Development and validation of a low-cost laparoscopic simulation box.

INTRODUCTION: The acquisition of laparoscopic technique skills in an operating room is conditioned by the expertise of the tutor and the number of training interventions by the trainee. For students and surgeons to use a laparoscopic simulator to train their skills, it must be validated beforehand. METHODS: A laparoscopic simulator box was designed, along with 6 interchangeable training games. The simulator was validated by a group of 19 experts, physicians with an experience from at least 100 laparoscopic surgeries, and 20 students of 4th to 6th grades of medical school (non-experts). To evaluate its construct validity, time-to-completion and the number of successfully completed games were assessed. We used 11 and 9-item questionnaires to gather information on content and face validity respectively. In both questionnaires, answers were collected through Likert-type scales, scored from 1 to 5. RESULTS: The group of experts required less time and successfully completed more games than the group of non-experts (p < 0.01). The group of non-experts gave a score ≥ 4 points on each of the questions regarding the content validity of the tool, however, the experts rated with a significant lower mean score the need for the simulator to learn the surgical technique (3.68 points; p < 0.01). Regarding the face validity, all items were graded with a score ≥ 4 points except for the question relating to the spatial realism (3.82 points). CONCLUSION: The laparoscopy simulation box and the games were valid means for training surgeons and medical students to develop the skills required for the laparoscopic technique.

Clinical and economic comparative analysis of laparotomy versus laparoscopy in the first gastric bypass surgeries in a bariatric and metabolic surgery service in a city in southern Brazil / Análise comparativa clínica e econômica das primeiras cirurgias de bypass gástrico realizado por laparotomia e bypass gástrico realizado por videolaparoscopia em um serviço de cirurgia bariátrica e metabólica de uma cidade do sul do Brasil

ABSTRACT Introduction: this paper aims to evaluate the main direct and indirect costs of the first laparotomies and laparoscopies in bariatric surgeries with a clinical-economical retrospective and cross-sectional analysis from 2017 to 2020 at a hospital with specialties besides the basic ones in southern Brazil. Methods: the study sample included 26 participants. The first 13 laparotomies, and the first 13 laparoscopies performed at the bariatric surgery service of the institution were evaluated. The values evaluated in such comparison analyzed the costs of operation and hospitalization. It is important to highlight that, in addition to the cost benefit, other costs take significance in the health area, such as: cost-utility, cost-effectiveness and cost-minimization, in addition to the cost-opportunity that is reassessed in the observation of the broad context associating all the values raised here. The software used for data analysis was Excel version® 365. The economic analysis was performed evidencing the profile of the patients and the direct and indirect costs involved in each segmentation. Results: the direct and indirect costs of videolaparoscopy amounted to BRL 10,108.10 and laparoscopy to the amount of BRL 12,568.14. Conclusion: it was concluded that laparoscopy presents more savings in the aspects of all health valuations to the detriment of laparotomy. It was concluded that the videolaparoscopy presents more savings in the aspects of all health valuations than the laparotomy.

RESUMO Introdução: o presente estudo tem como objetivo avaliar os principais custos diretos e indiretos das primeiras laparotomias e videolaparoscopias em cirurgias bariátricas em uma análise clínica-econômica, retrospectiva e transversal de 2017 a 2020 em um hospital terciário do sul do Brasil. Métodos: a amostra do estudo incluiu 26 participantes. Foram avaliadas as primeiras 13 laparotomias e as primeiras 13 videolaparoscopias realizadas no serviço de cirurgia bariátrica da instituição. Os valores avaliados em tal comparação analisaram os custos da operação e da internação. É importante ressaltar que além do custo-benefício, outros custos tomam significância na área da saúde. São eles: o custo-utilidade, o custo-efetividade e o custo-minimização, além do custo-oportunidade que é reavaliado na observação do contexto amplo associando todas as valorações aqui levantadas. O software utilizado para a análise dos dados foi o Excel® versão 365. A análise econômica foi realizada evidenciando o perfil dos pacientes e os custos direto e indireto envolvidos em cada segmentação. Resultados: os custos diretos e indiretos da videolaparoscopia somaram o montante de R$ 10.108.10 e da laparoscopia o montante de R$ 12.568,14. Conclusão: concluiu-se que a videolaparoscopia apresenta mais economia nas vertentes de todas as valorizações em saúde em detrimento da laparotomia.

Laparoscopic and laparotomy bariatric surgery in a public hospital in brazil: are there differences in costs and complications? / Cirurgia bariátrica laparoscópica e convencional em hospital público no brasil: há diferenças nos custos e complicações?

ABSTRACT BACKGROUND: Despite its increasing popularity, laparoscopy is not the option for bariatric surgeries performed in the Brazilian public health system. AIMS: To compare laparotomy and laparoscopic access in bariatric surgery, considering aspects such as morbidity, mortality, costs, and length of stay. METHODS: The study included 80 patients who were randomly assigned to perform a Roux-en-Y gastric bypass. They were equally divided in two groups, laparoscopic and laparotomy. The results obtained in the postoperative period were evaluated and compared according to the Ministry of Health protocol, and later, in their outpatient returns. RESULTS: The surgical time was similar in both groups (p=0.240). The costs of laparoscopic surgery proved to be higher, mainly due to staplers and staples. The patients included in the laparotomy group presented higher rates of severe complications, such as incisional hernia (p<0.001). Costs related to social security and management of postoperative complications were higher in the open surgery group (R$ 1,876.00 vs R$ 34,268.91). CONCLUSIONS: The costs related to social security and treatment of complications were substantially lower in laparoscopic access when compared to laparotomy. However, considering the operative procedure itself, the laparotomy remained cheaper. Finally, the length of stay, the rate of complications, and return to labor had more favorable results in the laparoscopic route.

RESUMO RACIONAL: Apesar de sua crescente popularidade, a laparoscopia não é a via de acesso em cirurgias bariátricas realizadas no sistema público de saúde brasileiro. OBJETIVOS: Comparar os acessos laparoscópico e laparotômico em cirurgia bariátrica, considerando aspectos como morbidade, mortalidade, custos e tempo de hospitalização. MÉTODOS: Foram incluídos 80 pacientes candidatos a by-pass gástrico em Y-de-Roux, aleatoriamente divididos em dois grupos, de acordo com a via de acesso. Os resultados obtidos no período pós-operatório foram avaliados e comparados de acordo com o protocolo do Ministério da Saúde, e posteriormente, em seus retornos ambulatoriais. RESULTADOS: O tempo cirúrgico foi semelhante em ambos os grupos (p=0.240). Os custos da cirurgia laparoscópica foram maiores, principalmente devido aos grampeadores e cargas. Contudo, os pacientes designados à via aberta apresentaram maior índice de complicações graves, como hérnia incisional (p<0.001). Desta forma, os custos com o tratamento das complicações e com o seguro social foram maiores neste grupo (R$ 1,876.00 vs R$ 34,268.91). CONCLUSÃO: Os gastos relacionados ao seguro social e ao tratamento de complicações foram substancialmente menores na cirurgia laparoscópica quando comparada à cirurgia aberta. Entretanto, considerando o procedimento operatório em si, a via aberta foi a mais acessível financeiramente. Por fim, o tempo de hospitalização, a taxa de complicações e o tempo de retorno ao trabalho tiveram resultados mais favoráveis na via laparoscópica.

