Birmingham Children's Hospital, Birmingham, UK.
Ann R Coll Surg Engl. 2021 Feb;103(2):130-133. doi: 10.1308/rcsann.2020.7014.
Laparoscopic pyloromyotomy is now an accepted procedure for the treatment of pyloric stenosis. However, it is clear that during the implementation period there are significantly higher incidences of mucosal perforation and incomplete pyloromyotomy. We describe how we introduced a new laparoscopic procedure without the complications associated with the learning curve.
Five consultants tasked one surgeon to pilot and establish laparoscopic pyloromyotomy before mentoring the others until they were performing the procedure independently; all agreed to use exactly the same instruments and operative technique. This involved a 5mm 30-degree infra-umbilical telescope with two 3mm instruments. Data were collected prospectively.
Between 1 January 2013 and 31 December 2017, 140 laparoscopic pyloromyotomies were performed (median age 27 days, range 13-133 days, male to female ratio 121:19). Fifty-five per cent of procedures were performed by trainees. Complications were one mucosal perforation and one inadequate pyloromyotomy. There were no injuries to other organs, problems with wound dehiscence or other significant complications. The median time of discharge was one day (range one to six days).
Our rate of perforation and incomplete pyloromyotomy was 1.4%, which is equivalent to the best published series of either open or laparoscopic pyloromyotomy. We believe that this resulted from the coordinated implementation of the procedure using a single technique to reduce clinical variability, increase mentoring and improve training. This approach appears self-evident but is rarely described in the literature of learning curves. In this age of increased accountability, new technologies should be incorporated into routine practice without an increase in morbidity to patients.
腹腔镜幽门肌切开术现已成为治疗肥厚性幽门狭窄的一种公认方法。然而，在实施过程中，黏膜穿孔和不完全幽门肌切开的发生率明显更高，这是显而易见的。我们介绍了一种新的腹腔镜手术方法，避免了与学习曲线相关的并发症。
五位顾问要求一位外科医生进行腹腔镜幽门肌切开术的试点和建立，然后指导其他医生，直到他们能够独立进行手术；所有医生都同意使用完全相同的器械和手术技术。这涉及到一个 5mm 30 度的下腹部望远镜和两个 3mm 的器械。数据是前瞻性收集的。
2013 年 1 月 1 日至 2017 年 12 月 31 日，共进行了 140 例腹腔镜幽门肌切开术（中位年龄 27 天，范围 13-133 天，男女比例 121:19）。55%的手术由受训者完成。并发症包括 1 例黏膜穿孔和 1 例不完全幽门肌切开术。没有其他器官损伤、伤口裂开或其他重大并发症。中位出院时间为 1 天（范围 1-6 天）。
我们的穿孔和不完全幽门肌切开术的发生率为 1.4%，与已发表的最佳的开腹或腹腔镜幽门肌切开术系列报道相当。我们认为，这是由于采用单一技术协调实施手术，减少临床变异性、增加指导和改善培训的结果。这种方法似乎不言而喻，但在学习曲线的文献中很少有描述。在这个责任日益增加的时代，新技术应该在不增加患者发病率的情况下纳入常规实践。
