Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.
Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey.
Int J Surg. 2016 Nov;35:51-57. doi: 10.1016/j.ijsu.2016.09.010. Epub 2016 Sep 12.
To assess the learning curve for total laparoscopic hysterectomy.
This study was a retrospective analysis of the learning curve for two surgeons during their first 257 consecutive cases of total laparoscopic hysterectomy at a teaching hospital. Patients were divided sequentially into groups comprising the first 75 patients, the next 75, and the final 107 patients. Age, body mass index, gestational parity, indications for laparoscopic hysterectomy, previous pelvic surgery, operating time, haemoglobin decline, complications, need for transfusion, and length of hospital stay were evaluated.
The mean operating time for total laparoscopic hysterectomy reduced significantly from 76.2 min to 68.9 min (p = 0.001) between the first and second 75-patient groups. Linear regression analysis showed a plateau was reached on the learning curve after 71-80 cases. The rate of all complications started at 8% in the first group of 75 patients, reduced to 6.7% in the next group, and decreased further in the final group to 4.7%. The decline was not statistically significant (p = 0.6). The difference in the need for transfusion was statistically significant between the first 75 patients and the second group of 75 (p = 0.04). Conversion from laparoscopy to laparotomy was required in five patients, four in the early group and one in the final group. Age, body mass index, parity, previous pelvic surgery, decline in haemoglobin, and length of hospital stay were similar among the three groups.
A plateau in the learning curve for TLH was reached after the first 75 cases. We can infer that there is a learning curve for TLH as confirmed by the decrease in operating time (accompanied by no change in complications) correlated to gain in experience. On the other hand, one should not disregard the fact that laparoscopy is not a complication-free surgery and achievement of the learning curve does not exclude complications. Gynaecological surgeons can perform TLH securely during the learning curve.
评估全腹腔镜子宫切除术的学习曲线。
本研究回顾性分析了两位外科医生在教学医院首次进行的 257 例连续全腹腔镜子宫切除术的学习曲线。患者按顺序分为前 75 例、中间 75 例和最后 107 例。评估年龄、体重指数、孕次、腹腔镜子宫切除术的指征、既往盆腔手术、手术时间、血红蛋白下降、并发症、输血需求和住院时间。
全腹腔镜子宫切除术的平均手术时间从第 1 组和第 2 组的 76.2 分钟显著减少至 68.9 分钟（p=0.001）。线性回归分析显示，在完成 71-80 例病例后，学习曲线达到平台期。所有并发症的发生率从第 1 组的 75 例中的 8%开始，在第 2 组中降低至 6.7%，在最后一组中进一步降低至 4.7%。下降无统计学意义（p=0.6）。第 1 组 75 例与第 2 组 75 例之间输血需求的差异有统计学意义（p=0.04）。有 5 例患者需要从腹腔镜转为开腹手术，其中 4 例在早期组，1 例在最后一组。三组患者的年龄、体重指数、孕次、既往盆腔手术、血红蛋白下降和住院时间相似。
TLH 的学习曲线在完成前 75 例后达到平台期。我们可以推断，TLH 存在学习曲线，因为手术时间的缩短（同时并发症没有变化）与经验的增加有关。另一方面，我们不应忽视腹腔镜并非无并发症的手术，而且达到学习曲线并不能排除并发症。妇科外科医生可以在学习曲线期间安全地进行 TLH。
