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背景腹腔镜肾部分切除术的高难度和挑战性使许多腹腔镜外科医生采用机器人辅助肾部分切除术治疗肾脏小肿瘤。从腹腔镜肾部分切除术到机器人辅助肾部分切除术的过渡期我们评估一个资深腹腔镜外科医生的学习曲线。方法我们比较同一外科医生施行的早期20例机器人辅助肾部分切除术和最近18例腹腔镜肾部分切除术的围术期结果。所有手术是在2005年4月～2009年7月间完成的。既往该医生成功施行100余例腹腔镜肾部分切除术和100余例机器人辅助手术。2组手术步骤相同,在镜下充分游离肾动静脉后,完整游离肿瘤表面,利用术中超声来界定肿瘤边界,哈巴狗血管阻断钳控制肾动脉,在热缺血状态下切除肿瘤,2-0可吸收线连续缝合肾实质,如果集合系统切开后也予以缝合。学习曲线的定义指能熟练地在较短的手术时间和热缺血时间内完成机器人辅助肾部分切除术的例数。利用散点图显示机器人辅助肾部分切除术的学习曲线,用以比较2种术式的手术时间和热缺血时间。结果 2组患者术前临床资料和肿瘤病理学结果的比较无统计学差异。2组均无切缘阳性病例。2组手术并发症也无统计学差异。在机器人辅助肾部分切除术的学习曲线(图1)中,手术时间和热缺血时间均呈下降趋势。经过早期5例手术后,机器人辅助肾部分切除术的平均手术时间即可接近最近18例腹腔镜肾部分切除术的平均手术时间。前5例机器人辅助肾部分切除术的平均手术时间是242.8 min,远远长于后15例机器人辅助肾部分切除术平均手术时间171.3 min(P=0.011)。结论 一个资深腹腔镜外科医生从腹腔镜到机器人辅助肾部分切除术过渡是一个非常迅速的过程。2组热缺血时间、术中估计出血量和住院时间均无统计学差异。经过前5例机器人辅助肾部分切除术后,一个资深腔镜外科医生行机器人辅助和腹腔镜肾部分切除术的手术时间大致相同。
Background The difficult and challenging laparoscopic partial nephrectomy has led many laparoscopic surgeons to use robotic-assisted partial nephrectomy for small renal tumors. From the Laparoscopic Partial Nephrectomy to the Robotic Assisted Nephrectomy Transitional Period We evaluated the learning curve of a senior laparoscopic surgeon. Methods We compared perioperative outcomes of the earlier 20 robotic-assisted partial nephrectomy and the last 18 laparoscopic partial nephrectomy performed by the same surgeon. All operations were completed between April 2005 and July 2009. In the past the doctor successfully implemented more than 100 cases of laparoscopic partial nephrectomy and more than 100 cases of robot assisted surgery. The two groups of surgical procedures were the same, the complete free of the renal artery and vein in the microscope, the complete surface of the tumor, the use of intraoperative ultrasound to define the border of the tumor, pug vascular blocking clamp control of renal artery, resection of the tumor in the warm ischemia, 2- 0 absorbable suture continuous renal parenchyma, if the collection system is also sutured after incision. The definition of the learning curve refers to the number of cases where skilled robotic-assisted partial nephrectomy can be accomplished in a shorter period of surgery and warm ischemia. A scatter plot was used to show the learning curve of robotic-assisted partial nephrectomy to compare the duration of surgery and the duration of warm ischemia with two procedures. Results There was no significant difference in preoperative clinical data and tumor pathology between the two groups. No case of positive margins in both groups. There was no significant difference in the surgical complications between the two groups. In the robotic-assisted partial nephrectomy learning curve (Figure 1), both the operation time and the warm ischemia time showed a decreasing trend. After the first five cases of surgery, the average operative time for robotic-assisted partial nephrectomy can approach that of the last 18 cases of laparoscopic partial nephrectomy. The average robot-assisted partial nephrectomy surgery time was 242.8 min in the first five cases, which was much longer than the average of 171.3 minutes (P = 0.011) in the last 15 cases of robotic-assisted partial nephrectomy. Conclusion The transition from laparoscopy to robotic-assisted partial nephrectomy by a senior laparoscopic surgeon is a very rapid process. There were no significant differences between the two groups in the time of warm ischemia, intraoperative blood loss and length of stay. After the first 5 cases of robotic-assisted partial nephrectomy, a senior laparoscopic surgeon performed robotic-assisted and laparoscopic partial nephrectomy for roughly the same time.