Is YouTube a reliable tool for approaching robotic assisted transabdominal preperitoneal surgery? A critical review of the available resources.

INTRODUCTION: The robotic transabdominal preperitoneal approach (rTAPP) is a relatively recent technique for the treatment of inguinal hernia. To achieve optimal results, the 10 golden rules described must be followed. Surgeons in training often review videos to familiarize themselves with new techniques, YouTube being one of the most used platforms. The objective of this study is to carry out an evaluation of the 10 most viewed videos on YouTube of inguinal hernia repair by transabdominal preperitoneal approach (rTAPP) to determine if the 10 golden rules are met. METHODS: Identify and evaluate the 10 videos with the highest number of views related to rTAPP. Three experienced Surgeons evaluated compliance with the 10 golden rules using a Likert scale. Data were analyzed in Excel (Microsoft) and plotted with Tableau (Tableau Inc). The consistency between evaluators was determined using Cronbach's alpha, considering a value >0.7 acceptable. RESULTS: The average overall evaluation was 3.63 with a range of 2.6 to 4.9. The scores related to compliance with the rules 1, 2, 9, 10 were satisfactory; on the other hand, rules 3, 4, 5, 7 and 8 were weak, particularly rule number 7. Internal consistency was observed between raters with a Cronbach's alpha of 0.98. CONCLUSIONS: The lack of compliance with the 10 golden rules in most of the videos demonstrates that the use of videos (YouTube) is not an adequate resource for learning robot-assisted inguinal hernia cure.

Analysis of the Impact of the Learning Curve on the Safety Outcome of the Totally Robotic-Assisted Biliopancreatic Diversion with Duodenal Switch: a Single-Institution Observational Study.

INTRODUCTION: Totally robotic-assisted biliopancreatic diversion with duodenal switch (BPD/DS) learning curve has been described to be longer at approximately 50 cases, at which point operative time and complications rate decrease and tend to stabilize. This study aimed to form an analysis of the impact of the learning curve on the safety outcomes of the totally robotic-assisted BPD/DS. METHODS: A retrospective review of patients who underwent primary totally robotic-assisted BPD/DS by one of our certified bariatric and metabolic surgeon member of our institution was performed. The patients were classified into two groups, the learning stage group (first 50 cases) and the mastery stage group. Differences in operative time in minutes and postoperative outcomes were analyzed. RESULTS: Two hundred seventy-six patients were included. The operative time and the postoperative length of stay were significantly higher in the learning stage group (173.8 ± 35.8 min vs. 139.2 ± 30.2 min, p= 0.0001; 3.4 ± 1.4 days vs. 2.6 ± 0.9 days, p= 0.0002). The overall leakage rate was significantly higher in the learning stage group (8% vs. 0.4%, p= 0.0001). The global rate of complications for the learning stage group was 14%, and for the mastery stage group was 6.6% (p= 0.08). CONCLUSIONS: After the first 50 cases, the operative time, the length of stay, and the overall rate of complications decreased, being especially significant the decrease in the duodeno-ileal anastomosis leakage rate after reaching the learning curve.

Improving efficiency and reducing costs in robotic surgery: a Lean Six Sigma approach to optimize turnover time.

Operating room (OR) turnover time (TOT) is the time it takes to prepare an OR for the next surgery after the previous one has been completed. Reducing OR TOT can improve the efficiency of the OR, reduce costs, and improve surgeons' and patients' satisfaction. The objective of this study is to evaluate the effectiveness of an operating room (OR) turnover time (TOT) reduction initiative using the Lean Six Sigma methodology (DMAIC) in the bariatric and thoracic service lines. Performance improvement strategies consist of simplifying steps (surgical tray optimization) and concurrent steps (parallel task execution). We compared 2-month pre-implementation vs. post-implementation. A paired t-test was used to assess whether the difference in the measurements was statistically significant. The study found that TOT was reduced by 15.6% from an average of 35.6 ± 8.1 to minutes 30.09 ± 9.7 min (p < 0.05). Specifically, in the bariatric service line, TOT was reduced by 17.15% and in the thoracic service line, TOT was reduced by 9.6%. No adverse events related to the initiative were reported. The results of this study indicate that the TOT reduction initiative was effective in reducing TOT. The efficient use of operating rooms is crucial in hospital management, as it not only impacts finances but also affects the satisfaction of surgical teams and patients. This study shows the effectiveness of Lean Six Sigma methodology in reducing TOT and improving the efficiency in the OR.