Development and validation of a low-cost laparoscopic simulation box.

INTRODUCTION: The acquisition of laparoscopic technique skills in an operating room is conditioned by the expertise of the tutor and the number of training interventions by the trainee. For students and surgeons to use a laparoscopic simulator to train their skills, it must be validated beforehand. METHODS: A laparoscopic simulator box was designed, along with 6 interchangeable training games. The simulator was validated by a group of 19 experts, physicians with an experience from at least 100 laparoscopic surgeries, and 20 students of 4th to 6th grades of medical school (non-experts). To evaluate its construct validity, time-to-completion and the number of successfully completed games were assessed. We used 11 and 9-item questionnaires to gather information on content and face validity respectively. In both questionnaires, answers were collected through Likert-type scales, scored from 1 to 5. RESULTS: The group of experts required less time and successfully completed more games than the group of non-experts (p < 0.01). The group of non-experts gave a score ≥4 points on each of the questions regarding the content validity of the tool, however, the experts rated with a significant lower mean score the need for the simulator to learn the surgical technique (3.68 points; p < 0.01). Regarding the face validity, all items were graded with a score ≥4 points except for the question relating to the spatial realism (3.82 points). CONCLUSION: The laparoscopy simulation box and the games were valid means for training surgeons and medical students to develop the skills required for the laparoscopic technique.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Construction and application of a low-cost laparoscopy training simulator as a teaching tool through motor coordination and two-dimensional vision practices / Construção e aplicação de simulador de videotreinamento de baixo custo como ferramenta de ensino por meio de práticas de coordenação motora e experiência com visão bidimensional

ABSTRACT Objectives: to describe the construction of a low-cost laparoscopy training simulator and evaluate its level of acceptance, impact on learning, and skill development in medical students. Methods: we built a video training simulator using low-cost materials. We then carried out a cross-sectional study, with the use of an applied questionnaire to medical students. Results: 51 medical students participated in the research, of whom 76.47% gained confidence in relation to laparoscopic surgery, 100% stated that the model successfully trained the skills of motor coordination and two-dimensional visual-spatial field, in addition to enabling a greater understanding of laparoscopy. All agreed that the simulator should be used before a real laparoscopic surgery scenario. Conclusion: the construction of the described laparoscopic surgery training simulator proved to be feasible and effective as an educational resource. It was well accepted by medical students, with easy handling, and promoted the development of motor and visual skills in video surgery.

RESUMO Objetivos: descrever a construção de um simulador de treinamento de videocirurgia de baixo custo e avaliar, por meio de sua aplicação, o nível de aceitação, de impacto no aprendizado e de desenvolvimento de habilidades em acadêmicos do curso de medicina. Método: foi construído um simulador, de videotreinamento com uso de materiais de baixo custo. Realizou-se um estudo transversal com a utilização de questionário aplicado a acadêmicos do curso de medicina. Resultados: a pesquisa contou com a participação de 51 acadêmicos de medicina. Após o uso do simulador 76,47% dos pesquisados adquiriram confiança em relação à videocirurgia, 100% afirmaram que o modelo treinou com satisfação as habilidades de coordenação motora e campo visoespacial bidimensional, além de possibilitar maior compreensão da videocirurgia. Todos concordaram que o simulador deveria ser utilizado antes da situação real. Conclusão: a construção do simulador de treinamento em videocirurgia descrito mostrou-se factível e eficaz como recurso educacional. Obteve boa aceitação pelos acadêmicos, com fácil manuseio, capaz de fomentar o desenvolvimento das habilidades motoras e visuais em videocirurgia.

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1, 552 cases operated in 20 years / Apendicectomia laparoscópica sem uso de materiais descartáveis - uma alternativa de baixo custo - 1. 552 casos operados em 20 anos

ABSTRACT Introduction: Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy. Objective: to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used. Methods: we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device. Results: 1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days. Conclusion: the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

RESUMO Introdução: a apendicectomia videolaparoscópica não tem protocolo único sobre sistematização técnica, vias de acesso, uso de energia e grampeadores. O custo de materiais descartáveis pode inviabilizar o emprego mais generalizado. Alternativas para diminuir o custo podem ajudar a disseminar o acesso laparoscópico para a realização de apendicectomia. Objetivo: introduzir um método para realizar a apendicectomia videolaparoscópica de baixo custo e visando bom resultado estético por meio da localização das incisões; mostrar a viabilidade por meio de aplicação em 1.552 casos de apendicectomia videolaparoscópica operados entre 2000 e 2019 com três portais, de muito baixo custo em insumos utilizados. Métodos: três punções - uma punção umbilical para introdução da câmera (de 5 ou 10mm de diâmetro), uma punção de 10mm em fossa ilíaca direita e uma punção em fossa ilíaca esquerda de 5mm. Os materiais utilizados - trocartes, pinças de apreensão, gancho, tesoura e porta-agulhas são de uso permanente, sem necessidade de qualquer material descartável. Resultados: foram operados 1.552 pacientes entre 2000 e 2019, sendo 56,25% do sexo feminino, média de idade de 32,66 anos (9 a 93 anos), tempo médio de internação de 1,74 dias (1 a 10 dias) e mediana de 1,2 dias. Conclusão: a técnica que descrevemos utiliza três trocartes metálicos e quatro instrumentos permanentes, além de um único fio de algodão. Trata-se, portanto, de procedimento laparoscópico de muito baixo custo. A aplicação demonstrou bons resultados e baixa morbidade, podendo tornar-se rotina a indicação preferencial da vídeocirurgia no tratamento da apendicite aguda.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center. / Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Construção de simulador laparoscópico de média fidelidade e avaliação da curva de aprendizagem / Construction of a medium fidelity laparoscopic simulator and evaluate the learning curve assessment

