Outcomes of laparoscopic management of multicompartmental pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse (POP) is an increasing medical problem with complex diagnostics and controversial surgical management. It causes a series of dysfunctions in the gynecological, urinary, and anorectal organs. Numerous procedures have been proposed to treat these conditions, but in recent years, ventral mesh rectocolposacropexy (VMRCS) has emerged as the procedure of choice for the surgical treatment of POP, especially by a laparoscopic approach. This surgical technique limits the risk of autonomic nerve damage, and the colpopexy allows the correction of concomitant prolapse of the middle compartment. However, symptoms derived from anterior compartment prolapse remain a major morbidity and sometimes require an additional procedure. The aim of this study is to evaluate the results of laparoscopic prosthetic rectocolposacropexy (LRCS) and colposacropexy (LCS) procedures performed to manage combined multicompartmental POP. METHODS: Between November 2008 and December 2017, 38 patients with symptomatic POP underwent rectocolposacropexy (RCS) or colposacropexy (CS) by a laparoscopic approach. Demographics, mortality, morbidity, hospital stay, and functional outcomes were retrospectively analyzed. RESULTS: The median operating time was 200 min (IQR 160-220). Additional simultaneous surgery for POP was performed in nine cases: five suburethral slings and four hysterectomies were performed. No mortality was recorded. The conversion rate was 7.89%. There were two intraoperative complications (5.26%): one enterotomy and one urinary bladder tear. Late complications occurred in 5.26% of cases. After a mean follow-up of 20 months, constipation was completely resolved or improved in 83.33% of patients, urinary stress incontinence was resolved or improved in 52.94%, and gynecological symptomatology was resolved or improved in 93.75%. The recurrence rate was 5.26%. CONCLUSIONS: Laparoscopic mesh rectocolposacropexy and colposacropexy are safe and effective techniques associated with very low morbidity. In the medium term, they provide good results for POP and associated symptoms, but urinary symptomology has a worse outcome.

ERCP's role in the management of acute biliary-pancreatic pathology in the laparoscopic era.

OBJECTIVES: Laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in the management of the acute biliopancreatic pathology. Nevertheless, controversy remains about the appropriate timing for retrograde cholangiopancreatography. METHODS: A retrospective study was undertaken on a consecutive series of 117 patients with acute biliary-pancreatic pathology, who underwent laparoscopic cholecystectomy between April 1995 and April 1999. Criteria for preoperative endoscopic retrograde cholangiopancreatography were defined, and the patients were divided into 3 groups based on the presence or absence of a preoperative retrograde cholangiopancreatography indication: (1) ERCP+LC group: patients with retrograde cholangiopancreatography indicated and performed (n = 30); (2) LC group: patients without retrograde cholangiopancreatography criteria treated only by LC (n = 47); (3) LC-ERCP group: patients with retrograde cholangiopancreatography criteria but not performed (n = 40). RESULTS: The groups were similar in age, sex, ASA, and clinical diagnosis. No statistical differences occurred in operative times (73.8 min, 68 min, 67 min), major complications (3.3%, 4.25%, 12.5%), and mean postoperative stay (3.7 +/- 4; 4.7 +/- 2; 5.7 +/- 2). Postoperative retrograde cholangiopancreatography had to be used, respectively, in 0%, 10.6%, and 7.5%. The best predictive criteria for common bile duct pathology were choledocholithiasis on an ultrasound scan and the presence of cholangitis. The other criteria tested had a low predictive value. CONCLUSIONS: Preoperative endoscopic retrograde cholangiopancreatography followed by early laparoscopic cholecystectomy can be performed safely in acute biliary-pancreatic pathology, avoiding 2-stage treatment of these patients and minimizing hospital stay and inconvenience to the patients. Nevertheless, this therapeutic/diagnostic tool must be used selectively.

Laparoscopic appendectomy by ultrasonically activated scalpel in acute appendicitis: preliminary report.

BACKGROUND AND PURPOSE: Laparoscopic appendectomy (LA) is increasingly being used in treating acute appendicitis. New instruments such as the ultrasonically activated scalpel (UAS) have been introduced for most laparoscopic procedures. We evaluated the use of UAS in the performance of LA, as the potential of this instrument in this type of surgery remains to be defined. PATIENTS AND METHODS: Three patients with acute right lower abdominal pain were managed by the laparoscopic approach. Once the diagnosis of acute appendicitis was established, laparoscopic appendectomy was performed with the UAS. RESULTS: The mean operative time was 42.3 minutes (range 32-49 minutes). There were no complications related to the treatment with UAS of either the vascular pedicle or the appendicecal stump. No electrosurgical coagulation, clips, loops, or endostapler was used in any patient. CONCLUSIONS: Total LA performed with UAS is feasible. Use of the UAS may make dissection and resection of the appendix easier, helping to reduce the mean operative time.

