Incorporating robotic surgery into the management of ovarian cancer after neoadjuvant chemotherapy.

INTRODUCTION: With the rapid uptake of robotic surgery in surgical oncology, its use in the treatment of epithelial ovarian cancers is being evaluated. Complete cytoreduction represents the goal of surgery either at primary cytoreduction or after neoadjuvant chemotherapy in the setting of interval cytoreduction. In selected patients, the extent of disease would enable minimally invasive surgery. The objective of this study was to evaluate the impact of introducing robotic surgery for interval cytoreduction of selected patients with stage III-IV ovarian cancer. METHODS: All patients who underwent surgery from November 2008 to 2014 (concurrent time period when robotic and open surgery were used simultaneously) after receiving neoadjuvant chemotherapy for advanced ovarian cancer (stage III-IV) were compared with all consecutive patients who underwent cytoreductive surgery by laparotomy after neoadjuvant chemotherapy between January 2006 and November 2008. Inclusion criteria included an interval cytoreductive surgery by laparotomy or robotic assistance for stage III-IV non-mucinous epithelial ovarian, fallopian tube, or primary peritoneal cancer. Exclusion criteria included patients treated concurrently for a non-gynecologic cancer, as well as secondary cytoreductive surgeries and diagnostic surgeries without an attempt at tumor reduction. Overall survival, progression-free survival, and peri-operative outcomes were compared for the entire patient cohort with those with advanced ovarian cancer who received neoadjuvant chemotherapy immediately before and after the introduction of robotic surgery. RESULTS: A total of 91 patients were selected to undergo interval cytoreduction either via robotic surgery (n=57) or laparotomy (n=34) after the administration of neoadjuvant chemotherapy. The median age of the cohort was 65 years (range 24-88), 78% had stage III disease, and the median follow-up time was 37 months (5.6-91.4 months). The median survival was 42.8±3.1 months in the period where both robotic surgery and laparotomy were offered compared with 37.9±9.8 months in the time period preceding when only laparotomy was performed (p=0.6). All patients selected to undergo interval robotic cytoreduction following neoadjuvant chemotherapy had a reduction of cancer antigen 125 by at least 80%, resolution of ascites, and CT findings suggesting the potential to achieve optimal interval cytoreduction. All these patients achieved optimal cytoreduction with <1 cm residual disease, including 82% with no residual disease. The median blood loss was 100 mL (mean 135 mL, range 10-1250 mL), and the median hospital stay was 1 day. CONCLUSION: Robotic interval cytoreductive surgery is feasible in well-selected patients. Future studies should aim to define ideal patients for minimally invasive cytoreductive surgery.

Minimizing pain medication use and its associated costs following robotic surgery.

INTRODUCTION: Minimally invasive surgery (MIS) has been associated with diminished postoperative pain and analgesia requirements. The objective of the current study was to evaluate the use of analgesia in the post-operative period following robotic surgery for endometrial cancer. METHODS: All consecutive patients who underwent robotic surgery for the treatment of endometrial cancer were included in this study. The timing, dose, and type of analgesics administered postoperatively were recorded from patients' electronic medical record. Data was compared to a matched historical cohort of patients who underwent laparotomy before the introduction of the robotic program. RESULTS: Only eight patients (2.4%, 5 during the first 25 cases and 3 following mini-laparotomy) received patient-controlled analgesia (PCA) following robotic surgery. Most patients' pain was alleviated by over-the-counter analgesics (acetaminophen, non-steroidal anti-inflammatories). In comparison to laparotomy, patients who underwent robotic surgery required significantly less opioids (71mg vs. 12mg IV morphine, p<0.0001) and non-opioids (4810mg vs. 2151mg acetaminophen, 1892 vs. 377mg ibuprofen, and 1470mg vs. 393mg naproxen; all p<0.0001). CONCLUSION: Patients require less analgesics (opioids and non-opioids) following robotic surgery in comparison to conventional laparotomy, including the elderly and the obese. The diminished pain medication use is associated with some cost savings.

Surgical treatment for severe pediatric tracheobronchomalacia: the 20-year experience of a single center.

