Study On The Learning Curve Of Laparoscopic Radical Gastrectomy For Gastric Cancer

Objective: Investigate the learning curve of laparoscopic radical gastrectomy forgastric cancer.,in order to provide reference for the gastrointestinal surgeons to passthe learning curve quickly, smoothly, and safely.Method: Clinical data of60patients undergoing laparoscopic radicalgastrectomy performed by the same team in our hospital from May2013to March2014was analyzed retrospectively.The patients were divided into six groups（groupA,B,C,D,E and F）according to the sequence of operation, with10cases in eachgroup.Using the concept of fast track surgery to treat the perioprative period.Theoperation time,blood loss,the number of lymph nodes resected,conversion to opensurgery,complications,postoperative time to get up of bed,time of bowel functionrecovery and time to eat semi-liquid diet were compared among the groups．SPSS18.0software was applied for statistical analysis.Results: No significant differences were found among the six groups ingender,age,gastrectomy approach,pTNM stages(P＞0.05).The operation time wasphased down,there were no differences between group A(248.80±24.24min）、B（239.50±31.96min）、C（229.00±5.68min）(P＞0.05)and no differences betweengroup D（184.80±15.72min）、E（171.20±16.80min）、F（164.00±13.30min）(P＞0.05),but there was significant difference between group A、B、C and group D、E、F(P＜0.05). The blood loss was also phased down from group A to group F,there weresignificant differences between group A（295.00±13.94ml）、B（249.00±19.55ml）、C（221.20±21.50ml） themselves and with other groups(P＜0.05),but there were nodifferences between group D（171.30±6.85ml）、E （162.20±4.16ml）and group E、F（154.30±4.14ml）(P＞0.05). Conversion to open surgery occurred in one case(groupB), the spleen was torn and hemorrhagic because of the splenic artery variation whenthe splenic hilus was seperated,resulting in an invalid laparoscopic hemostatic and aconvertion to laparotomy, and the total rate of conversion to open surgery was1.67%.Intraoperative complications occurred in group,A、B、C,with one case in each group,the vascular injury and hemorrhage occured in two cases (with one case in each B、Cgroup), one case was converted to laparotomy to hemostasis (group B), one casesucceeded in laparocopic hemostatic (group C);one case was subcutaneous emphysema and hypercapnia (group A) because the initial laparoscopic operation timewas longer, and was cured by given the Sodium Bicarbonate and a self-absorptionpostoperative; there were no significant differences in convertion to laparotomy andcomplications among the groups (P>0.05).The average number of lymph nodesresected was27.58±10.68, no significant differences were observed among the groups(P＞0.05).Due to the adoption of the concept of fast track surgery for theperioperative management, no significant differences were observed between thegroups in the postoperative time to get up of bed,time of bowel function recovery andtime to eat semi-liquid diet(P＞0.05).Postoperative complications were4cases, with1case in each group A、B、C、E,Among them,the pleural effusion occured in group Aand group E with one case in each group,one was a total gastrectomy patient,whichwas an irritation of the separation of gastrophrenic ligament and was self-absorptedafter a conservative treatment,another was transudate induced by postoperative lowprotein, and was cured by ultrasound guided puncture and drainage、SupplementaryHuman Albumin and strengthened nutrition support; one case occured in group B,which was a hemorrhage in abdominal wall induced by the pulled-off of the drainafter operation when going for toilet, and was hemostasis effectively by suture; onecase occured in group C, which was a small postoperative pancreatic leakage,and wascured by the full drainage and expectant treatment;the differences were notstatistically significant (P>0.05).The total complication rate was11.67%. There wasno death case.Conclusion: Although the laparoscopic radical gastrectomy is complicated,thosegastrointestinal surgeons with abundant experiences of open radical gastrectomy andother laparoscopic operation can achieve a more skilled degree after about30operations.To master the laparoscopic radical gastrectomy faster and more skilled,thereview of literature and our experience is to pay more attention to the learning curve:①c arrying out formal training and supervision in a planned way;②possessing theopen operation experiences and skilled laparoscopic operation technology;③payingattention to the grasp of operation indication;④understanding the characteristics oflaparoscopic anatomy fully;⑤developing a good psychological quality;⑥maintaininga fixed operation team relatively;⑦establishing a good operating environment;⑧constantly optimizing the operation steps;in addition,increasing the frequency ofoperation appropriately,accumulating in experience and quantity, and being diligent inlearning and communication,then to overcome the learning curve smoothly, safely andfast is hopeful.