New strategies to prevent laparoscopic bile duct injury - surgeons can learn from pilots
New strategies to prevent laparoscopic bile duct injury - surgeons can learn from pilots
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DOI：
10.1067/msy.2002.127681
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发表时间：
2002-11-01
期刊：
影响因子：
3.8
通讯作者：
Hugh, TB
中科院分区：
文献类型：
--
作者：
Hugh, TB
背景。胆管损伤是腹腔镜胆囊切除术 (LC) 最重要的并发症，在美国每年影响约 2000 名患者。传统的外科教学无法提供足够的胆外参考点。责备和羞辱的“个人方法”（与“系统方法”不同）显然未能成功控制这个问题。需要新的策略。航空和核电工业等高可靠性组织拥有完善的基于系统的错误预防程序，这些程序中使用的一些原理在腹腔镜手术中的应用值得评估。此外，一些历史悠久的保护胆管步骤的教学方法需要重新审视。对文献和作者提到的 34 例胆管损伤病例进行了回顾。对传统外科教学进行了评估，以确定其未能预防胆管损伤的原因。使用了新的胆外参考点。源自航空和海运业的防错策略经过修改后适用于 LC。这些原则已应用于一项前瞻性研究，该研究对 1 个手术室进行了 2000 次连续 LC，其中包括外科实习生的手术。结果。文献和病例回顾表明，胆道解剖结构的错误识别是胆管损伤的主要原因，并且四分之三的手术外科医生未能识别出损伤，这表明传统的外科教学为防止胆管错误识别提供了不足的参考点，发生了类似于导航错误的空间定向障碍，并且存在易导致错误的全身因素。应用了导航中使用的多种原理。应用了源自航空机组资源管理培训的“人的因素”教育原则。 2000 次 LC 手术中未发生胆管损伤。八名患者出现胆漏，但均在没有进一步手术干预的情况下康复。结论。腹腔镜胆管损伤继续以不可接受的速度发生。涉及航空和海运业采用的系统方法和使用原则的新策略在连续 2000 次 LC 中得到应用，没有胆管损伤。在手术室中应用常用的导航原理、使用胆外参考点（如鲁维埃沟）以及对外科医生进行人为因素教育，可以降低胆管损伤的频率。
Background. Injury to the bile ducts is the most important complication of laparoscopic cholecystectomy (LC), affecting approximately 2000 patients annually in the United States. Traditional surgical teaching fails to provide adequate extrabiliary reference points. A "Person approach" of blame and shame (as distinct from a "system approach") has evidently been unsuccessful in controlling this problem. New strategies are needed. High-reliability organizations such as aviation and the nuclear power industry have well-developed system-based error prevention programs,- the application to laparoscopic operations of some principles used in these programs merits evaluation. In addition, some time-honored teaching of steps to safeguard the bile duct needs to be re-examined.Methods. A review of the literature and of 34 cases of bile duct injury referred to the author was carried out. Traditional surgical teaching was evaluated to identify reasons why it has failed to prevent bile duct injury. New extrabiliary reference points were used. Error prevention strategies derived from the aviation and maritime industries were modified for application to LC. These principles have been applied in a prospective study of 2000 successive LCs carried out on 1 surgical unit, including operations by surgical trainees.Results. The literature and case review indicated that misidentification of biliary anatomy was the major cause of bile duct injury and the injury was unrecognized by the operating surgeon in 3 out of 4 cases, suggesting that traditional surgical teaching provides inadequate reference Points to prevent duct misidentification, that spatial disorientation analogous to navigation errors occurs, and that systemic factors predisposing to error are present. Several principles used in navigation were applied. "Human factors," educational principles derived from aviation crew resource management training, were applied. No bile duct injuries occurred in the 2000 LC operations. Eight patients had biliary leakage develop but all recovered without further surgical intervention.Conclusions. Laparoscopic bile duct injury continues to occur at an unacceptable rate. New strategies involving a system approach and using principles adopted by the aviation and maritime industries were applied in 2000 consecutive LCs without bile duct injury. The application in the operating room of commonly taught navigation principles, the use of extrabiliary reference points such as Rouviere's sulcus, and the introduction of human factors education for surgeons reduces the frequency of bile duct injury.