OBJECTIVE: In children with tracheobronchomalacia, surgical management should be reserved for the most severe cases and be specific to the type and location of tracheobronchomalacia. The goal of this study is to describe the presentation and outcomes of children with severe tracheobronchomalacia undergoing surgery. METHODS: Retrospective case series of 20 children operated for severe tracheobronchomalacia at a tertiary hospital from 2003 to 2023. Data were collected on symptoms age at diagnosis, associated comorbidities, previous surgery, age at surgery, operative approach, time of follow-up, and outcome. Surgical success was defined as symptom improvement. RESULTS: The most frequent symptoms of severe tracheobronchomalacia were stridor (50 %), cyanosis (50 %), and recurrent respiratory infections (45 %). All patients had one or more underlying conditions, most commonly esophageal atresia (40 %) and prematurity (35 %). Bronchoscopy were performed in all patients. Based on etiology, patients underwent the following procedures: anterior aortopexy (n = 15/75 %), posterior tracheopexy (n = 4/20 %), and/or posterior descending aortopexy (n = 4/20 %). Three patients underwent anterior aortopexy and posterior tracheopexy procedures. After a median follow-up of 12 months, 16 patients (80 %) had improvement in respiratory symptoms. Decannulation was achieved in three (37.5 %) out of eight patients with previous tracheotomy. The presence of dying spells at diagnosis was associated with surgical failure. CONCLUSIONS: Isolated or combined surgical procedures improved respiratory symptoms in 80 % of children with severe tracheobronchomalacia. The choice of procedure should be individualized and guided by etiology: anterior aortopexy for anterior compression, posterior tracheopexy for membranous intrusion, and posterior descending aortopexy for left bronchus obstruction.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin.

INTRODUCTION: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. METHODS: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. RESULTS: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. CONCLUSION: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Does single-site robotic surgery makes sense for gallbladder surgery?

BACKGROUND: Cholecystectomy is one of the most performed surgeries. Several techniques were created, generating less pain, better aesthetic results and faster return to activities. Robotic surgery through a single portal combined the advantages of single-incision surgery with the principles of conventional laparoscopy, making it a safe and feasible procedure. However, due to the high costs, this technology is hardly available in practice, especially in the public health system. The objective is to evaluate the safety of robotic cholecystectomy using the da Vinci Single-Site © Surgical Platform (DVSSP) in a tertiary public hospital, and to assess alternatives that can reduce the costs, influencing the final real value of the procedure. METHODS: Prospective and descriptive study evaluating robotic cholecystectomies using the DVSSP technology performed at Hospital de Clínicas de Porto Alegre from May 2017 to November 2018. RESULTS: A total of 37 cholecystectomies were performed. The average time of surgery was 82.62 min, and no intraoperative complications were observed. There was a need for conversion to conventional laparoscopy in two surgeries (5.4%). The average cost of the robotic procedure was U$ 1146.23 and the amount passed on to the institution by the Brazilian Unified Health System was on average U$ 212.59 (p < 0.05). Postoperative outcomes were satisfactory, with an incisional hernia index of 8.1%. CONCLUSION: Although robotic surgery in this setting is a safe and feasible alternative, the high cost of the procedure prevents its dissemination on a large scale. New alternatives are needed to reduce the value and to allow greater accessibility.

Laparoscopy as a Facilitator in the Early Diagnosis of a Mullerian Aplasia During Ordinary Surgery.

Laparoscopy was introduced more than 100 years ago. However, in some fields its use still meets resistance. Technology such as laparoscopy may help to identify rare and complex disorders, even in very ordinary procedures, such as inguinal hernia repair. This report highlighted the importance of early diagnosis of a complex condition using commonly available technology. To the best of our knowledge, there has not been a similar reported case in such a young patient during laparoscopic inguinal hernia repair.

Primary closure of a sternal cleft in the neonatal period.

