Department of Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman St. WACC 460, Boston, MA 02114, USA.
Surg Endosc. 2011 Jul;25(7):2288-95. doi: 10.1007/s00464-010-1550-8. Epub 2011 Feb 7.
Controversy exists concerning the importance of operative time on patient outcomes. It is unclear whether faster is better or haste makes waste or similarly whether slower procedures represent a safe, meticulous approach or inexperienced dawdling. The objective of the present study was to determine the effect of operative time on 30-day outcomes in laparoscopic surgery.
Patients who underwent laparoscopic general surgery procedures (colectomy, cholecystectomy, Nissen fundoplication, inguinal hernia, and gastric bypass) from the ACS-NSQIP 2005-2008 participant use file were identified. Exclusion criteria were defined a priori to identify same-day admission, elective procedures. Operative time was divided into deciles and summary statistics were analyzed. Univariate analyses using a Cochran-Armitage test for trend were completed. The effect of operative time on 30-day morbidity was further analyzed for each procedure type using multivariate regression controlling for case complexity and additional patient factors. Patients within the highest deciles were excluded to reduce outlier effect.
A total of 76,748 elective general surgical patients who underwent laparoscopic procedures were analyzed. Univariate analyses of deciles of operative time demonstrated a statistically significant trend (p<0.0001) toward increasing odds of complications with increasing operative time for laparoscopic colectomy (n=10,135), cholecystectomy (n=37,407), Nissen fundoplication (n=4,934), and gastric bypass (n=17,842). The trend was not found to be significant for laparoscopic inguinal hernia repair (n=6,430; p=0.14). Multivariate modeling revealed the effect of operative time to remain significant after controlling for additional patient factors.
Increasing operative time was associated with increased odds of complications and, therefore, it appears that speed may matter in laparoscopic surgery. These analyses are limited in their inability to adjust for all patient factors, potential confounders, and case complexities. Additional hierarchical multivariate analyses at the surgeon level would be important to examine this relationship further.
手术时间对患者结局的重要性存在争议。目前尚不清楚是更快更好，还是欲速则不达，或者类似地，较慢的手术过程代表安全、细致的方法，还是缺乏经验的拖延。本研究的目的是确定手术时间对腹腔镜手术 30 天结局的影响。
从 ACS-NSQIP 2005-2008 参与者使用文件中确定接受腹腔镜普外科手术（结肠切除术、胆囊切除术、Nissen 胃底折叠术、腹股沟疝和胃旁路术）的患者。预先定义排除标准以确定当天入院和择期手术。将手术时间分为十分位数，并进行汇总统计分析。使用 Cochran-Armitage 趋势检验进行单变量分析。使用多变量回归控制病例复杂性和其他患者因素，进一步分析每种手术类型的手术时间对 30 天发病率的影响。为了减少离群值的影响，排除最高十分位数的患者。
共分析了 76748 例接受腹腔镜手术的择期普外科患者。手术时间十分位数的单变量分析显示，随着手术时间的增加，腹腔镜结肠切除术（n=10135）、胆囊切除术（n=37407）、Nissen 胃底折叠术（n=4934）和胃旁路术（n=17842）的并发症发生率呈统计学显著趋势（p<0.0001）。腹腔镜腹股沟疝修补术（n=6430；p=0.14）的趋势不显著。多变量建模显示，在控制其他患者因素后，手术时间的影响仍然显著。
手术时间的增加与并发症发生率的增加相关，因此，腹腔镜手术中速度似乎很重要。这些分析受到无法调整所有患者因素、潜在混杂因素和病例复杂性的限制。进一步检查这种关系的重要性是在外科医生层面进行分层多变量分析。