Introducing the E100: will the improvement make a significant difference? Financial analysis based on sleeve gastrectomy.

Robotic-assisted surgery has been shown to offer significant benefits for both patients and surgeons. However, the high cost of the equipment remains a major barrier to its widespread adoption in the medical field. To ensure cost-effectiveness of these procedures, it is important to implement strategies that can help reduce the costs involved. One potential strategy to reduce costs is to compare the performance of different generators used in these procedures. In this study, we compared the performance of two generators: the E100 (Intuitive Surgical, Inc.) and the ERBE VIO dV 2.0 (Elektromedizin GmbH). The analysis focused on several key metrics, including the number of times the generators were activated, the average time per seal, total sealing time, and console time. The financial impact of transitioning to the E100 was also evaluated based on annual volume. We analyzed a total of 1457 sleeve gastrectomies, with 746 performed using the ERBE generator and 711 performed using the E100. There were no significant differences in preoperative BMI or bleeding complication rates between the two groups. The average activation of the generator per case was similar in both groups. However, the sealing time was 42.3% lower, and the average console time was 8 min shorter in cases where the E100 was used. Based on our financial analysis, transitioning to the E100 generator would result in cost savings of approximately $33-$34 K per year. This suggests that introducing the new generator is a successful strategy for reducing costs associated with robotic-assisted procedures.

Minimally Invasive Management of Post-treatment Rectovesical Fistulae.

Objective: The aim of this study is to report our experience in minimally invasive management of rectovesical fistulae (RVFs). Materials and Methods: Between 2004 and 2021, 24 patients who underwent minimally invasive RVF repair by a single surgeon at 3 international institutions were retrospectively reviewed. Baseline demographic characteristics and perioperative and postoperative variables were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Guidelines Panel Assessment and Recommendations. Fistula repair was defined as confirmation of fistula closure by imaging and complete resolution of fistula-related symptoms at the 12-month follow-up. Continuous variables are reported as medians and quartiles, whereas categorical variables are reported as frequencies and percentages. Results: Twenty-four patients with RVFs were treated: 22 males (91.7%) and 2 females with a median age of 66 (64.2-68) years. Twenty cases (83.3%) occurred postsurgery, three cases (12.5%) after surgery with combined radiotherapy, and one case (4.1%) after a combination of energy treatments. A robotic approach was performed in 19 patients (79%) and laparoscopic approach in 5 patients (21%). Ninety-six percent of patients had previous fecal diversions. No intraoperative complications were recorded. The median operative time was 180 (140-282) minutes, estimated blood loss was 50 (40-125) mL, and length of hospital stay was 2 (2-3) days. There were two Grade II complications and one Grade IIIb complication. All patients met criteria for repair. Conclusions: Minimally invasive management of RVFs is feasible. More studies are needed to assess the role of this approach among all RVF management options.

Robotic surgery: financial impact of surgical trays optimization in bariatric and thoracic surgery.

The incorporation of new technologies in the surgical field, such as the robotic da Vinci System, has made it possible to offer a series of advantages to the patient and the surgeon, with important benefits for both. However, cost continues to be a limiting factor to the adoption of this technology. The development of strategies to maximize the measures that can lead to reduced expenses is a key factor to improve cost-benefit ratio. According to some studies, more than 50% of the costs of a surgical procedure are related to materials and medical supplies, which is why any measure aimed at optimizing their use is pertinent. Our institution, the Orlando Regional Medical Center (ORMC), created a working group whose main purpose is to optimize the Robotic OR process. Their first step was to optimize the surgical trays, and this was carried out in four stages: observation, modification, trial period, and cost analysis. The specialties involved in this initiative were Bariatric and Thoracic Surgeries. Once the optimization process ended, the number of laparoscopic/thoracoscopy instruments in the trays decreased by 63 and 87% for bariatric and thoracic surgery, respectively; and the number of conventional surgery instruments was also reduced by 47 and 64%, for the same specialties, respectively. The financial analysis concluded that implementing this measure will lead to an estimated six-figure savings per year.

