Rosen Seth A, Rupji Manali, Liu Yuan, Paul Olson Terrah J
Department of Surgery, Emory University, Atlanta, GA, USA.
Department of Biostatistics, Emory University, Atlanta, GA, USA.
Am Surg. 2023 Dec;89(12):5332-5339. doi: 10.1177/00031348221146931. Epub 2022 Dec 22.
Multiple authors have described an initial learning curve (LC) for robotic proctectomy (RP), but there is scant literature regarding continued technical progression beyond this stage. Total operating time is the most commonly used metric to measure proficiency. Our goal was to examine RP experience after the initial LC looking for evidence of further technical progression.
We reviewed our robotic surgery database for a single surgeon during operations 100 through 550 to identify 83 RPs for tumor. These were divided into quartiles by series order, indicating surgeon experience level over time. Demographics and outcomes were compared among the groups. We defined (PCT) as a new metric. PCT was defined as console time divided by total operative time (TOT).
From March 2014 through March 2019, 450 robotic colorectal operations were performed, including 83 RPs for polyp or cancer. No significant differences were found among the quartiles in regard to demographics, tumor features, hospital stay, conversions, or readmissions. As experience was gained, there were significant increases in intracorporeal anastomosis (ICA), TOT, and PCT. Complications decreased with experience. Number of lymph nodes in the specimen increased. On multivariate analysis, later experience group, body mass index ≥30, and ICA were associated with increased PCT.
ICA became a routine part of RP after the initial LC, with increases in TOT and PCT. Number of lymph nodes increased and number and severity of complications decreased with experience. Increased PCT may indicate increased expertise during RP.
多位作者描述了机器人直肠切除术（RP）的初始学习曲线（LC），但关于此阶段之后技术持续进展的文献很少。总手术时间是衡量熟练程度最常用的指标。我们的目标是研究初始学习曲线之后的机器人直肠切除术经验，寻找进一步技术进展的证据。
我们回顾了一位外科医生在第100至550例手术期间的机器人手术数据库，以确定83例肿瘤机器人直肠切除术。这些病例按手术顺序分为四分位数，表明外科医生随时间的经验水平。对各组的人口统计学和结果进行比较。我们将操作控制台时间占比（PCT）定义为一个新指标。PCT定义为控制台时间除以总手术时间（TOT）。
2014年3月至2019年3月，共进行了450例机器人结直肠手术，包括83例息肉或癌症的机器人直肠切除术。在人口统计学、肿瘤特征、住院时间、中转率或再入院率方面，四分位数之间未发现显著差异。随着经验的积累，体内吻合术（ICA）、总手术时间和操作控制台时间占比显著增加。并发症随着经验的增加而减少。标本中的淋巴结数量增加。多因素分析显示，后期经验组、体重指数≥30和体内吻合术与操作控制台时间占比增加有关。
在初始学习曲线之后，体内吻合术成为机器人直肠切除术的常规部分，总手术时间和操作控制台时间占比增加。随着经验的增加，淋巴结数量增加，并发症的数量和严重程度降低。操作控制台时间占比增加可能表明机器人直肠切除术中专业技能的提高。
