单中心腹腔镜肝部分切除术学习曲线分析

doi:10.3877/cma.j.issn.1674-3946.2021.04.007

目的

探讨单中心腹腔镜肝部分切除术(LH)的学习曲线。

方法

学习曲线累计求和分析法分析2014年6月至2020年6月完成的118例LH一般资料。采用SPSS 22.0进行统计分析；采用Minitab17.0绘制CUSUM控制图及拟合曲线。当P≤0.05时判断曲线拟合成功，R²值判断拟合优度，R²值越接近1说明拟合度越好。

结果

手术时间累积和拟合曲线公式：CUSUM(n) ＝ 27.86+17.00 n-0.1938 n²+0.000415n²(n为病例数)，拟合系数R²＝0.963。据拟合曲线分析将118例腹腔镜肝部分切除术的学习曲线划分为三个阶段，早期组(1～36例)、中期组(37～88例)和后期组(89～118例)。后期组在手术时间(P<0.001)、术中出血量(P＝0.003)、术后住院时间(P<0.001)均优于其他两组，差异均有统计学意义；在中转开腹率(P＝0.336)、术后并发症发生率(P＝0.099)方面三组差异无统计学意义。

结论

积和分析法得出LH的学习曲线由三个特征性阶段组成，术者基本掌握LH需累积完成37～88例手术。

关键词: 肝切除术, 腹腔镜, 肝肿瘤, 学习曲线, 累积和分析法

Objective

To explore the learning curve of laparoscopic partial hepatectomy (LH) in single-center.

Methods

The general data of 118 cases of LH from June 2014 to June 2020 were analyzed by using learning curve analysis. SPSS 22.0 were used for statistical analysis. Minitab 17.0 was used to draw CUSUM control chart and fitting curve. When P≤0.05, the fitting curve was recognized as successful, and the R2 value was used to judge the goodness of fitting. The closer the R² value is to 1, the better the goodness of fitting is.

Results

The cumulative operative time and the fitting curve formula: CUSUM(n)=27.86+ 17.00 n-0.1938 n²+ 0.000415 n²(n is the number of cases), the fitting coefficient R²=0.963. According to the fitting curve analysis, the learning curve of laparoscopic partial hepatectomy was divided into three phases: the early phase group (1~36 cases), the middle phase group (37~88 cases) and the late phase group (89~118 cases). The operative time (P<0.001), intraoperative blood loss (P=0.003) and postoperative time of hospitalization (P<0.001) in the late phase group were better than those in the other two phase groups, with statistical significant difference. There were no significant difference in conversion rate (P=0.336) and the incidence of postoperative complications (P=0.099) among the three groups.

Conclusion

Cumulation and analysis show that the learning curve of laparoscopic partial hepatectomy consists of three characteristic phases. The operator basically mastered LH need to complete a cumulative total of 37~88 cases.

Key words: Hepatectomy, Laparoscopes, Liver neoplasms, Learning curve, Cumulation and analysis

表1 118例肝占位行LH手术患者医生学习曲线不同阶段的基线资料[(±s)，例]

组别	例	年龄(岁)	BMI (kg/m²)	性别	手术方式	病理类型
组别	例	年龄(岁)	BMI (kg/m²)	男/女	A/B/C/D	恶性/良性
前期组	36	50.8±6.4	21.4±1.6	27/9	18/9/8/1	30/6
中期组	52	52.1±6.2	21.9±1.7	41/11	21/16/12/3	47/5
后期组	30	51.4±6.3	22.1±2.2	26/4	9/11/6/4	29/1
H/χ²		0.896	2.914	1.413	5.255	3.216
P值		0.639	0.233	0.493	0.512	0.200

表1 118例肝占位行LH手术患者医生学习曲线不同阶段的基线资料[(±s)，例]

组别	例	年龄(岁)	BMI (kg/m²)	性别	手术方式	病理类型
组别	例	年龄(岁)	BMI (kg/m²)	男/女	A/B/C/D	恶性/良性
前期组	36	50.8±6.4	21.4±1.6	27/9	18/9/8/1	30/6
中期组	52	52.1±6.2	21.9±1.7	41/11	21/16/12/3	47/5
后期组	30	51.4±6.3	22.1±2.2	26/4	9/11/6/4	29/1
H/χ²		0.896	2.914	1.413	5.255	3.216
P值		0.639	0.233	0.493	0.512	0.200

图1 手术时间累积和控制图

图2 LLR-CUSUM学习曲线拟合图

图3 学习曲线不同时期术中出血量变化

表2 118例肝占位行LH手术患者医生学习曲线不同阶段围术期观察指标[四分位间距(IQR)]

组别	例	手术时间(min)	术中出血量(ml)
前期组	36	130.8(127.9～143.1)	356.3(246.0～481.5)
中期组	52	118.5(110.1～130.0)	400.0(200.0～600.0)
后期组	30	106.0(100.0～118.1)	202.5(75.0～393.8)
H/χ²		30.386	11.407
P值		<0.001	0.003
组别	例	术后住院时间(d)	中转开腹(例)	术后并发症(例)
前期组	36	10.2(7.8～12.8)	2	2
中期组	52	11.0(8.0～13.2)	1	0
后期组	30	7.7(6.6～8.0)	0	0
H/χ²		27.494	2.182	4.634
P值		<0.001	0.336	0.099

表2 118例肝占位行LH手术患者医生学习曲线不同阶段围术期观察指标[四分位间距(IQR)]

组别	例	手术时间(min)	术中出血量(ml)
前期组	36	130.8(127.9～143.1)	356.3(246.0～481.5)
中期组	52	118.5(110.1～130.0)	400.0(200.0～600.0)
后期组	30	106.0(100.0～118.1)	202.5(75.0～393.8)
H/χ²		30.386	11.407
P值		<0.001	0.003
组别	例	术后住院时间(d)	中转开腹(例)	术后并发症(例)
前期组	36	10.2(7.8～12.8)	2	2
中期组	52	11.0(8.0～13.2)	1	0
后期组	30	7.7(6.6～8.0)	0	0
H/χ²		27.494	2.182	4.634
P值		<0.001	0.336	0.099

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Learning curve of laparoscopic hepatectomy: a single-center study

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Learning curve of laparoscopic hepatectomy: a single-center study