摘要目的 分析具有一定腹腔镜手术基础的外科医生如何过渡至熟练掌握腹腔镜结直肠手术.方法 自2009年12月至2012年2月,一位具有一定腹腔镜基础和年手术量的胃肠外科医生连续、非选择地实施腹腔镜结直肠手术189例,选取其中的170例规范化结直肠癌根治术,按右半结肠癌、乙状结肠癌、上段直肠癌、低位直肠癌、经腹会阴联合直肠癌切除术等进行分类.根据前后时间段将每种术式分为前后两个阶段,从手术时间、术中出血量、淋巴结获取率,以及术中副损伤和术后并发症发生率等方面进行比较分析.结果 对根治性右半结肠手术,前期实施的D2手术在手术时间方面与其后实施的D3手术没有差异,但术中出血量较多、淋巴结获取数量较少.前期实施的高位直肠前切除术,耗时明显长于其后的手术,术中出血量没有区别.按TME原则实施的低位前切除术,后期手术时间明显较短,出血少.乙状结肠癌手术和Miles手术,手术时间在前后时间段有缩短的趋势.所有的术式在前后时间段所清扫的淋巴结数目未发现有差异.中转开腹率为1.05％.有8例患者在术中发生了不良事件,包括肠管损伤3例、远切缘不足2例、术中出血2例、阴道损伤1例.术后并发症主要包括尿潴留5.82％,肠梗阻4.76％,吻合口漏4.24％,会阴部感染23.08％ (6/26),伤口裂开2.65％,消化道出血1.59％,腹腔内感染1.06％.其中尿潴留和吻合口漏主要发生在低位直肠手术中,近期手术后发生吻合口漏的几率有减少的趋势.结论 具有一定腹腔镜技术基础和年结直肠手术量的结直肠专科医生,对不同结直肠手术方式,再经过15 ～ 25例的独立操作后可以达到较为熟练的稳定阶段.

abstractsObjective Laparoscopic colorectal surgery is a skill-dependent procedure.The present study aims to analyze the learning curve of a properly trained surgeon,with basic laparoscopic techniques,to become skillful in performing laparoscopic colorectal operations.Methods A series of non-selective,consecutive 189 cases of laparoscopic colorectal surgery were accomplished,from December 2009 to Feburary 2012,by one surgeon with years of skilled technique in laparoscopic cholecystectomy,rich experience in assisting laparoscopic colorectal surgery,and experience of aproximately 180 procedures of gastric and colorectal surgery annually.170 out of 189 procedures were radical operations for colorectal neoplasma,including right colectomies in 28 cases,left colectomies in 5 cases,sigmoidectomies in 28 cases,high Dixon procedures in 45 cases,low Dixon (total mesorectal excision,TME) procedures in 41 cases and Miles procedure in 23 cases.19 other patients underwent combined procedures for multi-primary tumors or inflammatory enteritis.All these procedures were analyzed according to time span (the earlier half and later half) in respect to length of surgery,intraoperative blood loss,number of lymph nodes retrieved,intraoperative events and postoperative complications.Results For radical right colectomy,the D2 dissection conducted in the earlier phase (n =8) had the similar length of surgery,more blood loss and less LN retrieval,compared with the D3 dissection conducted in recent phase (n =20).The earlier performed high Dixon procedures (n =22) consumed longer time than the later procedures (n =23) consumed,but with similar blood loss and LN retrieval.Low Dixon (TME) procedures showed significant differences in length of surgery and blood loss relative to time span.Recently performed simoidectomy and Miles procedures showed a trend of shorter time consumed compared with earlier performed procedures.Conversion ratio to open surgery was 1.05％.Adverse effects occurred in 8 cases of surgeries,including intestinal injury (3/189),insufficient distal margin (2/189),intraoperative bleeding (2/189) and vaginal injury (1/76).There was no operative death.Chief complications included urinary retention 5.82％,ileus 4.76％,anastomotic leak 4.24％,perineal infection 23.08％ (6/26),wound dehiscence 2.65％,gastrointestinal bleeding 1.59％,peritoneal infection 1.06％.Surgery for distal rectum tended to have more complications,such as urinary retention,anastomotic leak and perineal infection.The later performed low Dixon procedures produced insignificantly fewer anastomotic leaks than those in the earlier phase.Conclusions For a trained surgeon with basic laparoscopic techniques,there are at least 15-25 cases of different procedures needed for him/her to become skilled to perform laparoscopic surgery.The learning curve should also depend on the annual number of colorectal surgeries.