Experiencia y curva de aprendizaje de apendicectomía y colecistectomía laparoscópica de los residentes de cirugía general en un hospital latinoamericano
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abr 10, 2019
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Resumen
Introducción: La cirugía laparoscópica ha revolucionado el manejo quirúrgico de los pacientes y ha generado una necesidad de capacitación en el área. El rendimiento en la vida real es lo que permite una determinación global de las competencias en un procedimiento y establece un método de formación. El objetivo de este estudio es describir la evolución en la experiencia quirúrgica de un grupo de residentes de cirugía general. Metodología: Estudio observacional analítico de cohorte retrospectiva en el Hospital Universitario San Ignacio. Incluyó 4191 procedimientos realizados, divididos en 1045 apendicectomías laparoscópicas (AL) y 3146 colecistectomías laparoscópicas (CL), realizadas por un total de 52 residentes entre enero de 2008 y diciembre de 2014. Resultados: Tanto en AL como en CL se observó un aumento en el número de procedimientos anuales. Al comparar los tiempos promedios de AL por año de residencia, se observó una tendencia a la disminución en la mediana a medida que el residente era mayor. Las complicaciones intraoperatorias fueron del 0,77 % para AL y del 1,9 % para CL. La complicación postoperatoria más frecuente fue infección del sitio operatorio con una mortalidad menor al 0,5 %. Conclusión: Los resultados evocan la necesidad de continuar con programas de residencia que proporcionen preparación adecuada en el abordaje laparoscópico, posiblemente con exposición cada vez más temprana a procedimientos mínimamente invasivos.
Keywords
learning curve, laparoscopic cholecystectomy, laparoscopic appendectomy, residentscurva de aprendizaje, colecistectomía laparoscópica, apendicectomía laparoscópica, residentes
References
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2. McCoy AC, Gasevic E, Szlabick RE, Sahmoun AE, Sticca RP. Are open abdominal procedures a thing of the past?: An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ. 2013;70(6):683-9. http://dx.doi.org/10,1016/j.jsurg.2013,09,002
3. Shetty S, Zevin B, Grantcharov TP, Roberts KE, Duffy AJ. Perceptions, training experiences, and preferences of surgical residents toward laparoscopic simulation training: A resident survey. J Surg Educ. 2014;71(5):727-33. http://dx.doi.org/10,1016/j.jsurg.2014,01,006
4. Henao O, Escallón J, Green J, Farcas M, Sierra JM, Sánchez W, et al. Fundamentos de cirugía laparoscópica en Colombia empleando telesimulación: una herramienta adicional para la formació integral de cirujanos. Biomédica. 2013;33(1):1-24.
5. Priego JP, Lobo ME, Rodríguez VG, Cabañas MJ, Peromingo FR, Fresnada MV. ¿Es adecuada la formación del residente en cirugía laparóscopica? Rev Chil Cirugía. 2008;60:418-23.
6. Fahrner R, Turina M, Neuhaus V, Schöb O. Laparoscopic cholecystectomy as a teaching operation: Comparison of outcome between residents and attending surgeons in 1,747 patients. Langenbeck’s Arch Surg. 2012;397(1):103-10. https://doi.org/10,1007/s00423-011-0863-y
7. Lekawa M, Shapiro SJ, Gordon LA, Rothbart J, Hiatt JR. The laparoscopic learning curve. Surg Laparosc Endosc [Internet]. 1995 Dec [citado 2016 May 30];5(6):455-8. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/8611992
8. Shabtai M, Rosin D, Zmora O, Munz Y, Scarlat A, Shabtai EL, et al. The impact of a resident’s seniority on operative time and length of hospital stay for laparoscopic appendectomy: Outcomes used to measure the resident's laparcoscopic skills. Surg Endosc Other Interv Tech. 2004;18(9):1328-30.
9. Watanabe Y, Bilgic E, Lebedeva E, McKendy KM, Feldman LS, Fried GM, et al. A systematic review of performance assessment tools for laparoscopic cholecystectomy. Surg Endosc [Internet]. 2016;30(3):832-44. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/26092014
10. Harrison VL, Dolan JP, Pham TH, Diggs BS, Greenstein AJ, Sheppard BC, et al. Bile duct injury after laparoscopic cholecystectomy in hospitals with and without surgical residency programs: Is there a difference? Surg Endosc Other Interv Tech. 2011;25(6):1969-74.