Introdução: Nos cursos de graduação em medicina, a simulação realística está sendo aplicada, cada vez mais, como um meio de propiciar aos estudantes e aos médicos o desenvolvimento de competências técnicas por meio da repetição de tarefas, realizadas em ambiente controlado, não comprometendo a segurança do paciente. Objetivo: Este estudo teve como objetivo construir um simulador laparoscópico de média fidelidade e avaliar a curva de aprendizagem gerada pelo treinamento de estudantes e de médicos residentes de cirurgia geral. Método: Após a construção do simulador laparoscópico de média fidelidade, alunos do 3º e 4º anos de graduação, do Curso de Medicina da Universidade José do Rosário Vellano (UNIFENAS), campus Alfenas, e médicos residentes do Hospital Universitário Alzira Velano, foram submetidos a treinamento e suas curvas de aprendizagem foram avaliadas pela determinação do tempo de realização da tarefa e dos erros cometidos. Resultados: Participaram da pesquisa 27 sujeitos, de ambos os sexos (70% mulheres), sendo sete médicos residentes e 20 alunos do 5º ao 8º período do curso de medicina. A manufatura do simulador de média fidelidade foi viabilizada a um custo de R$ 300,00 por unidade. Os alunos que participaram previamente de ligas acadêmicas de cirurgia apresentaram menor tempo do primeiro teste em relação aos que não participaram (372,9 ± 89,1 vs. 259,0 ± 90,5 com p=0,032). Da mesma maneira, o número de repetições para atingir 90% do melhor escore foi inferior (7,0 ± 4,6 vs. 11,9 ± 1,7 com p=0,013). A intenção de seguir carreira cirúrgica também se mostrou associada à melhor pontuação no primeiro teste (282,9 ± 78,2 vs. 406,9 ± 87,6 com p=0,011) e menor número de repetições para atingir 90% do melhor escore (8,8 ± 4,1 vs. 12,4 ± 0,8 com p=0,017). Conclusão: O simulador laparoscópico possibilitou que todos os participantes tivessem uma melhora progressiva nos resultados da pontuação e redução do tempo de execução da tarefa, durante as repetições. Os alunos com interesse na área cirúrgica e que participaram de ligas acadêmicas apresentaram melhor rendimento na curva de aprendizagem. Estes achados, aliados ao baixo custo de produção do equipamento, revelam sua potencialidade como ferramenta de treinamento de habilidades cirúrgicas bem como apontam a necessidade de incorporação de novas tarefas ao simulador

Introduction: In undergraduate medical schools, realistic simulation has been applied more and more as a means of providing students and physicians with the development of technical skills through task repetition, performed in a controlled environment, without compromising the patient's safety. Objective: This study aimed to build a medium fidelity laparoscopic simulator and evaluate the learning curve generated by the training of general surgery students and residents. Method: After the construction of the medium fidelity laparoscopic simulator, 3rd and 4th year undergraduate students of José do Rosário Vellano University (UNIFENAS) School of Medicine, campus Alfenas, and resident doctors at Alzira Velano University Hospital, underwent training and their learning curve were evaluated by the time taken to perform the task and the mistakes made. Results: Twenty-seven subjects of both sexes (70% women) participated in the research, of which seven were residents and 20 were students between 5th to 8th semesters of medical school. The manufacture of the medium fidelity simulator was made possible at a cost of R$300.00 per unit. Students who previously participated in surgery academic leagues took less time in the first test compared to those who did not participate (372.9 ± 89.1 vs 259.0 ± 90.5 where p=0.032). Likewise, the number of repetitions needed to reach 90% of the best score was lower (7.0 ± 4.6 vs 11.9 ± 1.7 where p=0.013). The intention to follow a surgical career also proved to be associated with a better score on the first test (282.9 ± 78.2 vs 406.9 ± 87.6 where p=0.011) and a lower number of repetitions needed to reach 90% of the best score (8.8 ± 4.1 vs 12.4 ± 0.8 with p=0.017). Conclusion: The laparoscopic simulator allowed all participants to have a progressive improvement in scoring results and reduced task execution time during repetitions. Students interested in the surgical area and who participated in academic leagues showed better performance in the learning curve. These findings, sided with the equipment's low production cost, reveal its potential as a surgical skill training tool, as well as indicate the need of incorporating new tasks into the simulator

Fuentes de energía en apendicectomía laparoscópica en un programa académico de Cirugía general en Colombia / Energy sources in laparoscopic appendectomy in an academic program of General Surgery in Colombia

Introducción. La apendicectomía por laparoscopia se considera el patrón de oro en el tratamiento de la apendicitis aguda. Sin embargo, su disponibilidad es limitada en nuestro sistema de salud, principalmente por los costos asociados. El objetivo de este estudio fue evaluar la relación entre el uso de los diferentes tipos de energía y los métodos de ligadura de la base apendicular, con las complicaciones postoperatorias, al igual que describir los costos asociados. Métodos. Estudio observacional analítico de una cohorte retrospectiva de pacientes mayores de 15 años a quienes se les realizó apendicectomía por laparoscopia, en un hospital universitario entre los años 2014 y 2018. Se utilizaron modelos de regresión logística y lineal para evaluar la relación entre métodos de ligadura del meso y base apendicular, desenlaces operatorios y costos. Resultados. Se realizaron 2074 apendicectomías por laparoscopia, 58,2 % (n=1207) en mujeres, la edad mediana fue de 32 años. En el 71,5 % (n=1483) la apendicitis aguda no fue complicada. La energía monopolar para la liga-dura del meso apendicular fue la utilizada más frecuentemente en 57,2 % (n=1187) y el Hemolok® el más utilizado para la ligadura de la base apendicular en el 84,8 % (n=1759) de los pacientes. No se observaron diferencias estadísticamente significativas en la tasa de infección del sitio operatorio, reintervención o íleo. El uso de energía simple redujo los costos del procedimiento de manera significativa durante el período evaluado. Discusión. El uso de energía monopolar demostró ser una técnica segura, reproducible y de menor costo en comparación con el uso de energía bipolar, independientemente de la fase de la apendicitis aguda. Lo anterior ha permitido que se realicen más apendicectomías por laparoscopia y que los médicos residentes de cirugía general puedan realizar procedimientos laparoscópicos de forma más temprana

Introduction. Laparoscopic appendectomy is considered the gold standard in the treatment of acute appendicitis. However, its availability is limited in our health system mainly due to the associated costs. The objective of this study is to evaluate the relationship between the use of different types of energy and the methods of ligation of the appendicular base with postoperative complications, as well as to describe the associated costs. Methods. Retrospective observational study of a cohort of patients older than 15 years old who underwent laparoscopic appendectomy in a university hospital between 2014 and 2018. Logistic and linear regression models were used to evaluate the relationship between methods of ligation of the meso and appendicular base, operative outcomes and costs. Results: 2074 laparoscopic appendectomies were performed. Of those, 58.2% (n=1207) were women, median age was 32 years. In 71.5% (n=1483), acute appendicitis was uncomplicated. Monopolar energy for ligation was the most frequently used for ligation of the appendicular meso in 57.2% (n=1187) and Hem-o-lok® the most used for ligation of the appendicular base in 84.8% (n=1759) of the patients. There were no statistically significant differences in the rate of surgical site infection, reoperation, or ileus. The use of simple energy reduced the costs of the procedure significantly during the study period. Discussion. The use of monopolar energy proved to be a safe, reproducible and a lower cost technique compared to the use of bipolar energy, regardless of the phase of acute appendicitis. This has allowed more laparoscopic appendectomies to be performed and the general surgery residents to perform laparoscopic procedures earlier

