Watson D I, Baigrie R J, Jamieson G G
Royal Adelaide Centre for Endoscopic Surgery, Royal Adelaide Hospital, Australia.
Ann Surg. 1996 Aug;224(2):198-203. doi: 10.1097/00000658-199608000-00013.
The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it.
Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve.
The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience.
The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided.
A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.
本研究的目的是确定是否可以界定腹腔镜胃底折叠术的学习曲线，以及是否可以采取措施避免与之相关的任何困难。
尽管腹腔镜胃底折叠术的早期结果令人鼓舞，但该手术特有的并发症已被描述。学习曲线问题可能导致这些困难。虽然一些专业机构已经发布了培训建议，但对于在独立进行腹腔镜抗反流手术之前需要何种程度的充分监督经验以及学习曲线的实际长度存在分歧。
前瞻性评估了11位外科医生在46个月期间进行的280例腹腔镜胃底折叠术的结果。通过三种不同方式分析经验：1）按时间顺序排列的组内对总体学习经验进行评估；2）根据每位外科医生的经验对所有个体经验进行分组评估；3）将开展腹腔镜胃底折叠术的外科医生的早期手术结果与在机构总体经验中较晚开始腹腔镜胃底折叠术的外科医生的早期经验进行比较。
总体组进行的前50例手术以及每位外科医生进行的前20例手术中，并发症、再次手术和腹腔镜转为开放手术的发生率均较高。在最初的前20例手术以及前5例个体手术中，这些发生率更高。然而，当外科医生在总体经验中较晚开始进行胃底折叠术且能获得经验丰富的监督时，不良结果的可能性较小。
可以界定腹腔镜胃底折叠术的学习曲线。开始进行腹腔镜胃底折叠术的外科医生在其最初的20例手术过程中应寻求经验丰富的监督。这应能将与个体学习曲线相关的不良结果降至最低。
