经单切口腹腔镜完全腹膜外疝修补术（SILTEP）治疗腹股沟疝的学习曲线。
Learning curve of single-incision laparoscopic totally extraperitoneal repair (SILTEP) for inguinal hernia.
机构信息
Department of Surgery, College of Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, 271 Cheonbo-ro, Uijeongbu-si, Gyeonggi-do, 11765, Republic of Korea.
出版信息
Hernia. 2022 Jun;26(3):959-966. doi: 10.1007/s10029-021-02431-7. Epub 2021 Jun 7.
PURPOSE
Laparoscopic totally extraperitoneal hernia repair (TEP) is a widely used treatment for inguinal hernia. Single-incision laparoscopic TEP (SILTEP) has attracted the attention of several surgeons, given its superior cosmetic results and patient satisfaction, as well as comparable outcomes to multiport surgery. Nonetheless, no relevant studies have evaluated the learning curve (LC) of SILTEP in terms of both operation time (OT) and surgical failure. Therefore, we aimed to investigate the LC of SILTEP for inguinal hernia.
METHODS
Medical records of 180 patients who underwent SILTEP performed by a single surgeon from a single institution between October 2012 and November 2017 were retrospectively reviewed. The LC was analyzed using the moving average method and cumulative sum control chart (CUSUM) for OT and surgical failure. Surgical failure was defined as the need for additional ports, open conversion, severe postoperative complications (Clavien-Dindo ≥ IIIa), and recurrence. Eight patients who underwent combined surgery or bilateral hernia repair were excluded from the OT analysis.
RESULTS
From CUSUM graphs, the study period was divided into three phases: OT-phases 1 (1st-32nd), 2 (33rd-83rd), and 3 (84th-172nd) for OT and failure-phases 1 (1st-29th), 2 (30th-58th), and 3 (59th-180th) for surgical failure. Mean OTs were statistically different in the three OT phases (64.6 vs. 50.8 vs. 35.2 min; p < 0.001). Open conversion (31.0% vs. 0% vs. 2.5%) and additional port insertion (6.9% vs. 24.1% vs. 2.5%) stabilized consecutively at failure-phases 2 and 3 (p < 0.001). Surgical failure rates decreased to 5.7% by failure-phase 3 (37.9% vs. 24.1% vs. 5.7%; p < 0.001).
CONCLUSION
For an experienced laparoscopic surgeon, we estimated that approximately 60 cases are needed to overcome the LC for SILTEP in terms of both reducing OT and achieving a surgical failure rate < 10%. Further proficiency could be achieved after approximately 85 SILTEP procedures with a stable OT of approximately 35 min.
目的
腹腔镜完全腹膜外疝修补术（TEP）是一种广泛应用于治疗腹股沟疝的方法。单切口腹腔镜 TEP（SILTEP）因其良好的美容效果和患者满意度，以及与多端口手术相当的结果，引起了多位外科医生的关注。然而，目前尚无研究评估 SILTEP 在手术时间（OT）和手术失败方面的学习曲线（LC）。因此，我们旨在研究 SILTEP 治疗腹股沟疝的 LC。
方法
回顾性分析 2012 年 10 月至 2017 年 11 月期间由同一位外科医生在一家机构进行的 180 例 SILTEP 患者的病历。使用移动平均法和累积和控制图（CUSUM）分析 OT 和手术失败的 LC。手术失败定义为需要额外的端口、中转开放、严重的术后并发症（Clavien-Dindo≥IIIa）和复发。OT 分析中排除了 8 例接受联合手术或双侧疝修补术的患者。
结果
从 CUSUM 图来看，研究期间分为三个阶段：OT 阶段 1（第 1 至 32 例）、2（第 33 至 83 例）和 3（第 84 至 172 例）用于 OT 和失败阶段 1（第 1 至 29 例）、2（第 30 至 58 例）和 3（第 59 至 180 例）用于手术失败。三个 OT 阶段的平均 OT 差异有统计学意义（64.6 分钟 vs. 50.8 分钟 vs. 35.2 分钟；p<0.001）。中转开放（31.0% vs. 0% vs. 2.5%）和额外端口插入（6.9% vs. 24.1% vs. 2.5%）在失败阶段 2 和 3 连续稳定（p<0.001）。手术失败率在失败阶段 3 下降至 5.7%（37.9% vs. 24.1% vs. 5.7%；p<0.001）。
结论
对于有经验的腹腔镜外科医生，我们估计大约需要 60 例 SILTEP 手术才能克服 OT 方面的 LC，并将手术失败率降低至<10%。大约 85 例 SILTEP 手术后，OT 可稳定在 35 分钟左右，进一步提高熟练度。
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