Evaluación de fuerza de concordancia de hallazgos de endometriosis en RM y laparoscopía: análisis de una serie de casos / Assessment concordance of endometriosis findings on MRI and laparoscopy: analysis of a series of cases

OBJETIVO: Evaluar concordancia de sitios de hallazgos de endometriosis profunda encontrados por RM y laparoscopia. MATERIALES Y MÉTODOS: Estudio retrospectivo, no experimental, concordancia intertécnica. Se recolectaron datos en nuestra institución de todos los informes de RM de pelvis que incluyeran la palabra "endometriosis", entre mayo de 2015 y abril de 2018 (36 meses), identificando 339 registros. Se establecieron criterios de inclusión. De los 339 registros, 62 pacientes fueron excluidas por cirugía antes de la RM. Otras 243 pacientes fueron excluidas porque no presentaban registro de protocolo quirúrgico posterior a la RM. 34 pacientes cumplieron los criterios de inclusión del estudio, lo que equivale al 10% de las RM estudiadas. Se revisaron las ubicaciones de los implantes endometriósicos informados en RM y se correlacionaron con los hallazgos encontrados en la cirugía. Se confecciono tabla para identificar la presencia/ausencia de implantes en las ubicaciones descritas en la literatura. Análisis estadístico mediante software Stata, aplicando kappa ponderada con intervalo de confianza de 95%. RESULTADOS: El promedio de edad de las pacientes llevadas a cirugía fue de 38 años. Los lugares con correlación moderada-importante (0.41-0.80) correspondieron a útero, recto-sigmoides, ovario, vagina y fondos de saco. CONCLUSIÓN: La RM de Pelvis es fundamental en la evaluación de pacientes con endometriosis en las que se plantea un manejo quirúrgico, con el objetivo de caracterizar la ubicación, forma y número de lesiones, y así lograr un satisfactorio tratamiento laparoscópico.

OBJECTIVE: To assess inter-observer reliability of sites of deep endometriosis findings found by MRI and laparoscopy. MATERIALS AND METHODS: Retrospective, non-experimental study, inter-observer reliability. Data were collected at our institution from all pelvic MRI reports that included the word "endometriosis", between May 2015 and April 2018 (36 months), identifying 339 records. The following were established as inclusion criteria. Of the 339 records, 62 patients were excluded for surgery prior to MRI. Another 243 patients were excluded because they had no record of the surgical protocol after the MRI. 34 patients met the study inclusion criteria, equivalent to 10% of the MRIs studied. The locations of the endometrial implants reported on MRI were reviewed and correlated with the findings found in the surgery. A table was prepared to identify the presence / absence of implants in the locations described in the literature. Statistical analysis using Stata software, applying weighted kappa with a 95% confidence interval. RESULTS: The average age of the patients undergoing surgery was 38 years. The places with a moderate-important correlation (0.41-0.80) corresponded to the uterus, recto-sigmoid, ovary, vagina, and recto-uterine pouch. CONCLUSION: Pelvic MRI is essential in the evaluation of patients with endometriosis in whom surgical management is proposed, in order to characterize the location, shape and number of lesions, and thus achieve satisfactory laparoscopic treatment.

Comparison of outcomes and cost-effectiveness of laparoscopic and open appendectomies in public health services / Comparação de desfechos e custo-efetividade de apendicectomias laparoscópicas e abertas em serviços públicos de saúde

ABSTRACT Acute appendicitis is the leading cause of abdominal emergency surgery worldwide and appendectomy continues to be the definitive treatment of choice. This cost-effectiveness analysis evaluates laparoscopic versus open appendectomies performed in public health services in the state of Bahia (Brazil). We conducted a retrospective observational study using the database from the Department of Informatics of the Unified Health System (DATASUS). Available data on appendectomies between 2008 and 2019 were included, and we evaluated the temporal trend of hospital admissions, procedure-related mortality rates, length of stay, and costs. Statistical analysis was performed using the R-software (R Foundation, v.4.0.3) and the BioEstat software (IMDS, v. 5.3), considering p<0.05 as significant. During 2008-2019, 53,024 appendectomies were performed in the public health services in Bahia, of which 94.9% were open surgeries. The open technique was associated with a higher mortality rate (4.9/1,000 procedures; p<0.05) and a higher risk of death (RR=4.5; p<0.05) compared to laparoscopy (1.1/1,000 procedures). Laparoscopic appendectomy (median of 2.7 days) had a shorter length of stay compared to laparotomy (median of 4.15 days) (p<0.05). There was no difference in the medians of costs nor hospital services, per procedure (p=0.08 and p=0.08, respectively). Laparoscopic professional median costs were higher by US$ 1.39 (p<0.05). Minimally invasive surgery for appendicitis is a safe and efficacious procedure in Brazilian public health care services, as it provides advantages over the open method (including lower procedure-related mortality rate and earlier discharges), and it did not imply higher expenses for public service budgets in the state of Bahia.

RESUMO Apendicite aguda é a principal causa de cirurgia abdominal de emergência no mundo e a apendicectomia continua sendo o tratamento definitivo de escolha. A presente investigação avalia desfechos e custos das apendicectomias laparoscópicas versus abertas realizadas em serviços públicos de saúde no estado da Bahia (Brasil). Realizou-se estudo observacional retrospectivo, utilizando a base de dados do DATASUS. Incluiu-se dados disponíveis sobre apendicectomias na Bahia entre 2008 e 2019, avaliando-se a tendência temporal de internações, taxas de mortalidade por procedimentos, tempo de permanência e custos. A análise estatística foi realizada no R-software (Fundação R, v.4.0.3) e no software BioEstat (IMDS, v.5.3), considerando p<0,05 significativo. Entre 2008 e 2019, realizou-se 53.024 apendicectomias no serviço público de saúde na Bahia, das quais 94,9% foram cirurgias abertas. A laparotomia foi associada à maior taxa de mortalidade (4,9/1.000 procedimentos; p<0,05) e maior risco de morte (RR=4,5; p<0,05) do que laparoscopia (1,1/1.000 procedimentos). Apendicectomia laparoscópica (mediana de 2,7 dias) obteve menor tempo de internamento do que cirurgia laparotômica (mediana de 4,15 dias) (p<0,05). Não houve diferença entre as medianas dos custos e nem dos serviços hospitalares por procedimento (p=0,08 e p=0,08, respectivamente). A mediana do custo de profissionais na laparoscopia foi significativamente mais elevada, em US$ 1,39 (p<0,05). A cirurgia minimamente invasiva para apendicite é um procedimento seguro e eficaz, proporcionando vantagens sobre a laparotomia (incluindo menor taxa de mortalidade e alta precoce), não implicando, por sua vez, em maiores despesas para cofres públicos no estado da Bahia.

[Safety of total laparoscopic hysterectomy in a high complexity Hospital in Pereira, Colombia, between 2007 and 2017. Cohort study].