Sternal cleft is a rare malformation of the midline fusion of the sternal bars; the most common form is the superior partial defect. Surgical correction with primary closure is the gold standard. It is recommended that the procedure be performed before 3 months of age because of the greater compliance and maximal flexibility of the thoracic wall.  These features ensure a safer repair with a low risk of complications and allow for a less extensive procedure that does not require the use of additional techniques. A midline incision is performed in the anterior thoracic wall, and the major pectoralis flaps are raised. The main surgical goal is to change the remaining sternum from a U to a V shape. Transfixing interrupted sutures are placed in the cartilaginous borders for midline closure. Hemodynamics and ventilation are monitored at this time. Closure is performed by layers.

Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results.

INTRODUCTION: Bladder exstrophy (BE) is a rare, complex malformation. There are three major approaches to closure. Despite this choice, abdominal wall closure in such patients is usually a challenging procedure specially in large defects and redo cases. OBJECTIVE: Our aim is to present our ten first cases' results, using Anterior Component Separation (ACS) to abdominal wall closure in BE patients. STUDY DESIGN: Ten male patients with BE (median age 7 months, range from 3 to 24 months) were operated from March 2020 to March 2021 by a multi-institutional Brazilian group using the Kelly technique. In addition to BE correction, anterior component separation was performed for abdominal closure. RESULTS: Postoperative suprapubic fistulae occurred in two of ten patients, but both closed spontaneously. No evisceration, abdominal wall dehiscence, or herniation was observed at a mean follow-up time of 14 months (range from 10 to 22 months). A 3 cm extent of advancement is achievable upon traction in each side (Fig. 3). CONCLUSION: We proposed the use of anterior component separation as an alternative for abdominal closure after BE correction using the Kelly procedure. This new technique avoids mesh usage, loosens the abdominal wall tension, and reduces complications. Even However, further studies are required.

Complex ventral hernia repair in a child: An association of botulinum toxin, progressive pneumoperitoneum and negative pressure therapy. A case report on an arising surgical technique.

INTRODUCTION: The purpose of this manuscript is to report the management of a child born with giant omphalocele (GO) that developed a complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect. PRESENTATION OF CASE: The patient underwent a one-step surgery to correct a ventral hernia associated with a largely prolapsed enteroatmospheric fistula (EAF) along with an ileostomy. It was managed by a pre-operative association of botulinum toxin agent (BTA) application with preoperative progressive pneumoperitoneum (PPP) and trans-operative negative pressure wound therapy (NPWT) dressing with staged abdominal closure. The patient needed 4 reoperations due to enteric fistulas. Nine days after the first surgery, it was possible to completely close the abdominal wall without mesh substitution. No signs of hernia in 9 months of follow-up. DISCUSSION: This is the second report in the literature and it reinforces the safety and effectiveness of the BTA injection associated with PPP in children. CONCLUSION: The use of BTA in association with PPP should be encouraged and best investigated in patients with GO. The fistulas were not attributed to the negative pressure. Maybe it is time to start defining better criteria to categorize GO in order to choose the best management for each patient.

Laparoscopic gonad-sparing procedure in Ovotesticular disorder of sex development - Case video technique.

INTRODUCTION: Ovotesticular disorder of sex development (OTD) is a rare condition. There's a lack of literature addressing gonad-sparing surgery for OTD. OBJECTIVE: Report the laparoscopic partial gonadectomy technique - gonad-sparing surgery - in an 11-year-old child, 46, XX karyotype with OTD with atypical genitalia. MATERIAL AND METHODS: After a complete diagnostic evaluation the patient underwent feminizing genitoplasty followed by laparoscopic partial gonadectomy (gonad-sparing surgery). The patient was positioned on supine position and Trendelenburg. One 5 mm port was placed on the umbilicus and two 3 mm ports in both flanks. A gonadal wedge biopsy was performed to achieve histopathological confirmation before resection. The testicular component of the ovotestis is clearly identified based on macroscopic aspects, and resected with laparoscopic scissors and limited use of electrocautery. DISCUSSION: This case was classified as bipolar or terminal ovotestis. At the 5-month follow-up, the patient attained menarche. No adverse outcomes have been recorded. Postoperative third year follow-up hormone evaluation revealed a= female pattern characteristic and ultrasound demonstraed uterine volume increase, as well as bilateral ovarian tissue development with follicles. CONCLUSIONS: Gonad-sparing procedure is feasible and desirable whenever possible, especially in 46, XX patients with female sex of rearing, since it preserves the fertility potential. The risk of malignancy must be monitored.

