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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) ›› 2024, Vol. 17 ›› Issue (01) : 45 -50. doi: 10.3877/cma.j.issn.1674-6899.2024.01.011

论著

"筷子技术"于经脐单孔腹腔镜全子宫切除手术的可行性和学习曲线
钟魁艳1, 邓黎1, 姚远洋1, 凌开建1, 邓媛1, 李秋蓉1, 王延洲1,†()   
  1. 1. 400038　重庆，陆军军医大学第一附属医院妇产科
  • 收稿日期:2024-01-28 出版日期:2024-02-28
  • 通信作者: 王延洲

The feasibility and learning curve of laparoendoscopic single-site total hysterectomy using the "chopstick technique"

Kuiyan Zhong1, Li Deng1, Yuanyang Yao1, Kaijian Ling1, Yuan Deng1, Qiurong Li1, Yanzhou Wang1,†()   

  1. 1. Department of Obstetrics and Gynecology, The First Affiliated Hospital of Army Medical University, Chongqing 400038, China
  • Received:2024-01-28 Published:2024-02-28
  • Corresponding author: Yanzhou Wang
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钟魁艳, 邓黎, 姚远洋, 凌开建, 邓媛, 李秋蓉, 王延洲. "筷子技术"于经脐单孔腹腔镜全子宫切除手术的可行性和学习曲线[J]. 中华腔镜外科杂志(电子版), 2024, 17(01): 45-50.

Kuiyan Zhong, Li Deng, Yuanyang Yao, Kaijian Ling, Yuan Deng, Qiurong Li, Yanzhou Wang. The feasibility and learning curve of laparoendoscopic single-site total hysterectomy using the "chopstick technique"[J]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2024, 17(01): 45-50.

目的

探讨使用"筷子技术"行经脐单孔腹腔镜下全子宫切除术(transumbilical laparoendoscopic single-site surgery，TU-LESS)的可行性和学习曲线。

方法

回顾性收集2016年12月至2019年6月于陆军军医大学第一附属医院妇产科行经脐单孔腹腔镜全子宫切除术或行传统多孔腹腔镜全子宫切除术的患者，共354例，其中包括124例使用"筷子技术"行经脐单孔腹腔镜全子宫切除术(TU-LESS组)和230例行传统多孔腹腔镜(traditional laparoscopic，TL)全子宫切除术(TL组)的患者。比较两组病例的围术期指标，同时回顾性分析由同一妇瘤医师连续完成的35例经脐单孔腹腔镜下全子宫切除术的临床资料，用CUSUM法分析学习曲线。

结果

两组患者的基本资料均衡具有可比性。TU-LESS组和TL组的主要测量指标：手术时间和术中出血量比较差异均无统计学意义[131(102，155)min vs. 120(90，150)min、100(100，200)ml vs. 100(80，150)ml]。两组术后排气时间、术后12 h、24 h疼痛视觉模拟评分(visual analogue scale，VAS)、围术期并发症差异也无统计学意义(P>0.05)。但TU-LESS组的术后住院天数较TL组明显缩短，差异有统计学意义(P<0.05)。CUSUM法分析结果显示拟合曲线在手术例数累积11例时达到顶点，以此分成两个阶段，第1 ～11例为第一阶段(初始学习阶段)、第12～35例为第二阶段(巩固练习阶段)。两个阶段的手术时间分别为(137.2±37.6) min和(107.3±31.7) min，第二阶段的手术时间明显缩短，差异有统计学意义(P<0.05)。

结论

使用"筷子技术"行经脐单孔腹腔镜下全子宫切除术有着不亚于传统腹腔镜手术的围术期结局。11例病例后手术技能得到提高，表现为手术时间缩短。

关键词: 筷子技术, 经脐单孔腹腔镜, 子宫切除, 学习曲线
Objective

To explore the feasibility and learning curve of transumbilical laparoendoscopic single-site total hysterectomy using the "chopstick technique" .

Methods

A retrospective collection of 354 patients from Dec. 2016 to Jun. 2019 at the First Affiliated Hospital of Army Medical University with umbilical single-port or traditional laparoscopic total hysterectomy, including 124 patients with laparoendoscopic single-site total hysterectomy using the "chopstick technique" (TU-LESS group) and 230 patients with traditional laparoscopic total hysterectomy (TL group). The perioperative indexes of the two groups were compared, and the clinical data of 35 consecutive laparoendoscopic single-site total hysterectomy performed by the same physician were retrospectively analyzed; the learning curve was analyzed by CUSUM method.

Results

The basic data were balanced and comparable between the two groups. No statistical differences between the TU-LESS group and TL group: operative time and intraoperative bleeding [131 (102, 155) min vs. 120 (90, 150) min, 100 (100, 200) ml vs. 100 (80, 150) ml]. There was no statistical difference between postoperative exhaust time, visual analogue scale(VAS) score at 12 h and 24 h after operation, and perioperative complications (P>0.05). However, The postoperative hospital stay was shorter in the TU-LESS group than in the TL group, and the difference was statistically significant (P<0.05). The CUSUM analysis showed that the fitting curve reached the peak of 11 surgical cases, which was divided into two stages. Cases 1 to 11 were the first stage (initial learning stage) and cases 12 to 35 were the second stage (consolidation practice stage). The operation time of the two stages was (137.2 ± 37.6) min and (107.3 ± 31.7) min respectively, The operation time in the second stage was significantly shortened, and the difference was statistically significant (P<0.05).

