Medicina. Ahora los cirujanos pueden ensayar con simuladores como los pilotos

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n los años 90, los niños que jugaban a ser cirujanos solían pedirles a sus padres el juego Operación, que consistía en una caja de cartón con el dibujo de un paciente impreso en la parte superior. Este venía con varias aberturas rodeadas por una argolla metálica. Con una pinza del mismo material había que extraer del interior de la caja las partes que le causaban malestar al paciente. Cuando la pinza tocaba la circunferencia metálica, la lámina de cartón vibraba y se prendía una luz roja: el niño había perdido la partida.

Ese niño pudo haber sido Gustavo Mastroianni, hoy de 29 años, jefe de residentes del Hospital Italiano, sede San Justo, en la provincia de Buenos Aires. En este momento, Gustavo busca aumentar su destreza en el simulador de cirugía laparoscópica, una forma de operar que evita abrir el cuerpo del paciente. En su lugar, inflan la panza con dióxido de carbono y hacen tres incisiones pequeñas. Luego introducen dos pinzas y una cámara de fibra óptica.

La simulación quirúrgica se convirtió en una herramienta fundamental para la formación, la evaluación y la investigación médica en contextos que imitan situaciones reales.

Ahora, él tiene en sus manos las dos tenazas que valen alrededor de US$1000 cada una. Ambas atraviesan un torso de plástico junto con la cámara que proyecta sus movimientos en una pantalla. Debajo del plástico, hay un riñón de vaca y un chinchulín. El objetivo es practicar cómo hacer una unión entre la vía biliar y el intestino.

Las dos tenazas atraviesan un torso de plástico junto con la cámara que proyecta sus movimientos en una pantalla.
Las dos tenazas atraviesan un torso de plástico junto con la cámara que proyecta sus movimientos en una pantalla. Fuente: Brando – Crédito: Sebastián Pani

“Acá me concentro en la técnica. Acá no hay sangrado, acá no pasa nada. Entonces, cuando voy al escenario real, ya no me concentro en la técnica porque lo hago de manera mecánica y me puedo concentrar en lo externo, como puede ser un sangrado o la descompensación del paciente. Para mí, esta práctica es una gran herramienta“, asegura Mastroianni.

El Hospital Italiano cuenta con uno de los centros de simulación quirúrgica más avanzados del país. Esta práctica se convirtió en una herramienta fundamental para la formación, la evaluación y la investigación médica en contextos que imitan situaciones reales. En 2018 pasaron por sus simuladores 1964 residentes de distintas especialidades, que acumularon 10.260 horas de aprendizaje. Es decir que, entre todos los puestos de simulación, sumaron el equivalente a casi 17 meses de uso ininterrumpido.

Por el centro de simulación quirúrgica del Hospital Italiano, uno de los más avanzados de la región, ya pasaron unos 2000 residentes.

“Los procedimientos quirúrgicos, tradicionalmente, se hacían con el paciente, es decir, el médico joven se recibía, entraba a un sistema de residencia y ayudaba a operar. Luego de colaborar observando en varias cirugías, pasaba a la etapa en la que se involucraba en la cirugía bajo la supervisión directa de un cirujano experimentado que lo ayudaba. Y, así, se iba formando”, dice Esteban Langlois, de 53 años, director médico del Hospital.

"Dentro de cinco o seis años no va a ser ético que un médico opere a un paciente sin haber pasado por un laboratorio de simulación", dice Martín Palavecino.
“Dentro de cinco o seis años no va a ser ético que un médico opere a un paciente sin haber pasado por un laboratorio de simulación”, dice Martín Palavecino. Fuente: Brando – Crédito: Sebastián Pani

Langlois explica que hace ya casi dos décadas el mundo descubrió que esa no era la mejor manera para ganar experiencia porque había varios costos ocultos en ese aprendizaje: “Había un costo biológico, que lo sufría el paciente, porque esa cirugía demoraba más y el paciente estaba más tiempo anestesiado, y muchas veces no quedaba igual que si lo hubiera hecho el médico experimentado. Además, para las instituciones, también representaba un costo altísimo porque no es lo mismo hacer una operación de vesícula en 20 minutos que en una hora. La hora quirófano es lo más caro que hay”.

La nueva dimensión

En la actualidad, gran parte de las cirugías dentro de la zona abdominal, como la operación de vesícula, de hernia, la cirugía bariátrica para las personas obesas, e incluso el cáncer de riñón, se tratan con cirugía laparoscópica. Esto requiere una gran orientación espacial porque el cirujano va a manejar el bisturí, los hilos y las agujas con una pinza, y verá sus movimientos en una pantalla.