Surgical treatment for severe pediatric tracheobronchomalacia: the 20-year experience of a single center

Abstract Objective: In children with tracheobronchomalacia, surgical management should be reserved for the most severe cases and be specific to the type and location of tracheobronchomalacia. The goal of this study is to describe the presentation and outcomes of children with severe tracheobronchomalacia undergoing surgery. Methods: Retrospective case series of 20 children operated for severe tracheobronchomalacia at a tertiary hospital from 2003 to 2023. Data were collected on symptoms age at diagnosis, associated comorbidities, previous surgery, age at surgery, operative approach, time of follow-up, and outcome. Surgical success was defined as symptom improvement. Results: The most frequent symptoms of severe tracheobronchomalacia were stridor (50 %), cyanosis (50 %), and recurrent respiratory infections (45 %). All patients had one or more underlying conditions, most commonly esophageal atresia (40 %) and prematurity (35 %). Bronchoscopy were performed in all patients. Based on etiology, patients underwent the following procedures: anterior aortopexy (n = 15/75 %), posterior tracheopexy (n = 4/20 %), and/or posterior descending aortopexy (n = 4/20 %). Three patients underwent anterior aortopexy and posterior tracheopexy procedures. After a median follow-up of 12 months, 16 patients (80 %) had improvement in respiratory symptoms. Decannulation was achieved in three (37.5 %) out of eight patients with previous tracheotomy. The presence of dying spells at diagnosis was associated with surgical failure. Conclusions: Isolated or combined surgical procedures improved respiratory symptoms in 80 % of children with severe tracheobronchomalacia. The choice of procedure should be individualized and guided by etiology: anterior aortopexy for anterior compression, posterior tracheopexy for membranous intrusion, and posterior descending aortopexy for left bronchus obstruction.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin / Onfalocele gigante: Uma nova abordagem para reparo primário no período neonatal utilizando toxina botulínica

ABSTRACT Introduction: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. Methods: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. Results: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. Conclusion: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

RESUMO Introdução: onfalocele gigante (OG) é uma condição complexa para a qual muitas alternativas terapêuticas foram desenvolvidas; no entanto, não há consenso sobre qual o melhor tratamento. Os benefícios e eficácia da toxina botulínica A (TBA) no reparo de grandes defeitos da parede abdominal em adultos foram comprovados, e o relato de uso em crianças cresceu recentemente. O objetivo deste estudo é descrever uma nova técnica para reparo primário de OG utilizando TBA durante o período neonatal e relatar nossa experiência inicial. Métodos: os pacientes foram acompanhados de agosto de 2020 a julho de 2022. A TBA foi aplicada na parede abdominal lateral nos primeiros dias de vida, seguida de correção cirúrgica do defeito abdominal. Resultados: enquanto aguardavam a cirurgia, os pacientes tiveram mínima manipulação, sem ser exigida ventilação mecânica, permaneceram em alimentação enteral plena e mantiveram contato com os pais. A linha média foi aproximada sem tensão e sem necessidade de técnicas adicionais ou uso de prótese. Os pacientes receberam alta com o defeito reparado. Conclusão: essa abordagem representa um meio-termo entre o reparo estagiado e o tratamento não-operatório. Não requer intervenções agressivas no início da vida, permitindo a manutenção do vínculo materno-infantil e a alta do paciente com defeito reparado sem a necessidade de uso de técnicas adicionais ou prótese. Acreditamos que esta técnica deva ser considerada como um novo possível recurso no manejo desta complexa condição.

[Impact of vaginal delivery after a previous cesarean section on perinatal outcomes]. / Impacto do parto vaginal após uma cesárea prévia sobre os resultados perinatais.