Development of a robot-assisted thoracic surgery (RATS) program. Lessons learned after 2500 cases.

Robotic surgery provides significant advantages in terms of an optimal three-dimensional and magnified view of the surgical field, superior maneuverability of surgical instruments, removal of surgeon's tremor and excellent ergonomics. Nonetheless, the adoption of this technology in thoracic surgery has been slower than in other specialties such as urology, gynecology or digestive surgery. In this article we describe our institution's experience in robotic-assisted thoracic surgery (RATS) in the span from 2012 to 2020. During this time the average annual growth of the program has been 55%. Among the most frequently procedures performed were lobectomies, wedge resection and segmentectomies. Surgical time and length of stay decreased as the number of procedures performed increased, relative to the learning curve. Additional important elements considered relevant to the success of the program are the resources available, leadership, motivation of the surgical team, adequate and stepwise training, as well as the collection of data for periodic analysis of results. All those initiatives have led to a relevant improvement of financial variables reflecting a cost reduction.

Robot-assisted duodenal switch with DaVinci Xi: surgical technique and analysis of a single-institution experience of 661 cases.

Metabolic and bariatric surgery is an effective treatment for the management of obesity and related comorbidities. Although the duodenal switch has demonstrated superior results in terms of resolution of obesity-related comorbidities and weight loss, it is one of the less performed procedures. The use of robotic surgical platforms offers many advantages in obese patients and is particularly useful in technically demanding procedures such as duodenal switch. Observational, retrospective and analytical study of cases corresponding to robot-assisted duodenal switch performed between 2016 and 2021. We describe our technique using the system DaVinci Xi. Operative and perioperative variables, postoperative complications, and readmission rate were determined. A total of 661 patients underwent duodenal switch which correspond to the 20.7% of the total bariatric procedures performed in this period. A clear decrease in surgical time and length of stay was observed as the number of cases progressively increased. The complication rate during the first 30 days was 9.1%. Among these, only 1.9% corresponded to major complications, being strictures the most frequent (0.9%), followed by leaks (0.45%). Readmission rate in this period was 6.1%. Between 30 and 90 days postoperatively, the complication rate was 0.91%. Robotic-assisted duodenal switch is a safe surgery with a low complication rate. This procedure is highly effective in terms of durable weight loss in obese and super-obese patients. Robotic DaVinci Xi system allows surgeons to achieve a high level of proficiency and master technique resulting in reduction of surgical time and length of stay.

Minimally Invasive Management of Rectourethral Fistulae.

OBJECTIVE: To report our experience and outcomes in minimally invasive management of rectourethral fistula (RUF). METHODS: From 2004 to 2021, 15 patients who underwent minimally invasive RUF repair by a single surgeon at 2 international institutions were retrospectively reviewed. Baseline demographic characteristics, perioperative, and postoperative data were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Panel Assesment and Recommendations. Success was defined as complete resolution of fistula-related symptoms at 12-month follow-up along with confirmation of fistula closure by imaging or cystoscopy. Categorical variables were presented as frequencies and percentages whereas continuous variables were reported as median and quartiles. RESULTS: Fifteen male patients with a median age of 71 (64-79.2) years were treated. Four cases (26.6%) occurred postsurgery, 8 cases (53.3%) occurred after energy treatments, and 3 cases (20%) after surgery combined with an energy treatment modality. A robotic and laparoscopic approach was performed in 9 (60%) and 6 (40%) patients, respectively. No intraoperative complications were reported. Median operative time was 264 (217.5-341) minutes, estimated blood loss was 175 (137.5-200) mL, and the length of hospital stay was 4 days. Nine postoperative complications were reported. All patients were followed-up for 12 months with no recurrence reported. All patients reached our criteria for successful RUF repair. CONCLUSIONS: Minimally invasive surgery could represent an efficient way to manage RUF in selected patients. More studies and treatment standardization are needed to assess the role of minimally invasive surgery in the management of RUF.