“Cuando se hacían cirugías abiertas, el cirujano se acostumbraba a trabajar con las manos. Ahora tenemos que manejar la bidimensionalidad en vez de la tridimensionalidad. Es muy distinto cuando tus movimientos solo los ves en una pantalla”, dice Juan Montagne, 31 años, especialista en cirugía torácica y uno de los principales impulsores del área de simulación médica del Hospital.

Los cirujanos tienen que aprender a manejar la bidimensionalidad en vez de la tridimensionalidad.
Los cirujanos tienen que aprender a manejar la bidimensionalidad en vez de la tridimensionalidad. Fuente: Brando – Crédito: Sebastián Pani

“Hay que entrenar la destreza de lo táctil en la capacidad de tensión de una sutura o de un tejido. Cuando uno empieza, tiende a ajustar de más o de menos, hasta que adquirís la tensión exacta. Esto lleva tiempo. Por eso, la simulación es fundamental”, explica Guillermo Arbues, 50 años, subjefe del servicio de cirugía.

Los primeros modelos de simulación comenzaron en Estados Unidos, donde el médico practicaba con animales antes de operar a una persona. La cuestión es que el animal también representaba un costo, entonces comenzaron a desarrollar modelos no animados para la práctica quirúrgica. Hoy, el camino es el siguiente: modelos no animados, luego pasan a trabajar con animales y, en una última instancia, con personas.

Los primeros modelos de simulación comenzaron en Estados Unidos, donde el médico practicaba con animales antes de operar a una persona.

“Nosotros también empezamos con animales y fuimos incorporando tecnología. El desarrollo, inicialmente, fue con fines quirúrgicos, pero ahora también hay simulación de procedimientos no quirúrgicos”, dice Langlois. Él se refiere, por ejemplo, a intubar a un paciente que sufre un paro cardiorrespiratorio: “Hay maniquíes que hasta simulan arritmias para que el médico tenga que evaluar de qué modo usar el desfibrilador”. También hay ejemplos de prácticas para procedimientos sencillos, como el de las enfermeras al poner el suero. Esto se entrena utilizando materiales plásticos que simulan la piel humana.

Futuro sintético

De nuevo en el Hospital Italiano de San Justo, una versión digital de Martín Palavecino, coordinador del área quirúrgica del Centro Universitario de Enseñanza basada en la Simulación (Cuesim), aparece en la pantalla de una notebook. Él está en Seattle, Estados Unidos. Fue a visitar uno de los centros de simulación quirúrgica más avanzados del mundo que está financiado por el Departamento de Defensa de ese país.

La simulación es el futuro de la educación médica.
La simulación es el futuro de la educación médica. Fuente: Brando – Crédito: Sebastián Pani

“Vine a conocer esta realidad que siempre es distinta, no es que sea mejor, porque ahí lo que tenemos no tiene nada que envidiarle a lo que tienen acá. Sí hay más disponibilidad de recursos económicos. La simulación es el futuro de la educación médica. Dentro de cinco o seis años no va a ser ético que un médico opere a un paciente sin haber pasado por un laboratorio como el que vos estás viendo”, dice Palavecino.

En el laboratorio donde se encuentra, los investigadores estudian los tejidos a partir de órganos humanos, para que luego todos los materiales sintéticos posean las mismas propiedades que los reales. “La idea es hacer un páncreas sintético o cualquier otro órgano para no tener que sacrificar animales o usar cadáveres de personas”.

“Hay muchas más muertes por errores quirúrgicos que por errores en aviones, y aún no se ha dicho que un médico debe pasar muchas horas en el simulador antes de que pueda tocar a un paciente, como sucede con un piloto. En Estados Unidos, la tercera causa de muerte es el error médico; la deuda que tiene la medicina con los pacientes, en este sentido, es muy grande”, concluye.

Aeronáutica y medicina

La industria que más ha profundizado en la simulación de situaciones para ganar práctica en la técnica y evitar accidentes es la aeronáutica. De hecho, en Aerolíneas Argentinas, una vez que el piloto acumula 900 horas de vuelo y se encuentra habilitado para hacer vuelos comerciales, debe sumar 24 horas al año en distintos simuladores para mantener su permiso. Algo que deberá repetir durante toda su carrera.

En diciembre de 2008, se realizó el 89º Congreso Argentino de Cirugía. Allí, Aerolíneas Argentinas participó con una presentación que estuvo a cargo de Alejandro Miodyk, director del Centro de Formación y Entrenamiento de Pilotos de la República Argentina de Aerolíneas Argentinas (Cefepra): “La contribución de la industria de la aviación a la práctica médica es enorme y se trata de un camino que la medicina está profundizando. Tanto cirujanos como pilotos operamos. La simulación de factores técnicos, humanos y organizacionales busca fortalecer la seguridad operacional, y toda esta práctica es transferible a la simulación quirúrgica”, expuso.Por: Alejandro Horvat

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