Conclusion

Laparoendoscopic single-site total hysterectomy using the "chopstick technique" has no less perioperative outcomes than traditional laparoscopic surgery. Surgical skills were improved after 11 cases, which was manifested by shortened operation time.

Key words: Chopstick technique, Transumbilical laparoendoscopic single-site surgery, Hysterectomy, Learning curve
表1 两组患者一般资料比较
  TU-LESS组(n＝124) TL组(n＝230) 统计参数 P值
年龄(岁) 47(44，50) 47(45，49) Z＝－0.278 0.781
BMI(kg/m2) 23.27(21.96，25.80) 23.9(21.9，25.8) Z＝－0.676 0.499
子宫大小[n(%)]     χ2＝1.028 0.311
<12周 89(71.8) 153(66.5)    
≥12周 35(28.2) 77(33.5)    
产次 1(1，2) 2(1，2) Z＝－1.349 0.177
盆腹腔手术史[n(%)]     χ2＝0.176 0.675
无手术史 77(62.1) 148(64.3)    
有手术史 47(37.9) 82(35.7)    
表2 两组患者围术期指标对比
  TU-LESS组(n＝124) TL组(n＝230) 统计参数 P值
手术时间(min) 131(102，155) 120(90，150) Z＝－1.777 0.075
术中出血量(ml) 100(100，200) 100(80，150) Z＝－1.156 0.248
术后肛门首次排气时间[n(%)]     χ2＝0.028 0.867
12～24 h 35(28.2) 63(27.4)    
24～36 h 89(71.8) 167(72.6)    
术后12 h VAS评分(分) 3(2，3) 3(2，3) Z＝－0.522 0.602
术后24 h VAS评分(分) 2(2，2) 2(2，2) Z＝－1.395 0.163
术后住院天数(d) 4(3，4) 4(4，5) Z＝－3.12 0.002
术后发热[n(%)] 3(2.4) 2(0.9) χ2＝0.500 0.480
术中出血≥500 ml[n(%)] 3(2.4) 7(3.0) χ2＝0.000 0.998
图1 "筷子技术"用于经脐单孔腹腔镜全子宫切除术的学习曲线注：A.手术序数间与手术时间关系图；B.手术序数与手术时间CUSUM值间拟合曲线；C.初始学习阶段的CUSUM拟合图；D.巩固练习阶段的CUSUM拟合图。
表3 "筷子技术"用于经脐单孔腹腔镜全子宫切除术患者不同阶段的临床资料对比
变量 初始学习阶段(n＝11) 巩固练习阶段(n＝24) 统计参数 P值
年龄(±s,岁) 45.3±4.7 47.8±6.7 t＝－1.120 0.271
孕次(±s,次) 2.8±1.0 3.5±1.4 t＝－1.559 0.128
产次(±s,次) 1.5±0.5 1.7±0.9 t＝－0.713 0.480
BMI(±s, kg/m2) 24.2±3.62 24.0±2.56 t＝0.213 0.833
诊断[n(%)]     χ2＝5.857 0.2558
宫颈高级别病变 3 (27.3) 5 (20.8)    
子宫肌瘤 4 (36.4) 9 (37.5)    
子宫腺肌病 2 (18.2) 9 (37.5)    
子宫内膜病变 0 1 (4.2)    
其他 2 (18.2) 0    
子宫大小[n(%)]     χ2＝1.952 0.162
<12周 10 (90.9) 17 (70.8)    
≥12周 1 (9.1) 7 (29.2)    
手术范围[n(%)]     χ2＝8.702 0.019
全子宫 8 (72.7) 5 (20.8)    
全子宫＋双输卵管 2 (18.2) 13 (54.2)    
全子宫＋双附件 1 (9.1) 6 (25.0)    
手术时间(±s, min) 137.2±37.6 107.3±31.7 t＝2.447 0.020
出血量(±s, ml) 111.8±40.5 103.7±62.6 t＝0.390 0.699
排气时间[n(%)]     χ2＝1.193 0.392
12～24 h 1 (9.1) 6 (25.0)    
24～36 h 10 (90.9) 18 (75.0)    
术后12 h VAS评分[n(%)]     χ2＝0.477 0.689
2分 4 (36.4) 6 (25.0)    
3分 7 (63.6) 18 (75.0)    
术后24 h VAS评分[n(%)]     χ2＝0.339 0.536
2分 10 (90.9) 23 (95.8)    
3分 1 (9.1) 1 (4.2)    
术后住院时间(±s, d) 3.6±0.8 3.8±0.8 t＝－1.014 0.318
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