Champagne Bradley J, Lee Eward C, Valerian Brian, Armstrong David, Ambroze Wayne, Orangio Guy
Department of Surgery, Case Medical Center, Cleveland, OH 44106, USA.
J Am Coll Surg. 2008 Oct;207(4):554-9. doi: 10.1016/j.jamcollsurg.2008.03.005. Epub 2008 May 19.
It has been suggested that hand-assisted colectomy (HAC) may help residents progress along the learning curve, but there is currently no evidence to support this claim. Previous studies address procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary end points. We measured the percentage of cases completed by a resident as the operating surgeon as the primary end point to determine the most effective approach for teaching laparoscopic colectomy.
All patients who underwent left-sided HAC or straight laparoscopic colectomy (SLC) by a single resident starting as the primary surgeon were included. If the assisting attending physician assumed the role of the operating surgeon during the case, it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end points.
A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship, including 81 left-sided procedures. There were 44 patients in the HAC group and 37 SLC patients. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC, 88%; HAC, 72%; p=0.06). There were also differences in mean operative time favoring SLC (HAC, 142 minutes [range 100 to 170 minutes] versus SLC, 133 minutes [range 95 to 195 minutes]; p=0.04). Complications were similar in the 2 groups (HAC, 19% versus SLC, 21%), as were conversions (HAC, 5.6% versus SLC, 4.5%).
Both hand-assisted and straight laparoscopic techniques for left colectomy can be applied to successfully train surgical residents with the assistance of a staff surgeon outside of their learning curve. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach during training.
有人提出，手辅助结肠切除术（HAC）可能有助于住院医师在学习曲线上取得进步，但目前尚无证据支持这一说法。以往的研究涉及不同技能水平的 staff 外科医生或住院医师所进行的手术，并将手术时间和中转率作为其主要终点指标。我们将住院医师作为主刀医生完成的病例百分比作为主要终点指标进行测量，以确定腹腔镜结肠切除术教学的最有效方法。
纳入所有由一名住院医师作为主刀医生开始进行左侧 HAC 或直接腹腔镜结肠切除术（SLC）的患者。如果在手术过程中辅助主治医师承担了主刀医生的角色，则该病例记录为住院医师的未完成病例。手术时间和中转情况作为次要终点指标。
一名住院医师在住院期间和结直肠专科培训期间作为主刀医生开始了 147 例腹腔镜结肠切除术，其中包括 81 例左侧手术。HAC 组有 44 例患者，SLC 组有 37 例患者。直接腹腔镜手术完成的病例比 HAC 完成的病例更有可能由住院医师完成（SLC，88%；HAC，72%；p = 0.06）。平均手术时间也存在差异，SLC 更具优势（HAC，142 分钟[范围 100 至 170 分钟] vs SLC，133 分钟[范围 95 至 195 分钟]；p = 0.04）。两组的并发症相似（HAC，19% vs SLC，21%），中转率也相似（HAC，5.6% vs SLC，4.5%）。
在 staff 外科医生的协助下，左侧结肠切除术的手辅助和直接腹腔镜技术均可成功应用于培训外科住院医师，使其在学习曲线之外取得进步。在培训期间，住院医师和结直肠专科培训学员完成直接腹腔镜结肠切除术可能比适应新颖的手辅助方法更成功。
