Groupe Hospitalier Diaconesses - Croix Saint-Simon, Service de Chirurgie Digestive, 125, rue d'Avron, 75020, Paris, France.
Research and Biostatistics Unit, Rothschild Foundation Hospital, Paris, France.
Surg Endosc. 2020 Sep;34(9):3936-3943. doi: 10.1007/s00464-019-07164-4. Epub 2019 Oct 9.
Surgery demonstration (SD) is considered to be a mainstay of surgical education, but controversy exists concerning the patient's safety. Indeed, the presence of visiting surgeons is a source of distraction and may have an impact on surgeon's performance. This study's objective was to evaluate possible differences in outcomes between robotic sphincter-saving rectal cancer surgery (RRCS) performed during routine surgical practice versus in the presence of visiting surgeons in the operating room (OR) with direct access to the surgeon.
Retrospective case-matched studies were conducted from a prospectively collected database. 114 patients (38 with the presence of visiting surgeons) who underwent RRCS between January 2013 and September 2018 were included. Patients were matched in a 1:2 basis after propensity score analysis using five criteria: gender, body mass index, preoperative chemoradiation, type of mesorectum excision, and synchronous liver metastasis.
There was no difference between the two groups with regard to mean operating time, estimated blood loss, conversion, and hospital stay. Also, overall (44% vs. 40%; P = 0.6), major morbidity (26% vs. 19%; P = 0.5), and unplanned reoperation (17% vs. 15%; P = 1.0) rates were not statistically different. No difference was noted with regard to the quality of mesorectum excision, or positive rate of circumferential and distal longitudinal resection margins. The mean number of harvested lymph nodes (17 vs. 14.5; P = 0.04) was lower in the SD group and the number of patients with < 12 harvested lymph nodes (31% vs. 16%; P = 0.09) was greater after SD although it did not reach statistical significance. No differences were observed in disease-free or overall survival.
The presence of visiting surgeons in the OR seems not to interfere in the quality of rectal resection and does not compromise patient's short-term outcome and survival. However, mild differences in the extent of lymphadenectomy were observed and the surgeons performing SD may be aware of this.
手术示教（SD）被认为是外科教育的主要手段，但患者的安全性仍存在争议。事实上，来访外科医生的存在会分散注意力，并可能影响外科医生的表现。本研究的目的是评估在手术室（OR）中存在直接接触外科医生的来访外科医生的情况下，机器人保肛直肠肿瘤切除术（RRCS）的结果与常规手术实践之间是否存在差异。
回顾性病例匹配研究来自一个前瞻性收集的数据库。纳入了 2013 年 1 月至 2018 年 9 月期间接受 RRCS 的 114 例患者（38 例存在来访外科医生）。通过倾向评分分析使用五个标准进行 1:2 配对：性别、体重指数、术前放化疗、直肠系膜切除类型和同步肝转移。
两组之间的平均手术时间、估计失血量、转化率和住院时间无差异。此外，总体（44%对 40%；P=0.6）、主要发病率（26%对 19%；P=0.5）和计划外再次手术（17%对 15%；P=1.0）率也无统计学差异。直肠系膜切除质量、环周和远端纵向切缘阳性率也无差异。SD 组的淋巴结采集数（17 对 14.5；P=0.04）较低，SD 后淋巴结采集数<12 个的患者比例（31%对 16%；P=0.09）较高，但无统计学意义。无病生存率和总生存率无差异。
OR 中存在来访外科医生似乎不会干扰直肠切除的质量，也不会危及患者的短期结果和生存。然而，淋巴结清扫的程度存在轻微差异，进行 SD 的外科医生可能会意识到这一点。