Programa de entrenamiento para la cirugía laparoscópica de acalasia en modelos inertes y orgánicos. Estudio observacional / Training Program for Laparoscopic Achalasia Surgery in Inert and Organic Models. Observational Study

La educación en cirugía ha experimentado cambios de paradigmas en las últimas décadas, principalmente en la adquisición de habilidades y destrezas quirúrgicas. La simulación surge como una herramienta complementaria de aprendizaje en cirugía laparoscópica. Objetivo : Diseñar un programa de entrenamiento para el desarrollo de habilidades y destrezas en el abordaje laparoscópico de la cirugía de la acalasia. Métodos : Se trata de un estudio observacional, longitudinal, prospectivo y analítico basado en un programa de entrenamiento con modelos inertes y ex vivo. Los participantes fueron residentes de postgrado de cirugía general de la Universidad Central de Venezuela. Resultados : Se realizaron 30 prácticas con 6 residentes del mismo nivel de experiencia. Se observó una disminución del 22,64% del tiempo entre la evaluación inicial y final, con una mejoría de las habilidades con la escala GOALS del 33,3%.Conclusión : El programa de entrenamiento permitió reproducir algunos de los pasos para la cirugía de acalasia, constituyendo un método efectivo, de bajo costo y fácil de implementar para la enseñanza y adquisición de habilidades laparoscópicas(AU)

Surgery education has experienced paradigm shifts in recent decades, mainly in the acquisition of surgical skills and abilities. Simulation emerges as a complementary learning tool in laparoscopic surgery.Objective: To design a training program for the development of abilities and skills in the laparoscopic approach to achalasia surgery. Methods : This is an observational, longitudinal, prospective and analytical study based on a training program with inert and ex vivo models. The participants were postgraduate residents of general surgery at the Central University of Venezuela.Results : 30 practices were carried out with 6 residents of the same level of experience, a decrease of 22.64% in the time between the initial and final evaluation was observed, with an improvement in skills with the GOALS scale of 33.3%.Conclusion : The training program allowed to reproduce some of the steps for achalasia surgery, constituting an effective, low cost and easy to implement method for teaching and acquiring laparoscopic skills(AU)

Rol de la simulación en el entrenamiento de cirugía mínimamente invasiva. Artículo de revisión / Role of simulation in minimally invasive surgery training

La cirugía laparoscópica ha sido uno de los grandes adelantos de la medicina moderna, sin embargo, la incorporación de esta tecnología a la práctica quirúrgica trajo consigo implicaciones en la enseñanza de la cirugía. La cirugía laparoscópica es una técnica más difícil de dominar que la cirugía abierta, en la cual se realizan procedimientos y maniobras particulares que requieren de laadquisición de habilidades específicas. La tendencia en la enseñanza de nuevas técnicas o procedimientos se ha enfocado en el uso de la simulación como una herramienta que permite adquirir las destrezas necesarias en un ambiente seguro, sin comprometer la seguridad y eficacia de los procedimientos. Por otro lado, decidir el momento en el cual el cirujano en entrenamiento ha alcanzado las destrezas necesarias para incorporarse a cirugíasin vivo, requiere de objetivos métodos de evaluación . En la búsqueda de alternativas de mayor objetividad, la tendencia mundial durante los últimos años ha sido dirigir la atención hacia el estudio depatrones de movimientos al momento de realizar determinada tarea o procedimiento(AU)

Laparoscopic surgery has been one of the great advances in modern medicine, however the incorporation of this technology into surgical practice brought with it implications in the teaching of surgery, laparoscopic surgery is a more difficult technique than open surgery, in which particular procedures and maneuvers are performed that require the acquisition of specific skills. The trend in the teaching of new techniques or procedures has focused on the use of simulation as a tool that allows acquiring the necessary skills in a safe environment, without compromising the safety and effectiveness of the procedures. On the other hand, deciding the moment in which the surgeon in training has reached the necessary skills to join in vivo surgeries requires objective evaluation methods. In the search for more objective alternatives, the global trend in recent years has been to direct attention towards the study of movement patterns when performing a certain task or procedure(AU)

Multi-informant universal screening: Evaluation of rater, item, and construct variance using a trifactor model.

