Department of Obstetrics and Gynecology, Tokai University, School of Medicine, Shimokasuya 143 Isehara, Kanagawa, 2591193, Japan; Department of Obstetrics and Gynecology,Yokohama Municipal Citizen's Hospital, Okazawa 56 Hodogaya, Yokohama, Kanagawa, 408555, Japan.
Department of Obstetrics and Gynecology, Fukui Prefectural Hospital, Yotsui 2-1-8, Fukui City, Fukui, 9108526, Japan; Department of Obstetrics and Gynecology,Yokohama Municipal Citizen's Hospital, Okazawa 56 Hodogaya, Yokohama, Kanagawa, 408555, Japan.
Surg Oncol. 2020 Dec;35:254-260. doi: 10.1016/j.suronc.2020.09.008. Epub 2020 Sep 10.
Minimally invasive surgery including lymphadenectomy for endometrial cancer is widely standardized for the management of endometrial cancer in recent decades. However, the learning curve for laparoscopic para-aortic lymphadenectomy is poorly reported, specifically that for the extraperitoneal approach.
We examined the learning curve for laparoscopic extraperitoneal para-aortic lymphadenectomy by cumulative sum (CUSUM) analysis by retrospectively analyzing 134 patients with early-stage endometrial cancer who had undergone laparoscopic extraperitoneal para-aortic lymphadenectomy, including the first case. Data on the surgical factors that improved and were statistically correlated with the number of procedures experienced were extracted and used to create CUSUM curves.
The average time for para-aortic lymphadenectomy was 149.4 min to harvest an average of 65.3 para-aortic lymph nodes. Intra- and postoperative complications were observed in nine cases (6.7%). A switch to the transperitoneal approach was necessary in three cases (2.2%). The number of harvested para-aortic lymph nodes and the procedure time were strongly correlated with the number of procedures the patient underwent (p < 0.01). The CUSUM curve of the number of harvested para-aortic lymph nodes indicated an inflection point at the 51st case. The procedure time for para-aortic lymphadenectomy stabilized after the 59th case. CUSUM analysis of "unexpected events," including intra- and postoperative complications and switch to the transperitoneal approach, showed an improved incidence at 60 cases and later.
Gaining proficiency in laparoscopic extraperitoneal thorough para-aortic lymphadenectomy is associated with a long learning curve of over 60 procedures. Careful management is required when introducing the procedure.
包括淋巴结切除术在内的微创外科手术在近几十年来已广泛应用于子宫内膜癌的治疗。然而，腹腔镜下腹主动脉旁淋巴结清扫术的学习曲线却鲜有报道，尤其是腹膜外入路的情况。
我们通过回顾性分析首例患者在内的 134 例早期子宫内膜癌患者的腹腔镜腹膜外腹主动脉旁淋巴结清扫术的资料，采用累积和（CUSUM）分析来研究腹腔镜腹膜外腹主动脉旁淋巴结清扫术的学习曲线。提取并使用与手术经验相关的、改善且具有统计学意义的手术因素数据来创建 CUSUM 曲线。
平均每例患者进行腹腔镜腹主动脉旁淋巴结清扫术的时间为 149.4 分钟，平均清扫 65.3 个腹主动脉旁淋巴结。9 例（6.7%）患者出现术中及术后并发症。3 例（2.2%）患者需要转为经腹腔途径。清扫的腹主动脉旁淋巴结数量和手术时间与患者接受的手术次数呈强相关（p<0.01）。清扫的腹主动脉旁淋巴结数量的 CUSUM 曲线在第 51 例时出现拐点。第 59 例之后，腹主动脉旁淋巴结清扫术的手术时间趋于稳定。包括术中及术后并发症和转为经腹腔途径在内的“意外事件”的 CUSUM 分析显示，在第 60 例及之后，这些事件的发生率有所改善。
熟练掌握腹腔镜腹膜外彻底性腹主动脉旁淋巴结清扫术需要超过 60 例的手术经验，在引入该手术时需要谨慎管理。