11. Koulas SG, Tsimoyiannis J, Koutsourelakis I, Zikos N, Pappas-Gogos G, Siakas P, et al. Laparoscopic cholecystectomy performed by surgical trainees. JSLS [Internet]. 2006;10(4):484-7. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3015736&tool=pmcentrez&rendertype=abstract
12. Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al. TG13: Updated Tokyo GUIDELINES for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci [Internet]. 2013 Jan [citado 2016 May 30];20(1):1-7. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/23307006
13. Mercado MA, Domínguez I. Classification and management of bile duct injuries. World J Gastrointest Surg [Internet]. 2011;3(4):43-8. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3083499&tool=pmcentrez&rendertype=abstract
14. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211(1):132-8. http://dx.doi.org/10,1016/j.jamcollsurg.2010,02,053
15. Carson JS, Smith L, Are M, Edney J, Azarow K, Mercer DW, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: Implications for surgical skills curricula development? Am J Surg. 2011;202(6):720-6. http://dx.doi.org/10,1016/j.amjsurg.2011,06,045
16. Chung RS, Ahmed N. The impact of minimally invasive surgery on residents’ open operative experience: analysis of two decades of national data. Ann Surg [Internet]. 2010 Feb [citado 2016 May 8];251(2):205-12. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/19858698
17. Jolley J, Lomelin D, Simorov A, Tadaki C, Oleynikov D. Resident involvement in laparoscopic procedures does not worsen clinical outcomes but may increase operative times and length of hospital stay. Surg Endosc Other Interv Tech. 2015;1-9. http://dx.doi.org/10,1007/s00464-015-4674-z
18. Rattner DW, Apelgren KN, Eubanks WS. The need for training opportunities in advanced laparoscopic surgery. Surg Endosc [Internet]. 2001 Oct [citado 2016 May 31];15(10):1066-70. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/11727071
19. Pariani D, Fontana S, Zetti G, Cortese F. Laparoscopic cholecystectomy performed by residents: a retrospective study on 569 patients. Surg Res Pract [Internet]. 2014;2014:912143. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4208583&tool=pmcentrez&rendertype=abstract
20. Lin YY, Shabbir A, So JBY. Laparoscopic appendectomy by residents: Evaluating outcomes and learning curve. Surg Endosc Other Interv Tech. 2010;24(1):125-30.
21. Advani V, Ahad S, Gonczy C, Markwell S, Hassan I. Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J Surg. 2012;203(3):347-52. http://dx.doi.org/10,1016/j.amjsurg.2011,08,015
22. Gifford E, Kim DY, Nguyen A, Kaji AH, Nguyen V, Plurad DS, et al. The effect of residents as teaching assistants on operative time in laparoscopic cholecystectomy. Am J Surg. 2016;211(1):288-93. http://dx.doi.org/10,1016/j.amjsurg.2015,06,019
23. Schwartz SI, Yaghoubian AT, Andacheh ID, Green SH, Falor AE, Kaji AH, et al. Senior residents as teaching assistants during laparoscopic cholecystectomy in the 80-hour workweek era: Effect on biliary injury and overall complication rates. J Surg Educ. 2013;70(6):796-9. http://dx.doi.org/10,1016/j.jsurg.2013,09,011
24. Kauvar DS, Braswell A, Brown BD, Harnisch M. Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res [Internet]. 2006 May 15 [citado 2016 May 31];132(2):159-63. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/16412471