Universal screening is a proactive method for identifying student risk, yet remains under-utilized in school systems. Instead, many schools rely on teacher reports and referrals without accounting for different informant perspectives. In the current study, multi-informant universal screening in evaluated using a trifactor model. The study utilized the Social, Academic, and Emotional Behavior Risk Screener (SAEBRS), specifically the teacher (SAEBRS-TRS) and student (mySAEBRS) self-report forms, with items indicating risk for social, academic, and emotional behavior. Data from a national sample of over 24,000 K-12 teacher-student dyads were used to examine the extent and variance of discrepant reports between students and teachers of common, perspective, and item factors. Results demonstrated that informant perspective factors were a strong predictor for student and teacher emotional behavior item ratings. Whereas age had a positive effect on younger student reports of risk on the behavior items compared to older student reports, teachers showed the opposite effect. The teacherperspective of social and emotional behaviors of students was predicted by gender. Implications and directions for future research are further discussed.

Robot-assisted surgery and incisional hernia: a comparative study of ergonomics in a training model.

Over the years, incisional hernia repair has evolved. Currently, primary closure of the defect before placing the mesh is a critical step in incisional hernia repair and minimally invasive surgery incorporation has an important role due to great advantages. Despite its benefits, laparoscopic closure with suture intracorporeal knotting is physically demanding and technically complex. Robotic technology provides an optimal three-dimensional view, maneuverability of the instruments but no study has assessed the impact of the DaVinci system in the ergonomics which is the objective in this study. Fourteen surgeons were able to achieve surgical repair of a defect in an incisional hernia inanimate model. The task was performed with conventional laparoscopy and robotic assistance. The mental effort was registered and physical disturbances were measured with the Local Experienced Discomfort scale. The subjects expressed discomfort mainly in the dominant side (p = 0.006). In the comparative analysis between the two approaches, upper limb less disturbance (p = 0.04) and lower mental effort (p = 0.001) were reported with robotic approach. Robotic assistance decreases mental and physical effort during the primary closure of a defect in an incisional hernia inanimate model.

Colecistectomía laparoscópica: impacto de la implementación de una lista de chequeo en la adecuada preparación del quirófano / Laparoscopic cholecystectomy: impact of the implementation of a checklist in the adequate preparation of the operating room

Evaluar el impacto de la implementación de una lista de chequeo en la adecuada preparación del quirófano para realización de colecistectomía laparoscópica. Métodos: Se trata de un estudio prospectivo, controlado, no aleatorio, donde se estudió el impacto del uso de una lista de chequeo en la incidencia de eventos adversos relacionados con la preparación del quirófano para realización de colecistectomía laparoscópica. Se compararon dos grupos, grupo A, en el cual se utilizó lista de chequeo y grupo B (control) donde la preparación del quirófano se llevó a cabo sin el uso de la lista. Para el estudio, los eventos adversos se clasificaron según su naturaleza en "ausencia y/o posición" y "defecto y/o configuración". El análisis estadístico se llevó a cabo utilizando el test exacto de Fisher considerando diferencia significativa p<0,05. Resultados: Se estudiaron un total de 40 procedimientos, (grupo A: 20, grupo B: 20). La incidencia de eventos adversos relacionados con la preparación del quirófano fue de 45 %, en contraste con el grupo control, en el cual en el 100 % de los procedimientos se documentaron eventos (p<0,001). La mayoría de los eventos documentados estuvo en relación con equipo o instrumental de hemostasia. La lista de chequeo fue útil en reducir significativamente los eventos adversos relacionados con "ausencia y/o posición" (70 % vs 5 %, p<0,001) pero no los relacionados "defecto y/o configuración" (70 % vs 40 %; p=0,057). Conclusiones: La lista de chequeo es una herramienta útil para la reducción de eventos adversos relacionados con la preparación de quirófano para colecistectomía laparoscópica, pero no elimina completamente el riesgo de su aparición(AU)

