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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2022, Vol. 15 ›› Issue (05): 270 -274. doi: 10.3877/cma.j.issn.1674-6899.2022.05.004

论著

经口腔前庭入路机器人甲状腺手术的学习曲线分析
李陈钰1, 贺青卿2, 庄大勇2, 周鹏2, 岳涛2, 邵长秀1, 刘永祥1, 徐婧2, 李小磊2,†()   
  1. 1. 121000　锦州医科大学联勤保障部队第九六〇医院研究生培养基地；250031　济南，解放军联勤保障部队第九六〇医院甲乳外科
    2. 250031　济南，解放军联勤保障部队第九六〇医院甲乳外科
  • 收稿日期:2022-02-17 出版日期:2022-10-30
  • 通信作者: 李小磊
  • 基金资助:
    国家重点研发计划专项课题(2019YFC0119205); 国家自然科学基金项目(81702448); 济南市临床医学科技创新计划(202019010); 原济南军区总医院院长基金资助项目(2016ZD02, 2017MS04)

A prospective study of learning curve of transoral robotic thyroidectomy

Chenyu Li1, Qingqing He2, Dayong Zhuang2, Peng Zhou2, Tao Yue2, Changxiu Shao1, Yongxiang Liu1, Jing Xu2, Xiaolei Li2,†()   

  1. 1. Postgraduate Training Base of Jinzhou Medical University, The 960th Hospital of People′s Liberation Army, Jinzhou 121000, China; Department of Thyroid and Breast Surgery, The 960th Hospital of People′s Liberation Army, Jinan 250031, China
    2. Department of Thyroid and Breast Surgery, The 960th Hospital of People′s Liberation Army, Jinan 250031, China
  • Received:2022-02-17 Published:2022-10-30
  • Corresponding author: Xiaolei Li
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目的

探讨经口腔前庭入路机器人甲状腺手术(transoral robotic thyroidectomy, TORT)的学习曲线。

方法

前瞻性收集并分析2020年4月至2021年11月期间，就诊于解放军联勤保障部队第九六〇医院行TORT的70例患者的临床数据。采用累积和分析法拟合学习曲线，根据累积和值分为学习阶段和熟练阶段，探讨两个阶段的临床数据资料。

结果

70例患者均顺利完成TORT，无中转开放手术，手术时间129～490 min，平均(223.82±72.05)min；随访时间1～20个月，平均(10.23±5.43)个月；均无复发转移。选择并收集70例中连续进行的50例行甲状腺腺叶切除(含中央区淋巴结清扫)患者的临床数据进行统计分析，手术时间148～262 min，平均(205.68±57.59)min。采用累积和分析法发现，23例为跨越学习曲线掌握TORT的最低手术例数；学习阶段手术时间148～380 min，平均(238.17±63.32)min；熟练阶段手术时间134～262 min，平均(178±32.57)min。学习阶段和熟练阶段患者的手术时间比较，差异有统计学意义(P<0.05)；患者年龄、性别、肿瘤大小、中央区淋巴结清扫数、中央区淋巴结阳性数、术后拔管时间、并发症率比较，差异无统计学意义(P>0.05)。

结论

对于经验丰富的外科医师，严格选择合适患者后，TORT是安全、可行的，跨越TORT学习曲线需要累积的最低手术例数为23例。

关键词: 甲状腺肿瘤, 达芬奇机器人手术系统, 经口腔前庭入路, 学习曲线, 累积和分析法
Objective

To investigate the learning curve of transoral robotic thyroidectomy.

Methods

From Apr. 2020 to Nov. 2021, the clinical data of 70 patients who had received transoral robotic thyroidectomy (TORT) at the 960th Hospital of PLA were gathered and studied prospectively. The cumulative sum analysis (CUSUM) was used to fit the learning curve. According to the CUSUM value, it was divided into learning stage and proficiency stage, and the clinical data of the two stages were analyzed.

Results

All the 70 patients successfully underwent TORT without conversion to open operation. The mean operation time was (223.82±72.05)min, 129- 490 min. There was no recurrence or metastasis after a mean follow-up time of (10.23±5.43)months, 1-20 months. The data of 50 consecutive cases of thyroidectomy (including central lymph node dissection) were selected and collected for statistical analysis. The mean operation time was (205.68 ± 57.59)min, 148-262 min. The lowest number of operations to master TORT and cross the learning curve was explored using CUSUM: the mean operation time in the learning stage was(238.17 ± 63.32)min, 148-380 min, and the mean operation time of proficiency stage was (178 ± 32.57) min, 134-262 min. There was significant difference in operation time between learning stage and proficiency stage(P<0.05); There was no significant difference in age, gender, tumor size, the number of dissect of lymph nodes, the number of lymph nodes positive in the central area, the extubation days after surgery, and the rate of complications between the two stages(P>0.05).

Conclusions

TORT is safe and feasible for expert surgeons who carefully choose appropriate patients. It′s a total of 23 operations that must be accumulated to cross the TORT learning curve.

Key words: Thyroid tumor, Da Vinci robotic surgery system, Transoral vestibular approach, Learning curve, Cumulative sum analysis
图1 70例行TORT患者中50例单侧腺叶切除(含中央区淋巴结清扫)的手术时间累积和学习曲线注：经口腔前庭入路机器人甲状腺手术(transoral robotic thyroidectomy, TORT)
表1 70例行TORT患者中50例单侧腺叶切除(含中央区淋巴结清扫)的学习阶段与熟练阶段的一般资料及围手术期数据
项目 学习阶段(23例) 熟练阶段(27例) P值
性别[例(%)]     0.674
  男 2(8.7) 4(14.8)  
  女 21(91.3) 23(85.2)  
年龄(岁，±s) 30.91±9.66 30.37±8.36 0.836
体质量指数(kg/m2，±s) 23.08±3.60 22.53±4.10 0.629
手术方式[例(%)]      
  腺叶 4(17.4)  4(14.8)  0.804 
  腺叶＋中央区 19(82.6) 23(85.2) 0．804
病理性质[例(%)]      
  乳头状癌 19(82.6) 23(85.2) 0.804
  滤泡性腺瘤 4(17.4) 3(11.1) 0．689
  结节性甲状腺肿 0(0.0) 1(3.7) >0.999
恶性肿瘤直径(cm，±s) 0.48±0.20 0.55±0.24 0.876
中央区淋巴结清扫数(枚，±s) 10±3.92 10±3.91 0.948
中央区阳性淋巴结数(枚，±s) 2.11±1.20 3.36±3.34 0.552
术后拔管时间(d，±s) 5.17±0.96 5.52±1.20 0.283
手术时间(min，±s) 238.17±63.32 178±32.57 <0.001
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