Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants-CHU de Limoges, Limoges Cedex, France.
Service de Chirurgie Viscérale Pédiatrique, Hôpital de ClochevilleTours Cedex, France.
J Laparoendosc Adv Surg Tech A. 2021 Apr;31(4):478-483. doi: 10.1089/lap.2020.0822. Epub 2021 Mar 2.
The widespread use of robotic surgery has provided surgeons a high-quality and alternative method to perform pyeloplasty. Indeed, robot-assisted technology has made it a lot easier to obtain the advanced technical skills required to perform this procedure. The learning curve (LC) reflects the increase in learning as a function of experience. Robot-assisted laparoscopic pyeloplasty (RALP) represents a well-standardized and reproducible procedure with an LC that allows reliable results to readily be obtained. The aim of our study was to compare the RALP LC of senior versus junior surgeons. We reviewed all of the RALP procedures performed at three pediatric surgery centers between November 2007 and November 2018. Three senior surgeons and 4 junior surgeons performed the robotic procedures. Neither the senior nor the junior surgeons had previous experience with robotic surgery; they had experience with conventional laparoscopic procedures but not with laparoscopic pyeloplasty. The primary metric that we selected to evaluate competence acquisition was a composite outcome defined by a combination of operative time (OT), complications, and surgical success. The complications were rated according to the Clavien-Dindo classification expressed by a complication factor; surgical success was expressed as a success factor, and we used a cumulative sum (CUSUM) analysis to determine the LC. The CUSUM method, through its multioutcome approach, is a very effective way to evaluate LCs. Between November 2007 and November 2018, 3 senior surgeons and 4 junior surgeons performed 88 RALP procedures. The included patients had a median age of 6.1 years (range 7 months-16 years). The median duration of follow-up was 6.4 years (range 14 months-12 years). The median OT was 198.86 minutes (range 106-335 minutes). By CUSUM analysis of the composite outcome, we found that despite the junior surgeons having performed fewer procedures than the senior surgeons, their LCs exhibited an earlier inflection point (Fig. 1) followed by a constant rate of improvement in proficiency, thus indicating a more rapid learning process. The median composite scores for the senior surgeons and the junior surgeons were 299 (range 210-370) and 193 (range 131-255), respectively, after seven procedures. Assuming proper exposure to robotics and an adequate case volume, we demonstrated that junior surgeons can readily achieve comparable levels of expertise compared with senior practitioners in the field of pediatric RALP. It can be assumed that the LC in robotic pyeloplasty is not only directly influenced by the individual surgical experience but also by the experience of the surgical team.
机器人手术的广泛应用为外科医生提供了一种高质量的替代方法来进行肾盂成形术。事实上,机器人辅助技术使得获得进行该手术所需的先进技术技能变得更加容易。学习曲线 (LC) 反映了经验的增加。机器人辅助腹腔镜肾盂成形术 (RALP) 是一种经过很好标准化和可重复的手术,其 LC 可以可靠地获得可靠的结果。我们研究的目的是比较高级和初级外科医生的 RALP LC。
我们回顾了 2007 年 11 月至 2018 年 11 月在三个小儿外科中心进行的所有 RALP 手术。三名高级外科医生和 4 名初级外科医生进行了机器人手术。高级和初级外科医生都没有机器人手术经验;他们有传统腹腔镜手术经验,但没有腹腔镜肾盂成形术经验。我们选择评估能力获得的主要指标是由手术时间 (OT)、并发症和手术成功率组合而成的综合结果。并发症根据 Clavien-Dindo 分类进行分级,表示为并发症因素;手术成功率表示为成功率因素,我们使用累积和 (CUSUM) 分析来确定 LC。CUSUM 方法通过其多结果方法,是评估 LC 的非常有效的方法。
2007 年 11 月至 2018 年 11 月,3 名高级外科医生和 4 名初级外科医生进行了 88 例 RALP 手术。纳入的患者中位年龄为 6.1 岁(7 个月至 16 岁)。中位随访时间为 6.4 年(14 个月至 12 年)。中位手术时间为 198.86 分钟(106-335 分钟)。通过综合结果的 CUSUM 分析,我们发现,尽管初级外科医生的手术次数少于高级外科医生,但他们的 LC 显示出更早的拐点(图 1),随后熟练程度的提高呈稳定的速度,表明学习过程更快。高级外科医生和初级外科医生的中位综合评分分别为 299(210-370)和 193(131-255),分别在 7 例手术后。
假设适当接触机器人技术并达到足够的手术量,我们证明了初级外科医生可以在小儿 RALP 领域与高级从业者相比,迅速达到相当的专业水平。可以假设,机器人肾盂成形术的 LC 不仅直接受到个体手术经验的影响,还受到手术团队经验的影响。