OBJECTIVE: To describe intra and postoperative complications of total laparoscopic hysterectomy (TLH) for benign uterine pathology and to compare with other hospitals with large volumes of laparoscopic hysterectomies. METHODS: Retrospective cohort study of women who underwent TLH for benign gynecological pathology between 2007 and 2017 in a private high complexity institution that serves populations covered by contributive and state-subsidized insurance in Pereira, Colombia. The procedures were performed by the group of surgeons of the ALGIA training center. Consecutive sampling was used. Sociodemographic and baseline clinical characteristics, intra-operative findings and intra- and post-operative complications are described. Descriptive statistics were used. RESULTS: A total of 1.350 patients were included during the study period. Surgical time was 95 minutes (SD ± 31), blood loss 88 cc (SD ± 66), and average uterine weight was 236 g (SD ± 133); 96.5% of the patients were assessed within the next 30 to 45 days; 3.48% had minor complications and 2.5% had major complications; 3 patients were converted to laparotomy. There were no deaths in the study sample. CONCLUSIONS: TLH is a safe procedure and the rate of complications is similar to the best international standards. Further prospective studies using objective criteria are important in order to compare the performance of different groups and institutions offering surgical procedures and training.

TITULO: SEGURIDAD DE LA HISTERECTOMÍA TOTAL POR LAPAROSCOPIA ENTRE EL 2007 Y 2017 EN UN HOSPITAL DE ALTA COMPLEJIDAD, PEREIRA, COLOMBIA. ESTUDIO DE COHORTE. OBJETIVO: Describir las complicaciones intra y posoperatorias de la histerectomía total por laparoscopia (HTL) para patología benigna del útero y hacer una comparación con otros hospitales que tienen altos volúmenes de HTL. METODOS: Estudio de cohorte retrospectivo en mujeres que se sometieron a HTL por patología ginecológica benigna entre 2007 y 2017 en una institución privada de alta complejidad, que atiende población perteneciente al régimen contributivo y subsidiado por el Estado en el Sistema General de Seguridad Social, en Pereira, Colombia, por el grupo de cirujanos del centro de entrenamiento ALGIA. Muestreo consecutivo. Se describen la características sociodemográficas y clínicas basales, los hallazgos intraoperatorios y las complicaciones intra y posoperatorias. Se usó estadística descriptiva. RESULTADOS: en el periodo de estudio se incluyeron 1.350 pacientes. El tiempo quirúrgico fue de 95 min (DE ± 31), el sangrado quirúrgico 88 cc (DE ± 66), el peso promedio del útero fue de 236 g (DE ± 133). El 96,5 % de las pacientes fueron evaluadas entre los 30 y 45 días. El 3,48 % de las pacientes tuvieron complicaciones menores y el 2,5 % complicaciones mayores. Tres pacientes requirieron conversión a laparotomía (0,23%). No hubo mortalidad en la muestra estudiada. CONCLUSIONES: la HTL es un procedimiento seguro y la tasa de complicaciones es similar a la de los mejores estándares internacionales. Es importante que se sigan haciendo estudios prospectivos con criterios objetivos de evaluación para comparar el desempeño de los diferentes grupos e instituciones que ofrecen procedimientos quirúrgicos y entrenamiento.

Safety of total laparoscopic hysterectomy in a high complexity Hospital in Pereira, Colombia, between 2007 and 2017. Cohort study / Seguridad de la histerectomía total por laparoscopia entre el 2007 y 2017 en un hospital de alta complejidad, Pereira, Colombia. Estudio de cohorte

RESUMEN Objetivo: describir las complicaciones intra y posoperatorias de la histerectomía total por laparoscopia (HTL) para patología benigna del útero y hacer una comparación con otros hospitales que tienen altos volúmenes de HTL. Materiales y métodos: estudio de cohorte retrospectivo en mujeres que se sometieron a HTL por patología ginecológica benigna entre 2007 y 2017 en una institución privada de alta complejidad, que atiende población perteneciente al régimen contributivo y subsidiado por el Estado en el Sistema General de Seguridad Social, en Pereira, Colombia, por el grupo de cirujanos del centro de entrenamiento ALGIA. Muestreo consecutivo. Se describen la características sociodemográficas y clínicas basales, los hallazgos intraoperatorios y las complicaciones intra y posoperatorias. Se usó estadística descriptiva. Resultados: en el periodo de estudio se incluyeron 1.350 pacientes. El tiempo quirúrgico fue de 95 min (DE ± 31), el sangrado quirúrgico 88 cc (DE ± 66), el peso promedio del útero fue de 236 g (DE ± 133). El 96,5 % de las pacientes fueron evaluadas entre los 30 y 45 días. El 3,48 % de las pacientes tuvieron complicaciones menores y el 2,5 % complicaciones mayores. Tres pacientes requirieron conversión a laparotomía (0,23%). No hubo mortalidad en la muestra estudiada. Conclusión: la HTL es un procedimiento seguro y la tasa de complicaciones es similar a la de los mejores estándares internacionales. Es importante que se sigan haciendo estudios prospectivos con criterios objetivos de evaluación para comparar el desempeño de los diferentes grupos e instituciones que ofrecen procedimientos quirúrgicos y entrenamiento.

ABSTRACT Objective: To describe intra and postoperative complications of total laparoscopic hysterectomy (TLH) for benign uterine pathology and to compare with other hospitals with large volumes of laparoscopic hysterectomies. Materials and Methods: Retrospective cohort study of women who underwent TLH for benign gynecological pathology between 2007 and 2017 in a private high complexity institution that serves populations covered by contributive and state-subsidized insurance in Pereira, Colombia. The procedures were performed by the group of surgeons of the ALGIA training center. Consecutive sampling was used. Sociodemographic and baseline clinical characteristics, intra-operative findings and intra- and post-operative complications are described. Descriptive statistics were used. Results: A total of 1.350 patients were included during the study period. Surgical time was 95 minutes (SD ± 31), blood loss 88 cc (SD ± 66), and average uterine weight was 236 g (SD ± 133); 96.5% of the patients were assessed within the next 30 to 45 days; 3.48% had minor complications and 2.5% had major complications; 3 patients were converted to laparotomy. There were no deaths in the study sample. Conclusion: TLH is a safe procedure and the rate of complications is similar to the best international standards. Further prospective studies using objective criteria are important in order to compare the performance of different groups and institutions offering surgical procedures and training.

