Abstract

ACEVEDO BETANCUR, Andrés Felipe; LOPERA, Carlos; VERGNAUD, Jean Pierre  and  VASQUEZ, Jesús. Bile duct lesions during laparoscopic cholecystectomy. Technical, anatomic and educational factors. rev. colomb. cir. [online]. 2006, vol.21, n.2, pp.116-123. ISSN 2011-7582.

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. Considerando que se subestima la real incidencia de lesiones de la vía biliar, el entrenamiento durante la residencia disminuye su aparición, posiblemente en relación con la superación durante el entrenamiento de la curva de aprendizaje. Se demuestra la importancia de la implementación del entrenamiento en laparoscopia básica durante la residencia en cirugía general.

Keywords : laparoscopic cholecystectomy; biliary tract; intraoperative complications; education medical graduate.

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