case. Two cases of urine leaks were observed on D10 out of a series of 40 operations, with no correlation with the number of cases performed.
The operating time and warm ischaemia time are directly correlated with the number of cases performed. Training on a porcine model appears to be a good way to reduce the learning curve in man. Ten operations are necessary to acquire the various steps of the procedure.
最近几个团队已证实腹腔镜部分肾切除术（LPN）在技术上是可行的。然而，该手术并未广泛开展，因为其技术难度大且出血并发症发生率高，即使对于经验丰富的团队也是如此。作者基于对以下标准的分析，使用猪模型研究了泌尿外科住院医师的LPN学习曲线：手术时间、热缺血时间以及术中及术后出血情况。
由同一位操作者进行40例LPN手术。所有手术均在动物动脉夹闭和肝素化后进行。肾切除部分始终相同，切除40%的肾脏且始终包括排泄道。对排泄道进行连续缝合，对实质进行间断缝合。记录手术时间和热缺血时间。对动物进行为期十天的监测。记录通过引流管的术中及术后出血量，并在第10天进行逆行尿路造影以确认排泄道无渗漏。线性回归统计测试研究了这些不同标准与手术例数之间的相关性。
平均总手术时间、热缺血时间和总出血量（术中及术后）分别为108分钟（70 - 140分钟）、38分钟（22 - 50分钟）和95毫升（10 - 300毫升）。线性回归分析显示手术例数与术中出血（p<0.001）和热缺血时间（p<0.001）之间存在直接相关性。这些参数在第10例手术后趋于稳定。在40例手术系列中，第10天观察到2例尿漏，与手术例数无关。
手术时间和热缺血时间与手术例数直接相关。在猪模型上进行训练似乎是减少人体学习曲线的好方法。需要进行十次手术才能掌握该手术的各个步骤。