to evaluate the impact of the implementation of a checklist to obtain an optimal setting of the operating room for laparoscopic cholecystectomy surgeries. Methods: it's a prospective, controlled, non-randomized study. The usefulness of checklist implementation was studied to know the incidence of adverse events related to operating room preparation for laparoscopic cholecystectomy. Two groups, group A (checklist group), and group B (control, without the implementation of a checklist) were compared. For statistical purposes, adverse events were classified according to their nature in "Absence and/or position" and "defect and/or configuration". Statistical analysis was carried out using Fisher's exact test considering significant difference a p value<0.05. Results: A total of 40 procedures were studied (group A: 20, group B: 20). The incidence of adverse events related to operating room preparation was 45 %, in contrast to the control group, in which events were documented in 100 % of the procedures (p<0.001). Most of the documented events were related to hemostasis equipment or instruments. The checklist was useful in reducing adverse events related to "absence and/or position" (70 % vs. 5 %, p<0.001) but not related to "defect and/or configuration" (70 % vs. 40 %; p=0.057). Conclusions: The checklist is a useful tool in order to reduce adverse events related to the preparation of an operating room for laparoscopic cholecystectomy, but does not completely eliminate the risk of its occurrence(AU)

Laparoscopic subtotal cholecystectomy: a surgical alternative to reduce complications in complex cases. / Colecistectomía laparoscópica subtotal como alternativa quirúrgica segura en casos complejos.

INTRODUCTION: Laparoscopic cholecystectomy is a common procedure in general surgery, and in complex cases it is important for the surgeon to know all the alternatives with low associated morbidity. Laparoscopic subtotal cholecystectomy should be considered as an option when a critical view of safety cannot be obtained, because it has a low complication rate and gives the advantages of minimally invasive surgery. METHODS: Retrospective study of laparoscopic subtotal cholecystectomies in an eight years period. RESULTS: A total of 1,059 laparoscopic cholecystectomies were performed; 22 were subtotal cholecystectomies, without conversion. Biliary fistula (9%) and intraabdominal collections (4.5%) were the most common complications described. No iatrogenic bile duct injuries or deaths were reported. Our follow-up period was 32months, no recurrences were reported. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a safe and effective procedure. It should be considered as an option in complex cases.

Robot-assisted video endoscopic inguinal lymphadenectomy for melanoma.

Inguinal lymphadenectomy is the indicated procedure in the regional lymph node management for patients with lower limb melanoma and positive nodes. This procedure is commonly associated with surgical site complications. Video endoscopic inguinal lymphadenectomy is a minimally invasive alternative with oncological principles and lower wound-related morbidity. Incorporation of robotic surgery with optimal vision and great maneuverability would offer great advantages. A 42-year-old male patient was diagnosed with acral lentiginous melanoma and palpable inguinal nodes T2 N1 M0. The patient was scheduled for robot-assisted left inguinal video endoscopic lymphadenectomy. The working space is created using blunt-finger dissection and then extended with the endoscope by sweeping with the lens. Two 8-mm robotic trocars and a 10-mm trocar for assistant are placed. The lymphadenectomy is carried out with Maryland and scissors. The operative time was 130 min, estimated blood loss 70 ml and hospital stay 2 days. The robot-assisted inguinal video endoscopic lymphadenectomy is a safe and feasible procedure for lower limb melanoma treatment. The incorporation of the robotic system to this approach where there is a limited working space would offer advantages to the technique.

