Consenso para la apertura y cierre de laparotomía media supra-infraumbilical utilizando metodología Delphi / Midline laparotomy technique consensus using the Delphi method

INTRODUCCIÓN: Una de las vías de acceso a la cavidad abdominal es la laparotomía media, siendo uno de los riesgos más temidos las complicaciones postoperatorias, las cuales pueden disminuirse con difusión de una adecuada técnica quirúrgica. OBJETIVO: Generar un consenso de expertos con pasos clave para realizar una laparotomía media supra-infraumbilical, a través de la metodología Delphi. MATERIALES Y MÉTODO: Por medio de una revisión de la literatura se extrajo el detalle de 37 pasos considerados en el procedimiento, organizado en secciones de preparación, apertura y cierre, siendo evaluados por un grupo de cirujanos de 7 hospitales docentes de Chile, mediante una encuesta online. RESULTADOS: El consenso se alcanzó en dos rondas, con 28 de los 37 pasos extraídos de la literatura, considerados importantes o muy importantes para la enseñanza de la técnica. Discusión: De los 28 pasos identificados como importantes, existe un alto grado de acuerdo para la preparación y apertura de una laparotomía, a diferencia del cierre en el cual no se observa una preferencia clara entre el cierre en una o varias capas entre el peritoneo y la fascia, debiendo analizarse en cada caso específico. CONCLUSIÓN: La identificación de 28 pasos estandarizados constituye un aporte en los programas de formación de residentes y en el desarrollo de modelos de simulación adecuados para la replicación del procedimiento. El aprendizaje correcto de la técnica basado en evidencia es fundamental para disminuir el riesgo de complicaciones asociadas, especialmente en el postoperatorio.

INTRODUCTION: Traditionally, the main surgical technique to access the abdominal cavity has been midline incision laparotomy, being postoperative complications a main concern. Proper teaching-learning methods could help improving the success of this procedure. AIM: Establish an expert's consensus throughout the Delphi Methodology regarding the main steps that need to be considered in a midline laparotomy. MATERIALS AND METHOD: Literature review was conducted, 37 steps were identified and grouped in 3 sections; preparation of the skin, opening incision, and closure. These steps were evaluated online by surgeons of 7 teaching hospitals in Chile. RESULTS: Consensus was reached in two rounds, 28 of the 37 steps were identified as important or very important for the procedure. DISCUSSION: There is a high level of agreement in steps related to preparation of the skin and opening incision. However, there is not a consensus regarding closure of the peritoneum and fascia in one or more layers, being a case to case decision. CONCLUSIONS: Establishment of 28 standardized steps constitutes a contribution to resident teaching programs and the development of simulation materials as an active learning strategy. Satisfactory learning outcomes have a direct impact in the success of the procedure and a lower rate of complications.

Perioperative care in an animal model for training in abdominal surgery: is it necessary a preoperative fasting? / Cuidados perioperatórios em modelo animal de treinamento em cirurgia abdominal: é necessário jejum pré-operatório?

PURPOSE: Demonstrate that the rabbit may be used in the training of surgery, in addition to present its perioperative care. METHODS: Thirty two animals, with age and weight, respectively, from 3 to 5.5 months old and 3000 to 4200 grams, were undergone different periods of pre-operative fasting, exclusive intramuscular anesthesia (ketamine+xylazine), laparotomy with total gastrectomy and total splenectomy. It was dosed the pre-operative (initial) and post-surgical (end) serum blood glucose, in addition to quantify the gastric content after the resection of the part. RESULTS: The anesthetical-surgical procedure presented a mortality rate of 3.125 percent (1:32) and a morbidity rate of 6.25 percent (2:32). It was evidenced an initial mean blood glucose = 199.4 mg/dl and the end = 326.1 mg/dl. In spite of extended fasting (minimum of 2 hours for the absolute fasting and maximum of 8.5 hours for liquids, and 20.5 hours for solids) all animals presented at the end of the surgical procedure any gastric content and a blood glucose increase. Those with fasting for liquids and solids when compared to the quantity of solid gastric content, presented a moderate negative degree of correlation. CONCLUSION: The rabbit is a good model to be used in training of surgery, with a low morbi-mortality, able to be anesthetized intramuscularly, with no need of pre-operative fasting and does not present hypoglycemia even with the extended fasting period.

OBJETIVO: Demonstrar que o coelho pode ser utilizado no treinamento em cirurgia, além de apresentar seus cuidados perioperatórios. MÉTODOS: Trinta e dois animais, com idade e peso respectivamente, entre 3 a 5,5 meses e 3000 a 4200 gramas, foram submetidos a variados tempos de jejum pré-operatório, anestesia intramuscular exclusiva (quetamina+xilasina), laparotomia com gastrectomia e esplenectomia totais. Dosou-se a glicemia sérica pré-operatória (inicial) e pós-cirúrgica (final), além de quantificado o conteúdo gástrico pós-gastrectomia. RESULTADOS: O procedimento anestésico-cirúrgico apresentou taxa de mortalidade de 3,125 por cento (1:32) e morbidade de 6,25 por cento (2:32). Evidenciou-se glicemia média inicial = 199,4 mg/dl e final = 326,1 mg/dl. Apesar de jejuns prolongados (mínimo de 2 horas para jejum absoluto e máximo de 8,5 horas para líquidos, e 20,5 horas para sólidos) todos os animais apresentaram no final do procedimento cirúrgico algum conteúdo gástrico e aumento da glicemia. Aqueles com jejum para líquidos e sólidos quando comparados com a quantidade de conteúdo gástrico sólido e total apresentaram grau moderadamente negativo de correlação linear. CONCLUSÃO: O coelho é um bom modelo para ser utilizado em treinamento de cirurgia, com baixa morbimortalidade, passível de ser anestesiado por via intramuscular, sem necessidade de jejum pré-operatório e ausência de hipoglicemia.