Lesiones de la Vía Biliar Durante la Colecistectomía Laparoscópica: Discusión

A pesar del bajo número de cirujanos encuestados, este estudio muestra que el entrenamiento en cirugía laparoscópica durante la residencia está relacionado con menor incidencia de lesiones de la vía biliar; no se determinó el papel de la colangiografía como medida preventiva, pues ninguno de los cirujanos encuestados la realiza en forma rutinaria. Asimismo, puede deducirse que hay una subestimación de la incidencia real de lesiones, pues algunos encuestados no determinaron en forma exacta el número de lesiones ocurridas durante su vida profesional.

De esta manera es difícil conocer la magnitud del problema, pues es bajo el número de encuestados en relación con la cantidad de cirujanos que realiza colecistectomía por laparoscopia en el país. Sin embargo, podemos concluir que el entrenamiento en laparoscopia básica está relacionado con una menor incidencia de lesiones de la vía biliar, posiblemente en relación con la superación de la curva de aprendizaje en forma más rápida.

Además de lo anterior, la diferencia no es marcadaf en ambos grupos, pues posiblemente el número de colecistectomías no varíe mucho entre los dos grupos; esto es indicador de que además de la curva de aprendizaje pueden y existen otros factores como las dificultades técnicas y anatómicas no evaluadas en esta encuesta.

La localización de las lesiones reportadas es similar a las informadas en la literatura mundial (19-24), en su mayoría en el conducto hepático común por debajo de la bifurcación de los hepáticos; esto es igual en ambos grupos, lo que podría indicar que el patrón del daño sería consecuencia del procedimiento y sus dificultades, más que del entrenamiento del cirujano (24-29). La mayoría de los cirujanos del grupo B que reportó lesiones hicieron el diagnóstico en el intraoperatorio; esto podría reflejar mayor conocimiento de la anatomía biliar, disección más cuidadosa u otros factores como el equipo y el instrumental. El manejo de las lesiones se hizo en su mayoría en forma temprana, y esto está en relación con un mejor pronóstico a largo plazo, al igual que con menores costos (30).

Aunque la necesidad de remisión reportada fue baja, creemos que esto podría estar subestimado, pues no se conoce la necesidad real de remisión de los pacientes a largo plazo.

Conclusiones

Uno de los beneficios del entrenamiento formal o residencia es la capacidad de aprender en forma directa y supervisada, evitando así improvisación o fallas en la técnica quirúrgica que pudiera ser responsable de la aparición de complicaciones.

Luego de la llegada a nuestro medio de la colecistectomía por laparoscopia, muchos cirujanos adoptaron el procedimiento sin la supervisión directa y esto hizo que muchos cometieran errores en la identificación adecuada de la anatomía, resultando en lesiones biliares.

Presumiendo que se está subestimando la real magnitud del problema creemos que la incidencia de lesiones de la vía biliar es mayor, por lo tanto, se necesita la realización de estudios con un mayor número de encuestados, de carácter obligatorio y multiinstitucional, que permitan evaluar el estado del conocimiento en cirugía laparoscópica de los cirujanos colombianos actualmente en ejercicio.

Bile Duct Lesions during Laparoscopic Cholecystectomy.
Technical, Anatomic and Educational Factors

Abstract

Objective: To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to assess the anatomic and technical details of bile duct injuries by surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency.

Summary background data: Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury of the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon’s experience. It is not known whether trainingin laparoscopic cholecystectomy during surgery residency influences this pattern.

Methods: An anonymous questionnaire was mailed to 250 surgeons across Colombia who completed an approved residency between 1980 and 1990 (group A) and to surgeons who completed resideney between 1992 and 1998 (group

B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

Results: 64 of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 13 surgeons (38.2%) in group A and 6 surgeons (20%) in group B. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were more likely to report one or more biliary injuries than their counterparts in group B. Bile duct injuries were more likely to be identified during surgery.

Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 10% of injuries were referred to another center for repair.

Conclusions: Accepting that the survey bias underestimates the true incidence of bile duct injuries, residency training decreases the likelihood of injuring of a bile duct, but only by decreasing the frequency of early “learning curve” injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Key words: laparoscopic cholecystectomy, biliary tract, intraoperative complications, education medical graduate.

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ANDRÉS FELIPE ACEVEDO
BETANCUR, MD
Correo electrónico:
aacevedo@epm.net.co
Medellín, Colombia