Lipoma retroperitoneal gigante (MDM2 negativo) en una paciente joven / Giant retroperitoneal lipoma (MDM2 negative) in a young patient

Las lesiones sólidas mesenquimales del retroperitoneo son infrecuentes representando menos del 1 %. De los sarcomas retroperitoneales el 10 a 15 % corresponde a liposarcomas, los cuales representan el primer diagnóstico diferencial de lipomas benignos. La realización de inmunohistoquímica, específicamente el MDM2,dará el diagnóstico histológico certero, donde su negatividad se traduce en benignidad. El tratamiento quirúrgico de elección es la resección R-0. Caso clínico: Presentamos el caso de paciente femenino de 24 años de edad quien refiere 5 meses previos al ingreso aumento de la circunferencia abdominal y dolor a predo-minio de flanco izquierdo. Exámenes clínicos y paraclínicos indican el diagnóstico presuntivo de un tumor de aspecto graso retroperitoneal. Se realiza laparotomía exploradora con los hallazgos de tumor de aspecto graso, de superficie lisa, de gran tamaño ubicado a nivel de retroperitoneo. Se realiza resección R-0 de la lesión sin complicaciones. Tiempo operatorio: 110 minutos, sangrado estima-do: 150 cc. Tumor de aspecto graso de 11 Kg y 55 cm. Paciente es dado de alta a las 48 horas tolerando vía oral. La biopsia reporta tejido adiposo maduro sin atipias. Inmunohistoquímica reporta tumor lipomatoso, MDM2 Negativo, descartando de esta manera el diagnóstico de liposarcoma. Conclusión: Podemos concluir que los lipomas gigantes a nivel de retroperitoneo corresponden a una patología poco frecuente. Donde la resolución quirúrgica se basa en la resección R-O. La realización del MDM2 permitirá un diag-nóstico histológico confiable y por ende le brindará al cirujano la capacidad de decidir el tratamiento post-operatorio(AU)

The mesenchymal solid retroperitoneal lesions are uncommon, representing less than 1%. Liposarcomas constitute 10 to 15% of the retroperitoneal sarcomas, which represent the first differential diagnosis of benign lipomas. The immunohistochemistry, specifically the MDM2, give the accurate histological diagnosis, where their negativity translates into benignity. The treatment of choice is surgical R-0 resection. Clinical case: We report the case of 24 years old female patient who refers five months before admission increased abdominal girth and pain, predominantly at the left flank. Clinical and laboratory tests indicate presumptive diagnosis of retroperitoneal fatty tumor. Exploratory laparotomy is done with the findings of large retroperitoneal lipomatous tumor. R-0 resection of the lesion is performed without complications. Operating time: 110 minutes, estimated blood loss: 150 cc. Fatty tumor aspect of 11 kg and 55 cm. The patient's progress was satisfactory and he was discharged on the second postoperative day. Mature adipose tissue biopsy reports without atypia. Lipomatous tumor immunohistochemistry reports, MDM2 negative, discarding liposarcoma diagnosing.Conclusion:We conclude that the giant retroperitoneal lipomas corresponds a rare condition. The surgical resolution is based on R-0 resection, and the MDM2 allow a reliable histological diagnosis and thus will provide the surgeon with the capacity to decide the postoperative treatment(AU)

Laparoscopic surgery skills evaluation: analysis based on accelerometers.

BACKGROUND AND OBJECTIVE: Technical skills assessment is considered an important part of surgical training. Subjective assessment is not appropriate for training feedback, and there is now increased demand for objective assessment of surgical performance. Economy of movement has been proposed as an excellent alternative for this purpose. The investigators describe a readily available method to evaluate surgical skills through motion analysis using accelerometers in Apple's iPod Touch device. METHODS: Two groups of individuals with different minimally invasive surgery skill levels (experts and novices) were evaluated. Each group was asked to perform a given task with an iPod Touch placed on the dominant-hand wrist. The Accelerometer Data Pro application makes it possible to obtain movement-related data detected by the accelerometers. Average acceleration and maximum acceleration for each axis (x, y, and z) were determined and compared. RESULTS: The analysis of average acceleration and maximum acceleration showed statistically significant differences between groups on both the y (P = .04, P = .03) and z (P = .04, P = .04) axes. This demonstrates the ability to distinguish between experts and novices. The analysis of the x axis showed no significant differences between groups, which could be explained by the fact that the task involves few movements on this axis. CONCLUSION: Accelerometer-based motion analysis is a useful tool to evaluate laparoscopic skill development of surgeons and should be used in training programs. Validation of this device in an in vivo setting is a research goal of the investigators' team.