Acute diverticulitis and diverticular disease of the colon: a safe indication for laparoscopic surgery.

AIM: We analyzed our experience with a laparoscopic method for the treatment of acute diverticular disease. METHODS: Between January 1994 and October 1999 a group of 52 patients who fulfilled the criteria for symptomatic diverticular disease in the descending and sigmoid colon underwent laparoscopy with resection of an average of 40 cm of the bowel. Intraabdominal mechanical anastomosis completed the procedure. RESULTS: The use of ultrasonic scissors made the laparoscopic technique easier and shortened operative time. Operative morbidity was 15%. Two patients with acute diverticulitis and associated sepsis were reconverted to open surgery, and 4 patients presented postoperative rectal bleeding which ceased spontaneously. No long-term complications were found except in 1 patient who developed an incisional hernia through an entry port. Oral intake began between the second and third day. Postoperative hospitalization was 3-8 days (mean: 5.5 days) and mean operative time was 130 min (range: 70-240 min). CONCLUSIONS: Despite the steep learning curve for this type of surgery, the good morbidity and mortality rates with the laparoscopic method, especially with high-risk groups of patients (age > 65 years, high blood pressure, etc.) suggest that this surgical option can be used efficiently and safely, and that it achieves better results than with open surgery. However, we feel that the treatment of patients with acute complications of diverticular colon disease requires extensive experience with laparoscopic colorectal surgery.

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh.

BACKGROUND: Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques. METHODS: A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays. RESULTS: The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05). CONCLUSIONS: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay.

Decrease in plasma levels of vasoactive intestinal polypeptide in short bowel syndrome: experimental study.

To investigate the behaviour of the vasoactive intestinal polypeptide (VIP) in short bowel syndrome (SBS), an experimental model of massive intestinal resection (MIR) was developed. For this purpose, 20 'minipigs' were divided into two experimental groups: A (control) and B (MIR). The parameters determined were the mean plasma levels of VIP and the degree of steatorrhea at four different times: T1 (basal), T2 (one week after surgery), T3 (two weeks after surgery), and T4 (24 weeks after surgery). The results indicated that, after MIR, a progressive decrease in the mean plasma levels of VIP takes place, with statistical significance in T3 (p < 0.05) and T4 (p < 0.01). This situation seems to be a direct result of the massive loss of intestinal tissue, and could lead to the use of this peptide to mark the evolution of the intestinal adaptation process.

Surgical treatment of the acute cholecystitis in the laparoscopic age. A comparative study: laparoscopy against laparatomy.

OBJECTIVE: The aim of this study was to assess the complications and results of the laparoscopic opposite to open treatment of the acute cholecystitis. METHODS: A retrospective randomized study with two groups of 30 patients each one. The parameters tested were age, sex, risk factors, surgical time, hospital stay, cholecystitis type, and early or late complications. RESULTS: In the two groups there were no significant differences in age, sex, risk factors, type of cholecystitis and surgical time. The average of hospital stay was significantly longer for open cholecystectomy (9.5) than for laparoscopic technique (2.30) (p < 0.001). The complication rate was higher (7.30%) in open cholecystectomy. CONCLUSIONS: The laparoscopic cholecystectomy should be the standard procedure for the treatment of the acute cholecystitis.

Intragastric migration of laparoscopic adjustable gastric band (Lap-Band) for morbid obesity.

The appearance of fistulas and the posterior intragastric inclusion of the adjustable silicone Lap-Band prothesis have been described, representing a severe complication of the Lap-Band procedure. A 45-year-old patient with severe obesity, weighing 115 kg, and having BMI (body max index) of 45 kg/m2 was assigned to a protocol to place a Lab-Band in her. An infection in the reservoir after 9 months indicated the beginning of the appearance of fistulas. The entire adjustable silicone gastric band device eroded inside the stomach between months 9 and 14 after its placement, resulting in reoperation. The gastric inclusion of the Lap-Band device represents a severe complication that requires reoperation, and raises concerns about the safety of this new alternative weight reduction operation.

Vertical ring gastroplasty (VRG) in the treatment of the serious clinical obesity. Results and complications.