Resultados clínicos y económicos de la cirugía laparoscópica versus abierta en el tratamiento del quiste hidatídico hepático / Clinical And Economic Results Of Laparoscopic Versus Open Surgery In The Treatment Of Hepatic Hydatid Cyst

Introducción: Nuestro país tiene una alta tasa de prevalencia de quiste hidatídico. El presente estudiofue realizado en un centro de referencia nacional y es el primer estudio peruano en comparar losresultados clínicos y económicos de las técnicas quirúrgicas para el tratamiento de esta enfermedad.Objetivo: Comparar los resultados clínicos y económicos de la cirugía laparoscópica y la cirugía abiertaen el tratamiento del quiste hidatídico hepático. Métodos: Estudio analítico y transversal. Se revisaron lashistorias clínicas de todos los pacientes adultos con quiste hidatídico hepático operados de quistectomíaparcial abierta y laparoscópica desde enero del 2013 a diciembre del 2015. Se evaluaron y compararonmorbilidad, mortalidad, recurrencia, tiempo operatorio, estancia hospitalaria, dolor, descanso médicopostoperatorio y costos. Resultados: 22 pacientes fueron operados de quistectomía parcial abierta (grupo1) y 13 por laparoscopia (grupo 2). No hubo diferencias en los tiempos operatorios, ni en las complicacionesquirúrgicas, siendo la morbilidad postoperatoria 27,3% (grupo 1) y 30,7% (grupo 2). La tasa de conversiónfue de 18,7%. No hubo casos de mortalidad intrahospitalaria y un caso de recurrencia (4,5%) postcirugíaabierta. No se encontraron diferencias significativas entre el costo intraoperatorio, postoperatorio y total. Sibien el costo total promedio fue menor para la cirugía laparoscópica (1 700,99 ± 1 195,82 USD para la abiertay 1 561,83 ± 702,53 USD para la laparoscópica) no tuvo diferencias significativas (p=0,64). Hubo menor dolorpostoperatorio, menor estancia hospitalaria y menor duración del descanso médico para la laparoscópica(p<0,05). Conclusión: Los resultados clínicos y económicos fueron similares; sin embargo, hubo menordolor post-operatorio, estancia hospitalaria y más rápida reinserción laboral con cirugía laparoscópica.

Introduction: Our country has a high prevalence rate of hydatid cyst. The present study, was performed ina national reference center, and it is the first Peruvian study to compare the clinical and economic resultsof surgical techniques for the treatment of this disease. Objective: To compare the clinical and economicresults for laparoscopic surgery and open surgery in the treatment of hepatic hydatid cyst. Methods: Themedical records of all patients who underwent open partial cystectomy and laparoscopic partial cystectomy(2013-2015) were retrospectively reviewed. Morbidity, mortality, recurrence, operative time, length ofhospital stay, postoperative pain, and medical rest were evaluated. The costs per patient were found usingthe ABC costing system. Results: 22 patients were underwent open partial cystectomy (group 1) and 13underwent laparoscopic (group 2). There weren ́t differences in operative time, surgical complications, withpostoperative morbidity of 27.3% (group 1) and 30.7% (group 2). The conversion rate was 18.7%. There weren ́tcases of in hospital-mortality and one case of recurrence (4.5%) post open surgery. There weren ́t differencesbetween operative, postoperative and overall cost. Although the overall cost was lower for laparoscopicsurgery (1 700.99 ± 1 195.82 USD for group 1 and 1 561.83 ± 702.53 USD for group 2) but without significantdifferences (p = 0.64). There was less postoperative pain, shorter hospital stay and duration of medical rest (p<0.05). Conclusion: The clinical and economic results were similar for both types of surgery; However, therewas less post-operative pain, hospital stay, and quicker reintegration into working life for patients operatedby laparoscopic surgery.Key words: Echinococcosis

Desarrollo y evaluación de modelo ex vivo para entrenamiento de anastomosis intracorpórea en hemicolectomía derecha laparoscópica / Development and assessment of an ex vivo simulated model for intracorporeal anastomosis training in laparoscopic right hemicolectomy

Resumen Introducción: Si bien la anastomosis intracorpórea (AI) ha demostrado beneficios clínicos sobre la anastomosis extracorpórea (AE) en la hemicolectomía derecha laparoscópica (HDL), su aplicación ha sido limitada por su dificultad técnica y curva de aprendizaje más larga. El presente estudio busca desarrollar y evaluar un modelo simulado para entrenar este procedimiento. Materiales y Método: Se desarrolló un modelo en base a tejido ex vivo, con colon porcino e intestino bovino, montados en un simulador de laparoscopía. Este se modificó sucesivamente en base a entrevistas semiestructuradas a cirujanos hasta lograr el modelo final. Para evaluar apariencia y reacción al modelo, coloproctólogos, cirujanos y residentes previamente expuestos a entrenamiento simulado, realizaron una ileotransverso anastomosis mecánica en el modelo y luego contestaron una encuesta. Resultados: Doce sujetos participaron. Cuatro coloproctólogos, 4 residentes de coloproctología, 2 residentes de cirugía general, 1 cirujano general y 1 cirujano digestivo. El 91,6% valoró positivamente la ergonomía lograda, mientras que el 83,3% y 75% valoraron positivamente el uso del instrumental y la relación anatómica entre estructuras, respectivamente. Todos los participantes consideraron el modelo útil para entrenar sutura manual laparoscópica, el 91,6% para entrenar enterotomías y 83,3% para entrenar el uso de endograpadora. Todos declararon que el módulo permite entender y reflexionar sobre la técnica propuesta. Conclusión: Este modelo desarrollado sería útil para entrenar habilidades críticas para realizar una AI en HDL. Su incorporación a un programa de entrenamiento en laparoscopía avanzada podría contribuir a acortar la curva de aprendizaje de este procedimiento.

Introduction: Although intracorporeal anastomosis has demonstrated clinical benefits over extracorporeal anastomosis in laparoscopic right hemicolectomy, its application has been limited due to its technical difficulty and longer learning curve. The present study aims to develop and evaluate a simulated model to train this procedure. Materials and Method: An ex vivo tissue model was developed with porcine colon and bovine small bowel mounted in a laparoscopic simulator. This was subsequently modified based on semi-structured interviews to experts until the final model was achieved. To evaluate appearance and reaction to the model, the participants performed an ileocolic mechanical anastomosis in the model and answered a survey. Results: Twelve subjects participated. Four colorectal surgeons, 4 colorectal surgery fellows, 2 residents of general surgery, 1 general surgeon and 1 upper digestive surgeon. Of all subjects, 91.6%, 83.3% and 75% deemed ergonomics achieved, the use of instruments, and the anatomical relationship between structures as similar to reality, respectively. All participants deemed the model useful to train laparoscopic manual suturing, while 91.6% and 83.3% of them considered it useful to train enterotomies and the use of an endostapler, respectively. All declared that the model allows to understand the proposed technique. Conclusion: This model would be useful to train critical skills to perform an intracorporeal anastomosis in laparoscopic right hemicolectomy. Its incorporation into an advanced simulated laparoscopy training program could help shorten the learning curve of this procedure.

