Department of Surgery, Jichi Medical University, Saitama Medical Centre, Saitamashi, Saitamaken, Japan.
World J Surg. 2009 Nov;33(11):2439-43. doi: 10.1007/s00268-009-0188-y.
This study was designed to look at the conversion rates and morbidity associated with laparoscopic operations performed by trainee surgeons ascending the learning curve when they are well supervised by staff surgeons.
A review of 204 consecutive cases was performed. We defined experienced staff surgeons as those who have performed more than 300 laparoscopic resection cases. The trainee surgeons had less than 50 cases of experience during the study period. All operations were performed by the experienced staff surgeon or by the trainee surgeon with the staff surgeon as the first assistant and supervisor.
A total of 204 laparoscopic resections for colorectal cancer were studied. The dissection was D3 in 73% (n = 149) of cases with a mean lymph node harvest of 19.4 nodes (range 1-56). The staff surgeons performed 90 cases and trainees performed 114 cases. Twenty-one cases (10.3%) required conversion. The overall morbidity rate was 17.6% and perioperative mortality rate was 1.5%. On bivariate analysis, trainee surgeons were not found to be significantly associated with a higher conversion risk. Multivariate analysis revealed that only the factor of T3 and above was an independent predictor of conversion (odds ratio (OR) 4.1; 95% confidence interval (CI) 1.09-15.48). Multivariate analysis of risk factors for morbidity revealed that it was not conversion (OR 2.37; 95% CI, 0.86-6.76) but rectal surgery (OR 4.09; 95% CI 2.04-9.9) that was the independent risk factor of morbidity.
Inexperienced surgeons do not cause more conversions or postoperative morbidity in laparoscopic colorectal surgery if they are well supervised. Conversion is not independently associated with increased postoperative morbidity.
本研究旨在观察在有经验的外科医生监督下，当受训外科医生在学习曲线上上升时，腹腔镜手术的转化率和发病率。
对 204 例连续病例进行了回顾性研究。我们将经验丰富的外科医生定义为完成超过 300 例腹腔镜切除术的医生。在研究期间，受训外科医生的经验不足 50 例。所有手术均由有经验的外科医生或受训外科医生进行，有经验的外科医生作为第一助手和监督者。
共研究了 204 例腹腔镜结直肠癌切除术。73%（n=149）的病例行 D3 解剖，平均淋巴结采集数为 19.4 个（范围 1-56）。有经验的外科医生完成了 90 例，受训外科医生完成了 114 例。21 例（10.3%）需要转为开放手术。总发病率为 17.6%，围手术期死亡率为 1.5%。在单变量分析中，受训外科医生的转化率并没有显著升高。多变量分析显示，只有 T3 及以上的分期是转化率的独立预测因素（优势比（OR）4.1；95%置信区间（CI）1.09-15.48）。对发病率的危险因素进行多变量分析显示，导致发病率的危险因素不是转化率（OR 2.37；95%CI，0.86-6.76），而是直肠手术（OR 4.09；95%CI 2.04-9.9）。
如果有经验的外科医生进行监督，经验不足的外科医生在腹腔镜结直肠手术中不会导致更多的转化或术后发病率。转化率与术后发病率增加无关。