25. Böckler D, Geoghegan J, Klein M, Weissmann Q, Turan M, Meyer L, et al. Implications of laparoscopic cholecystectomy for surgical residency training. JSLS [Internet]. Jan [citado 2016 May 31];3(1):19-22. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3015346&tool=pmcentrez&rendertype=abstract
26. Lim SH, Salleh I, Poh BK, Tay KH. Laparoscopic cholecystectomy: an audit of our training programme. ANZ J Surg [Internet]. 2005 May [citado 2016 May 31];75(4):231-3. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/15839972
27. Garg CP, Vaidya BB, Chengalath MM. Efficacy of laparoscopy in complicated appendicitis. Int J Surg [Internet]. 2009 Jul [citado 2016 May 31];7(3):250-2. Disponible en: http://europepmc.org/abstract/med/19393776
28. Lucena Olavarrieta JR, Coronel P. Formación del cirujano en técnicas quirúrgicas laparoscópicas. Rev la Fac Med [Internet]. [citado 2016 May 31];29(2):97-102. Disponible en: http://www.scielo.org.ve/scielo.php?script=sci_arttext&pid=S0798-04692006000200001&lng=es&nrm=iso&tlng=es
29. Long KL, Spears C, Kenady DE, Scott Roth J. Implementation of a low-cost laparoscopic skills curriculum in a third-world setting. J Surg Educ. 2014;71(6):860-4. http://dx.doi.org/10,1016/j.jsurg.2014,05,004
2. McCoy AC, Gasevic E, Szlabick RE, Sahmoun AE, Sticca RP. Are open abdominal procedures a thing of the past?: An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ. 2013;70(6):683-9. http://dx.doi.org/10,1016/j.jsurg.2013,09,002
3. Shetty S, Zevin B, Grantcharov TP, Roberts KE, Duffy AJ. Perceptions, training experiences, and preferences of surgical residents toward laparoscopic simulation training: A resident survey. J Surg Educ. 2014;71(5):727-33. http://dx.doi.org/10,1016/j.jsurg.2014,01,006
4. Henao O, Escallón J, Green J, Farcas M, Sierra JM, Sánchez W, et al. Fundamentos de cirugía laparoscópica en Colombia empleando telesimulación: una herramienta adicional para la formació integral de cirujanos. Biomédica. 2013;33(1):1-24.
5. Priego JP, Lobo ME, Rodríguez VG, Cabañas MJ, Peromingo FR, Fresnada MV. ¿Es adecuada la formación del residente en cirugía laparóscopica? Rev Chil Cirugía. 2008;60:418-23.
6. Fahrner R, Turina M, Neuhaus V, Schöb O. Laparoscopic cholecystectomy as a teaching operation: Comparison of outcome between residents and attending surgeons in 1,747 patients. Langenbeck’s Arch Surg. 2012;397(1):103-10. https://doi.org/10,1007/s00423-011-0863-y
7. Lekawa M, Shapiro SJ, Gordon LA, Rothbart J, Hiatt JR. The laparoscopic learning curve. Surg Laparosc Endosc [Internet]. 1995 Dec [citado 2016 May 30];5(6):455-8. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/8611992
8. Shabtai M, Rosin D, Zmora O, Munz Y, Scarlat A, Shabtai EL, et al. The impact of a resident’s seniority on operative time and length of hospital stay for laparoscopic appendectomy: Outcomes used to measure the resident's laparcoscopic skills. Surg Endosc Other Interv Tech. 2004;18(9):1328-30.
9. Watanabe Y, Bilgic E, Lebedeva E, McKendy KM, Feldman LS, Fried GM, et al. A systematic review of performance assessment tools for laparoscopic cholecystectomy. Surg Endosc [Internet]. 2016;30(3):832-44. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/26092014
10. Harrison VL, Dolan JP, Pham TH, Diggs BS, Greenstein AJ, Sheppard BC, et al. Bile duct injury after laparoscopic cholecystectomy in hospitals with and without surgical residency programs: Is there a difference? Surg Endosc Other Interv Tech. 2011;25(6):1969-74.