Análise do perfil clínico epidemiológico dos pacientes submetidos a Colecistectomia Videolaparoscópica em um hospital de ensino de Curitiba / Epidemiological and clinical assessment of patients undergoing Videolaparoscopic Cholecystectomy at a Curitiba teaching hospital

RESUMO Objetivo: Analisar o perfil clínico e epidemiológico de pacientes submetidos a colecistectomia por vídeo no Hospital da Cruz Vermelha do Paraná, unidade de Curitiba, operados no período de setembro de 2016 a setembro de 2018, assim como a influência de comorbidades, sexo e idade avançada no prognóstico pós-operatório, durante o mesmo internamento. Métodos: Estudo retrospectivo analítico, com dados coletados por revisão de prontuários. Análises estatísticas realizadas, considerando nível de significância p < 0,05. Resultados: 389 casos foram incluídos, sendo 265 mulheres e 124 homens. A média de idade foi de 51,5 anos, 58,8% dos pacientes eram portadores de pelo menos uma comorbidade e 74,6% dos doentes tinham sobrepeso ou eram obesos. A incidência de complicações intraoperatórias foi de 1,3%, pós-operatórias de 3,8% e, a mortalidade, de 0,3%. Foram identificados fatores clínicos relacionados a pior prognóstico pós-operatório, como DM, HAS, presença de uma ou mais comorbidades e, destacadamente, idade avançada, que relacionou-se com maior tempo de internamento (p < 0,001), necessidade de UTI (p < 0,001), conversão para operação aberta (p = 0,003) e risco de complicações pós-operatórias (p < 0,001). Além disso, o sexo masculino foi preditivo para maior tempo de internamento (p = 0,003) e maior necessidade de UTI (p = 0,01). Conclusão: o perfil clínico-epidemiológico corresponde àquele exposto na literatura e a presença de comorbidades, o sexo masculino e a idade avançada são fatores preditivos de mau prognóstico na evolução pós-operatória de pacientes submetidos a colecistectomia videolaparoscópica.

ABSTRACT Objective: to assess clinical and epidemiological factors of patients undergoing video cholecystectomy at the Hospital da Cruz Vermelha do Paraná, Curitiba unit, operated from September 2016 to September 2018, as well as the influence of comorbidities, sex and advanced age on the postoperative prognosis, while in the hospital. Methods: Analytic retrospective study. The analyzed variables were obtained by the review of medical records. Statistical analyses were performed considering the significance level p < 0.05. Results: 389 patients, of whom 265 were women and 124 men, were included. The mean age was 51.5 years, 58.8% of the patients were diagnosed with at least one comorbidity, and 74.6% were overweight or obese. The incidence of intraoperative complications was 1.3%, postoperative 3.8% and, mortality, 0.3%. Some risk factors were identified as worse postoperative prognosis, such as Diabetes Mellitus, hypertension, presence of one or more comorbidities and mainly, advanced age, which was related to longer hospitalization times (p < 0,001), need of intensive therapy (p < 0,001), conversion to open surgery (p = 0,003) and postoperative complications (p < 0,001). Furthermore, the male sex was predictive of longer hospitalization times (p = 0,003) and need of intensive therapy (p = 0,01). Conclusion: the presence of comorbidities, male sex, and advanced age are predictive factors of bad prognosis for patients undergoing video laparoscopic cholecystectomy.

Colangiopancreatografia retrógrada endoscópica para cálculos no ducto biliar comum: overview de revisões sistemáticas e estudos econômicos / Endoscopic retrograde cholangiopancreatography for common bile duct calculi: overview of systematic reviews and economic assessments

Objetivo: Avaliar a eficácia, segurança e custo-efetividade da colangiopancreatografia retrógrada endoscópica (CPRE) comparada à exploração laparoscópica do ducto biliar comum (ELDBC) para coledocolitíase. Métodos: Foi realizada uma busca eletrônica nas bases de dados Medline, The Cochrane Library, Lilacs e Center for Reviews and Dissemination por revisões sistemáticas e estudos econômicos que reportassem dados sobre a comparação entre a CPRE e a ELDBC em pacientes com coledocolitíase. Uma busca complementar foi realizada nas referências dos estudos incluídos, periódicos, resumos de congresso e Google Acadêmico. A seleção foi realizada por dois pesquisadores independentes. Além da síntese qualitativa, uma ressíntese quantitativa para os desfechos primários foi conduzida em Review Manager® 5.3 utilizando um modelo de efeitos randômicos. Resultados: Foram incluídos 15 estudos (9 revisões sistemáticas e 6 estudos econômicos). Não foi demonstrada diferença estatisticamente significativa entre a colecistectomia laparoscópica (CL)+CPRE e a CL+ELDBC em termos de remoção dos cálculos do colédoco (88,5% vs. 92,8%; RR = 0,97, valor-p = 0,08; N = 1.881), morbidade pós-operatória (14,1% vs. 13,8%; RR = 0,98, valor-p = 0,88; N = 1.469), mortalidade (0,8% vs. 0,2%; RR = 2,13, valor-p = 0,33; N = 1.471), cálculos retidos (7,3% vs. 5,8%; RR = 1,17, valor-p = 0,40; N = 1.731), conversão para outros procedimentos (8,7% vs. 6,7%; RR = 1,20, valor-p = 0,55; N = 1.287), duração do procedimento (MD = 10,91, valor-p = 0,61; N = 717) ou tempo de hospitalização (MD = 1,31, valor-p = 0,10; N = 757). A literatura de custo-efetividade é dividida, com alguns estudos favorecendo a CL+CPRE e outros, a CL+ELDBC. Conclusão: Não é possível concluir sobre a superioridade da ELDBC sobre a CPRE ou vice-versa para a remoção de cálculos no colédoco.

Objective: To evaluate the efficacy, safety and cost-effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) compared to laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods: An electronic search was conducted in the Medline, The Cochrane Library, Lilacs and Center for Reviews and Dissemination databases for systematic reviews and economic studies that reported data on the comparison between ERCP and LCBDE in patients with choledocholithiasis. A complementary search was conducted on references of included studies, journals, conference abstracts and Google Scholar. The selection was performed by two independent reviewers. In addition to the qualitative synthesis, a quantitative re-synthesis for primary outcomes was conducted in Review Manager® 5.3 using a random effects model. Results: Fifteen studies (9 systematic reviews and 6 economic studies) were included. There was no statistically significant difference between laparoscopic cholecystectomy (LC)+ERCP and LC+LCBDE in terms of removal of choledochal stones (88.5% vs. 92.8%, RR = 0.97, p-value = 0.08; N = 1,881), morbidity (14.1% vs. 13.8%, RR = 0.98, p-value = 0.88; N = 1,469), mortality (0.8% vs. 0,2%; RR = 2.13, p-value = 0.33, N = 1,471), retained stones (7.3% vs. 5.8%, RR = 1.17, p-value = 0.40; N = 1,731), conversion to other procedures (8.7% vs. 6.7%, RR = 1.20, p-value = 0.55, N = 1,287), duration of the procedure (MD = 10.91, p = 0.61, N = 717) or hospital stay (MD = 1.31, p-value = 0.10, N = 757). The cost-effectiveness literature is divided. Some studies favor LC+ERCP and others LC+LCBDE. Conclusion: It is not possible to conclude on the superiority of the LCBDE on ERCP or vice-versa for choledocholithiasis

