INVESTIGATION OF VARIOUS OPERATING TIMES AND LEARNING CURVES FOR LAPAROSCOPIC NEPHRECTOMY AND NEPHROURETERECTOMY PERFORMED BY A SINGLE SURGEON UNDER THE GUIDANCE OF A CERTIFIED LAPAROSCOPIC SPECIALIST: IS QUALIFICATION FOLLOWING AT LEAST 20 SURGERIES APPROPRIATE?
○ Hidero Minami, Osamu Ueki, Kouhei Kwaguchi ,Yuji Maeda, Mikio Namiki
Department of Urology,Noto General Hospital,Nanao,Ishikawa,and Kanazawa university、Ishikawa,Kanazawa,Japan
Purpose:The Japanese Urological Association and Japanese Society of Endourology and ESWL established the Endoscopic Surgical Skill Qualification System (ESSQS) for urological laparoscopy in 2004. Skill is assessed by double-blind evaluation of an unedited DVD recording of the whole procedure. Urologists that have completed ≥20 laparoscopic surgeries (nephrectomy, adrenalectomy, pyeloplasty, partial nephrectomy) over 2 years (except cases ending in open conversion) can apply. However, compared with the required number of surgeries in other countries, 20 surgeries is a very small number. Thus, is a minimum of 20 surgeries appropriate?
Subjects and methods:DVD recordings of 28 surgeries involving laparoscopic nephrectomy or nephroureterectomy performed by a single surgeon (those who received their laparoscopic surgeon certification this year) under the guidance of the same certified laparoscopic specialist from September 2010 to March 2014 were investigated. The pneumoperitoneum time during each step of the surgery was divided into the respective motions according to each approach as follows
[retroperitoneal approach (n=17): removal of the flank pad from the start of abdominal insufflation, tapered extra-myofascial incision, renal artery avulsion and transection from the expansion of the posterior aspect of the kidney, renal vein avulsion and transection from the expansion of the anterior aspect of the kidney, adrenal transection (adrenalectomy), and confirmation of kidney isolation, and hemostasis].
[Transperitoneal approach (n=11): incision to the retroperitoneum and colon mobilization from the start of abdominal insufflation, approach toward the iliopsoas muscle and identification of the renal artery after the mobilization, renal artery avulsion and transection, renal vein avulsion and transection, adrenal gland transection (adrenalectomy), and confirmation of kidney isolation, and hemostasis].
Each approach was retrospectively analyzed. Surgeries were divided according to the number (≤10 or >10 surgeries; including laparoscopic adrenalectomy and pyeloplasty that were initiated from 2009). The overall pneumoperitoneum time, time required for each step, and amount of bleeding were statistically investigated for any significant changes.
Results:Regarding the overall pneumoperitoneum time (both approaches combined), the >10 surgeries group (mean±SD: 169.1±33.8 min) had significantly shorter times compared with the ≤10 surgeries group (mean±SD: 239±27.9 min) (p<0.001). Regarding the retroperitoneal approach, the time required for removal of the flank pad was significantly shorter in the >10 surgeries group than in the ≤10 surgeries group (≤10 surgeries group, mean±SD: 32.4±10.8 min; >10 surgeries group, mean ± SD: 17.2±4.1 min) (p<0.001). With the transperitoneal approach, the time required for renal artery avulsion and transection was significantly shortened. (≤10 surgeries group, mean±SD: 42.5±3.5 min; >10 surgeries group, mean±SD: 20.7±8.5 min) (p<0.01).
Regarding other motions in both approaches, the time required was shortened, although not significantly.
The amount of bleeding was lesser in the >10 surgeries group for both approaches, although this was not significant. Retroperitoneal approach: ≤10 surgeries group, mean±SD: 60.71±71.20 ml; >10 surgeries group, mean±SD: 32.5±50.84 ml) (p=0.38); transperitoneal approach: ≤10 surgeries group, mean±SD: 75±21.21 ml; >10 surgeries group, mean±SD: 56.44±61.63 ml) (p=0.69).
Discussion:One factor behind this may have been that reduction, although not statistically significant, in time for all motions increased the tempo of the procedure, leading to a significant reduction in overall pneumoperitoneum time.
The reason for significant reduction in time not being observed for all motions may have been due to time for the procedure varying because of individual variation amongst patients, and consciousness of the ESSQS test causing subjects to perform more careful ablating taking anatomical membrane structures into account, and more thorough blood stanching.
Moreover, in the >10 surgeries group period, a dry box had been purchased, training time increased and spatial perception may also have improved so the subjects’ level of understanding of anatomy may also have increased.
Conclusion:Laparoscopic surgery under the guidance of a certified laparoscopic specialist significantly shortened the surgical time by improving the pace of surgery. Moreover, a minimum requirement of 20 surgeries to obtain a qualification was considered appropriate.