11. Koulas SG, Tsimoyiannis J, Koutsourelakis I, Zikos N, Pappas-Gogos G, Siakas P, et al. Laparoscopic cholecystectomy performed by surgical trainees. JSLS [Internet]. 2006;10(4):484-7. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3015736&tool=pmcentrez&rendertype=abstract
12. Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al. TG13: Updated Tokyo GUIDELINES for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci [Internet]. 2013 Jan [citado 2016 May 30];20(1):1-7. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/23307006
13. Mercado MA, Domínguez I. Classification and management of bile duct injuries. World J Gastrointest Surg [Internet]. 2011;3(4):43-8. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3083499&tool=pmcentrez&rendertype=abstract
14. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211(1):132-8. http://dx.doi.org/10,1016/j.jamcollsurg.2010,02,053
15. Carson JS, Smith L, Are M, Edney J, Azarow K, Mercer DW, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: Implications for surgical skills curricula development? Am J Surg. 2011;202(6):720-6. http://dx.doi.org/10,1016/j.amjsurg.2011,06,045
16. Chung RS, Ahmed N. The impact of minimally invasive surgery on residents’ open operative experience: analysis of two decades of national data. Ann Surg [Internet]. 2010 Feb [citado 2016 May 8];251(2):205-12. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/19858698
17. Jolley J, Lomelin D, Simorov A, Tadaki C, Oleynikov D. Resident involvement in laparoscopic procedures does not worsen clinical outcomes but may increase operative times and length of hospital stay. Surg Endosc Other Interv Tech. 2015;1-9. http://dx.doi.org/10,1007/s00464-015-4674-z
18. Rattner DW, Apelgren KN, Eubanks WS. The need for training opportunities in advanced laparoscopic surgery. Surg Endosc [Internet]. 2001 Oct [citado 2016 May 31];15(10):1066-70. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/11727071
19. Pariani D, Fontana S, Zetti G, Cortese F. Laparoscopic cholecystectomy performed by residents: a retrospective study on 569 patients. Surg Res Pract [Internet]. 2014;2014:912143. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4208583&tool=pmcentrez&rendertype=abstract
20. Lin YY, Shabbir A, So JBY. Laparoscopic appendectomy by residents: Evaluating outcomes and learning curve. Surg Endosc Other Interv Tech. 2010;24(1):125-30.
21. Advani V, Ahad S, Gonczy C, Markwell S, Hassan I. Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J Surg. 2012;203(3):347-52. http://dx.doi.org/10,1016/j.amjsurg.2011,08,015
22. Gifford E, Kim DY, Nguyen A, Kaji AH, Nguyen V, Plurad DS, et al. The effect of residents as teaching assistants on operative time in laparoscopic cholecystectomy. Am J Surg. 2016;211(1):288-93. http://dx.doi.org/10,1016/j.amjsurg.2015,06,019
23. Schwartz SI, Yaghoubian AT, Andacheh ID, Green SH, Falor AE, Kaji AH, et al. Senior residents as teaching assistants during laparoscopic cholecystectomy in the 80-hour workweek era: Effect on biliary injury and overall complication rates. J Surg Educ. 2013;70(6):796-9. http://dx.doi.org/10,1016/j.jsurg.2013,09,011
24. Kauvar DS, Braswell A, Brown BD, Harnisch M. Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res [Internet]. 2006 May 15 [citado 2016 May 31];132(2):159-63. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/16412471
25. Böckler D, Geoghegan J, Klein M, Weissmann Q, Turan M, Meyer L, et al. Implications of laparoscopic cholecystectomy for surgical residency training. JSLS [Internet]. Jan [citado 2016 May 31];3(1):19-22. Disponible en: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3015346&tool=pmcentrez&rendertype=abstract
26. Lim SH, Salleh I, Poh BK, Tay KH. Laparoscopic cholecystectomy: an audit of our training programme. ANZ J Surg [Internet]. 2005 May [citado 2016 May 31];75(4):231-3. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/15839972
27. Garg CP, Vaidya BB, Chengalath MM. Efficacy of laparoscopy in complicated appendicitis. Int J Surg [Internet]. 2009 Jul [citado 2016 May 31];7(3):250-2. Disponible en: http://europepmc.org/abstract/med/19393776
28. Lucena Olavarrieta JR, Coronel P. Formación del cirujano en técnicas quirúrgicas laparoscópicas. Rev la Fac Med [Internet]. [citado 2016 May 31];29(2):97-102. Disponible en: http://www.scielo.org.ve/scielo.php?script=sci_arttext&pid=S0798-04692006000200001&lng=es&nrm=iso&tlng=es
29. Long KL, Spears C, Kenady DE, Scott Roth J. Implementation of a low-cost laparoscopic skills curriculum in a third-world setting. J Surg Educ. 2014;71(6):860-4. http://dx.doi.org/10,1016/j.jsurg.2014,05,004
Cómo citar
Cortés Murgueitio, N., Cuevas, L., Díaz Castrillon, C. E., Pinzón, F., & Molina, G. R. (2019). Experiencia y curva de aprendizaje de apendicectomía y colecistectomía laparoscópica de los residentes de cirugía general en un hospital latinoamericano. Universitas Medica, 60(2), 1–10. https://doi.org/10.11144/Javeriana.umed60-2.curv
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