Pinza electro bipolar controlada con computadora para cirugía laparoscópica / Electro-controlled bipolar clamp with computer for laparoscopic surgery

INTRODUCCIÓN: a) Cuadro clínico: El cáncer es la segunda causa de muerte a nivel mundial y fue responsable de 8,8 millones de muertes en el año 2015. El manejo de las enfermedades oncológicas depende, entre otras variables, del estadio del cáncer. El tratamiento de un cáncer puede involucrar quimioterapia, radioterapia o cirugía (pudiendo ser de tipo abierta o laparoscópica). En la cirugía laparoscópica, se han desarrollado diversos instrumentos para la extracción de un tumor, manipulación de vasos sanguíneos y linfáticos, disección de tejidos, entre otros procedimientos. Estos instrumentos pueden ser desde pinzas monopolares, pinzas bipolares, clips o grapas o instrumentos ultrasónicos entre otros. Se postula el uso de la pinza electro bipolar controlada por computadora (PEBCP), debido a que podría facilitar las disección y hemostasia laparoscópica disminuyendo el tráfico de instrumentos durante la cirugía y el sangrado de la cirugía laparoscópica; pudiendo de esa forma, involucrar menos días de hospitalización para el paciente comparado con otras tecnologías o abordajes. b. Descripción de la tecnología: Las PEBCP pertenecen a un grupo de instrumentos también llamados selladores de vasos bipolares electro-térmicos. Esta tecnología emplea una configuración de alta corriente y baja tensión, usando una cantidad programada de retroalimentación de diatermia bipolar (calor inducido eléctricamente). Debido a este sistema, se regula la dosis de energía que se aplicará al tejido. Este método de sellado de vasos se basa en la aplicación de una cantidad precisa de electrocoagulación bipolar y presión en el tejido, lo que lleva a la desnaturalización del colágeno y la elastina en las paredes de los vasos, resultando en un sello hemostático. OBJETIVO: Evaluar la eficacia y seguridad, así como documentos relacionados a la cobertura de la pinza electro bipolar controlada con computadora para la cirugía laparoscópica, con especial enfoque en cirugía oncológica. METODOLOGÍA: Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE, LILACS, COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Académico y TRIPDATABASE para identificar revisiones sistemáticas (RS) y ensayos clínicos aleatorizados (ECAs). Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales instituciones internacionales oncológicas y agencias de tecnologías sanitarias que realizan evaluación de tecnologías sanitarias (ETS), guías de práctica clínica (GPC) y evaluaciones económicas (EE). RESULTADOS: Se seleccionaron dos RS y tres ECAs que evaluaron la eficacia y seguridad PEBCP en cirugía laparoscópica. No se encontraron GPC ni ETS que mencionen específicamente la tecnología ni EE de la región. CONCLUSIONES: La evidencia con respecto a la PEBCP para cirugía laparoscópica es abundante y se basa en ECAs. Comparado con dispositivos monopolares, los estudios seleccionados describen una mejora en el tiempo quirúrgico más no reportan diferencia en la pérdida de sangre. Comparado con dispositivos ultrasónicos, de los cinco estudios seleccionados sólo dos reportan menos pérdida de sangre con PEBCP y sólo un estudio reporta disminución del tiempo operatorio mientras que los otros estudios no reportan diferencias. Con respecto a PEBCP vs clips/grapas, de los cuatro estudios seleccionados sólo dos reportan mejora del tiempo quirúrgico con PEBCP y sólo un estudio reporta disminución de pérdida de sangre con PEBCP mientras que los otros estudios no reportan diferencias. La mayoría de los estudios coincide en que no hay diferencias en la estancia hospitalaria, complicaciones intraoperatorias ni conversión a cirugía abierta de PEBCP comparado con otras tecnologías.

Trócares descartables cortantes para cirugía laparoscópica / Disposable trocars for laparoscopic surgery

INTRODUCCIÓN: a. Cuadro clínico: La cirugía laparoscópica es un procedimiento mínimamente invasivo donde se insertan tubos flexibles que contienen cámaras e instrumentos en el cuerpo a través de pequeñas incisiones. Este procedimiento requiere múltiples instrumentos que tienen contacto directo e indirecto con las cavidades abdominal o pélvica: el laparoscopio, trócares, pinzas, pantalla de visualización, entre otros. El primer paso para la realización de un procedimiento laparoscópico es la introducción de un trócar seguido de la insuflación de dióxido de carbono en la cavidad peritoneal, lo que se denomina pneumoperitoneo. El trócar laparoscópico es uno de los instrumentos más comunes que se asocia a la presencia de complicaciones en laparoscopía (ya sea daño tisular o vascular por ejemplo), representando casi un tercio de estas complicaciones. b. Descripción de la tecnología: Los trócares descartables están hechos de materiales plásticos y están provistos de puntas afiladas o sin cuchilla que tienen un escudo retráctil que cubre la punta antes y después de la inserción. Los trócares reutilizables están hechos de metal y tienen una punta perforadora. Esta punta puede ser roma, en forma de cono o afilada y cortante (punta cónica, piramidal, tres filos o excéntrica). OBJETIVO: Evaluar la eficacia y seguridad, así como documentos relacionados a la cobertura, de trócares descartables cortantes comparados con otro tipo de trócares o sistemas de acceso laparoscópico. METODOLOGÍA; Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE, LILACS, COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Scholar y TRIPDATABASE. Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales instituciones internacionales de cirugía laparoscópica y agencias de tecnologías sanitarias que realizan revisiones sistemáticas (RS), evaluación de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC). RESULTADOS: Se identificaron una RS y una GPC. No se encontraron ETS ni EE de la región con respecto a la tecnología de interés. En el año 2015, se publicó una RS Cochrane con el objetivo de evaluar la eficacia y seguridad de tipos de trócares en laparoscopía. La fecha de búsqueda finalizó en mayo del 2015. No se encontró una comparación de resultados entre trócares cortantes descartables específicamente versus otros. Se describen los resusltados comparativos de trócar cortante ya sea descartable o reusable. CONCLUSIONES: La evidencia con respecto a los trócares descartables cortantes comparado con otro tipo de trócares es escasa. Sólo se identificó una RS de alta calidad metodológica que comparaba trócares cortantes en general frente a otros tipos de trócares. La escasez y heterogeneidad de estudios específicamente para trócares descartables comparado con otros trócares imposibilitó el análisis por subgrupos para nuestra tecnología de interés. Según este documento, hay evidencia de muy baja calidad que sugiere que el uso de trócares que se expanden radialmente en comparación con los trócares cortantes conduce a una menor incidencia de hemorragia en el sitio del trócar. Una GPC menciona que la decisión de utilización del tipo de trócar depende de la experticia del cirujano como de las preferencias del paciente.