Clinical and pathological features of colorectal cancer in patients at a community hospital in Puerto Rico.

OBJECTIVE: Colorectal cancer (CRC) is among the most common cancers in Puerto Rico. Few studies have correlated clinical and pathological variables with the overall survival of CRC patients in Puerto Rico. We report the clinical and pathological characteristics of patients who underwent surgical resection at a community hospital in Puerto Rico. METHODS: Demographic and pathological variables of patients who underwent CRC surgery at Hospital del Maestro from 2006 through 2011 were reviewed. Descriptive statistics (mean, range, and frequency) and the Cox proportional hazards model were used to determine the influence of demographic and pathological variables on survival, after adjusting for age. RESULTS: Two hundred and five CRC pathology reports were reviewed. Adenocarcinoma represented the most common pathology (202/205; 98.5%). Females represented 52% of the population (106/202) while males represented 48% (96/202). The median age was 71 years (30-96). The right colon was the most common site of presentation (49.7%; 100/201). Stage III was the most common stage at presentation. The presence of mucin, perineural or lymphatic invasion and tumor size were not related to decreased survival. Being male, having a higher stage at diagnosis, and having a moderately or poorly differentiated tumor were characteristics related to decreased survival. CONCLUSION: This study provides information on clinical and pathological variables and their influence on the overall survival of CRC patients at a community hospital in Puerto Rico. Further research must be performed to identify potential disparities and their influence on the prognosis of this patients.

Gastrectomía total laparoscópica asistida por sistema da vinci en el tratamiento de la enfermedad de ménétrier / Laparoscopic total gastrectomy assisted by da vinci system in the management of ménétrier's disease

La enfermedad de Ménétrier es una enfermedad poco frecuente que se caracteriza por presentar hipertrofia gástrica asociada con hipoproteinemia. Objetivo:Presentación de caso clínico y revisión de la literatura, de un paciente con el diagnóstico de enfermedad de Ménétrier, tratado en el servicio de Cirugía III del Hospital Universitario de Caracas. Métodos:Se presenta el caso de un apaciente femenina de 65 años de edad, quien acude por presentar,dolor en epigastrio posterior a las comidas, intolerancia a la vía oral y pérdida de peso. Se realiza una endoscopia digestiva superior donde se evidencia lesión infiltrativa estenosante del cuerpo gástrico que produce reducción de la luz en 100 %, la biopsia concluye hiperplasia foveolar reactiva y cambios reactivos en el epitelio glan-dular, sugestivos de enfermedad de Ménétrier. Resultados: Lapaciente es llevada a mesa operatoria donde se procede a la reali-zación de gastrectomía total más esófago-yeyuno anastomosis por abordaje laparoscópico asistido por robot, evolucionando de manera satisfactoria, egresando al octavo día del postoperatorio. Conclusión: El abordaje laparoscópico asistido por el sistema Da Vinci es una opción factible y segura. La incorporación de la tecnología robótica facilita la realización de procedimientos complejos mediante cirugía mínimamente invasiva(AU)

Ménétrier's disease is a rare disease characterized by gastric hypertrophy associated with hypoproteinemia. Objective: Presentation of clinical case and literature review of a patient with diagnosis of Ménétrier's disease managed at Service of Surgery III, Hospital Universitario de Caracas. Methods: We present a case of a 65 years old female patient who presented epigastric pain after meals, e oral intolerance and weight loss. Upper endoscopy is performed where is evidenced gastric mucosa with prominent folds in gastric body along with stenosis at antrum-pylorous, biopsy was taken and reported foveolar reactive hyperplasia and reactive glandular epithelium changes suggestive of Ménétrier's disease. Results: A robot-assisted laparoscopic total gastrectomy and an esophagusjejunum anastomosis was performed, patient's evolution was satisfactory and is discharged at the eighth postoperative day. Conclusion: The robot-assisted laparoscopic gastrectomy is a feasible and safe option that facilitates the performance of complex procedures(AU)