OBJECTIVE: The morbid obesity is a serious polysystematic disease to which it is necessary to offer a surgical solution when the conservative alternatives fail. METHODS: In a period of five years, 50 patients with vertical ring gastroplasty (VRG) have been evaluated and protocolized in the program of surgery of the morbid obesity, with an average weight of 134.3 kg corresponding to an overweight and body mass index (BMI) average respectively, of 69.7 kg and 49.8 kg/m2. RESULTS: The early morbidity has been scarce and the postoperative average stay of 7 days. The decrease of the percentage of weight, overweight and BMI was maximum 2 years later, with losses of 52 kg, with a percentage of loss of average overweight of 76.8% and a fall of 21 points in the BMI; however there was a partial recovery of the indexes in the following years. The accompanying pathology was solved in the period of studied time, although 84% of the patients referred vomits and practically 100% dietary limitations. CONCLUSIONS: The gastroplasty is a quick, simple technique and of scare morbimortality, although it is being subjected to criticism for the restrictions in the diet, quality of life and disruptions of the line of clamped. However, nowadays there is not a consensus on the ideal bariatric solution, and as a surgical alternative, the vertical gastroplasty can represent one of the techniques of choice for certain selected types of serious obesity.

The laparoscopic approach in the treatment of diverticular colon disease.

BACKGROUND AND OBJECTIVES: The experience with treatment of diverticular colon disease (DCD) by the laparoscopic method is analyzed. METHODS: Between January 1994 and July 1997, a group of 22 patients with criteria for symptomatic diverticular disease in the descending and sigmoid colon underwent laparoscopy with average resections of 40 cm. Intra-abdominal mechanical anastomosis completed the procedure. RESULTS: The operative morbidity was 28%. Two cases, in acute diverticulitis phase, were reconverted to open surgery, and three cases presented postoperative rectorrhagia which ceased spontaneously. No long-term complications have been found. Postoperative hospitalization was 4-8 days (mean 5.5) and mean operative time was 165 minutes (range 120-240). CONCLUSIONS: Nevertheless, the learning curve precise to practice this type of surgery, the acceptable morbity-mortality rates which the laparoscopic method presents, especially with these high-risk groups of patients (age > 65, high blood pressure, etc), encouraged us to modified the criteria indicating surgery for the disease, offering first choice operative treatment with efficiency and safety. However, we feel that those patients with acute complications of diverticular colon disease must be excluded initially for laparoscopic approach.

Gallbladder and cystic duct absence. An infrequent malformation in laparoscopic surgery.

Gallbladder absence is an infrequent anomaly normally accompanied by lack of the cystic duct. Of unknown etiology, in general it is accepted to be a congenital malformation. A male patient (age 59) diagnosed with nonfunctional symptomatic scleroatrophic gallbladder by echography and ERCP was operated on using a laparoscopic approach. Gallbladder and cystic absence was diagnosed during the procedure. A new case of gallbladder and cystic duct absence, diagnosed by laparoscopy, is presented. This type of extrahepatic bile duct malformation is quite rare, but it must be taken into account due to the generalization of laparoscopic surgery in biliar pathology because of the high risk of serious lesions to the hepatocholedochal system.

[The morphometric changes of chronic ischemia in the hepatocyte. An experimental study in the rat]. / Alteraciones morfométricas de la isquemia crónica sobre el hepatocito. Estudio experimental en la rata.

The effects of chronic ischemia on the rat hepatocyte are morphometrically analyzed in the present study. Rats Wistar-Lewis are used. Rats underwent a stenosis of the celiac artery by using a metallic guide. The interval between the experimentation until the sacrifice was 15, 30, 90, 180, and 360 days. We have performed a morphometric study using a semiautomated image analyzer system (VIDS III, Analytical Measuring Systems). Morphological disturbances in the chronic ischemia periods above mentioned can be measured: an increase in the hepatocyte area starting from 90 days of experimentation and also an increase in the hepatocyte perimeter starting from 30 days of ischemia. On the other hand, both the nuclear area and the nuclear perimeter are increased in every period studied. The number of hepatocytes per microscopic field doesn't show any change in relation to ischemia time. Cellular swelling suggests some degree of cellular hypoxia in contradiction with other observations.

[Behavior of thyroid function following massive intestinal resection. Experimental study]. / Comportamiento de la función tiroidea tras la resección intestinal masiva. Estudio experimental.

With the purpose of research the behaviour of the thyroid function after massive intestinal bowel resection, we have designed an experimental model of short bowel syndrome. For this aim two groups of study were employed, each one with seven animals (minipigs). RIA for T4, T3 y TSH were made in four different times: basal (R1), immediately after intestinal resection (R2), two weeks after it, and six months later (R4). The results show that, once short bowel syndrome is established, the animals remain in euthyroid state. But the transitory oscillations of T4 in R3 and T3 in R2 suggested that these could be caused for alterations in the enterohepatic circulation of thyroid hormones in the acute diarrheal state.