Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study.
Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study.
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DOI：
10.1016/j.amsu.2015.03.003
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发表时间：
2015-06
影响因子：
1.7
通讯作者：
Bucci, Luigi
中科院分区：
文献类型：
--
作者：
Luglio, Gaetano;De Palma, Giovanni Domenico;Tarquini, Rachele;Giglio, Mariano Cesare;Sollazzo, Viviana;Esposito, Emanuela;Spadarella, Emanuela;Peltrini, Roberto;Liccardo, Filomena;Bucci, Luigi
尽管腹腔镜结直肠手术的好处已得到证实，但在外科医生中仍未得到充分利用。学识渊博是其采用程度有限的原因之一。本研究的目的是确定在单一机构实施腹腔镜结直肠手术的可行性和发病率，“学习曲线”经验，实施标准化的手术技术和恢复方案。前50例患者接受了腹腔镜术。所有手术均由一名实习外科医生在一名顾问外科医生的监督下进行，按全系膜切除加中心血管结扎或TME的原则进行。患者接受了快速康复计划。对康复参数、短期结果、发病率和死亡率进行了评估。手术类型：左侧切除20例，右侧切除8例，低位前路切除/TME 14例，全结肠切除加IRA 5例，全直肠切除加全结肠加膀胱术3例。平均手术时间227min，平均淋巴结数18.7个。转化率：8%。平均排气时间：1.3天，平均排出固体大便时间：2.3天。平均住院时间：7.2天。总发病率：24%；重大发病率(Dindo-Clavien III)：4%。无吻合口瘘，无死亡，无30天再入院。正确的腹腔镜结直肠手术是安全的，即使在学习曲线设定的情况下，也能在恢复和短期结果方面带来极好的结果。更好的结果和缩短学习曲线的关键因素似乎是采用标准化的技术和培训模式，以及专家结直肠外科医生的严格监督。腹腔镜结直肠手术的好处已经被广泛证明。陡峭的学习曲线被认为是采用它的主要限制。我们在学习曲线前瞻性系列中呈现短期结果。模块化、循序渐进的方法会带来出色的结果。在严格的监督下，即使是学员也可以安全地学习腹腔镜术和开腹手术。
Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol. The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon. Benefits from laparoscopic colorectal surgery have been widely demonstrated. A steep learning curve is considered the main limitation to its adoption. We present short-term outcomes in a learning curve prospective series. A modular, stepwise approach leads to excellent results. Even trainees can safely learn both laparoscopic and open surgery, when strictly supervised.