PURPOSE: To analyze the impact of vaginal delivery after a previous cesarean section on perinatal outcomes. METHODS: Case-control study with selection of incident cases and consecutive controls. Maternal and perinatal variables were analyzed. We compared secundiparas who had a vaginal delivery after a previous cesarean delivery (VBAC) (n=375) with secundiparas who had a second cesarean section (CS) (n=375). Inclusion criteria were: secundiparas who underwent a cesarean section in the previous pregnancy; singleton and term pregnancy; fetus in vertex presentation, with no congenital malformation; absence of placenta previa or any kind of bleeding in the third quarter of pregnancy. RESULTS: The rate of vaginal delivery was 45.6%, and 20 (5.3%) women had forceps deliveries. We found a significant association between VBAC and mothers younger than 19 years (p<0.01), Caucasian ethnicity (p<0.05), mean number of prenatal care visits (p<0.001), time of premature rupture of membranes (p<0.01), labor duration shorter than 12 hours (p<0.04), Apgar score lower than seven at 5th minute (p<0.05), fetal birth trauma (p<0.01), and anoxia (p<0.006). In the group of newborns delivered by cesarean section, we found a higher frequency of transient tachypnea (p<0.014), respiratory disorders (p<0.048), and longer time of stay in the neonatal intensive care unit (p<0.016). There was only one case of uterine rupture in the VBAC group. The rate of neonatal mortality was similar in both groups. CONCLUSIONS: Vaginal delivery in secundiparas who had previous cesarean sections was associated with a significant increase in neonatal morbidity. Further studies are needed to develop strategies aimed at improving perinatal results and professional guidelines, so that health care professionals will be able to provide their patients with better counseling regarding the choice of the most appropriate route of delivery.

Impacto do parto vaginal após uma cesárea prévia sobre os resultados perinatais / Impact of vaginal delivery after a previous cesarean section on perinatal outcomes

OBJETIVO: Analisar o impacto do parto vaginal, após uma cesárea prévia, sobre os resultados perinatais. MÉTODOS: Estudo caso-controle, com seleção de casos incidentes e controles consecutivos, no qual foram analisadas variáveis maternas e perinatais. Compararam-se gestantes secundigestas com parto cesáreo prévio (n=375) e que deram à luz via transpélvica (PVPC), com gestantes com os mesmos critérios de inclusão, mas submetidas a operação cesariana (PCPC, n=375). Foram considerados critérios de inclusão: gestantes secundigestas que tenham dado à luz por meio de parto cesariana na gestação anterior; gestação única e de termo; feto em apresentação cefálica, sem malformação congênita; ausência de placenta prévia ou qualquer tipo de sangramento de terceiro trimestre gestacional. RESULTADOS: No estudo, a taxa de PVPC foi de 45,6%, sendo que 20 deles (5,3%) foram ultimados com o fórceps. Observou-se associação significante entre PVPC e idade materna inferior a 19 anos (p<0,01), etnia caucasiana (p<0,05), número médio de consultas de pré-natal (p<0,001), tempo de ruptura prematura das membranas (p<0,01), tempo de trabalho de parto inferior a 12h (p<0,045), índice de Apgar inferior a sete no 5º minuto (p<0,05), tocotraumatismo fetal (p<0,01) e anoxia (p<0,006). No grupo de recém-nascidos por PCPC observou-se maior frequência de taquipneia transitória (p<0,014), disfunções respiratórias (p<0,04) e maior tempo de internação na unidade de tratamento intensivo neonatal (p<0,016). Houve apenas um caso de ruptura uterina no grupo PVPC. O número de neomortos foi idêntico em ambos os grupos. CONCLUSÕES: A via de parto vaginal em secundigestas com cesárea prévia associou-se a aumento significativo da morbidade neonatal. Serão necessários mais estudos para elaborar estratégias que visem melhorias dos resultados perinatais e de auxílio aos profissionais, de forma que estes possam melhor orientar as suas pacientes na escolha da via de parto mais adequada.

PURPOSE: To analyze the impact of vaginal delivery after a previous cesarean section on perinatal outcomes. METHODS: Case-control study with selection of incident cases and consecutive controls. Maternal and perinatal variables were analyzed. We compared secundiparas who had a vaginal delivery after a previous cesarean delivery (VBAC) (n=375) with secundiparas who had a second cesarean section (CS) (n=375). Inclusion criteria were: secundiparas who underwent a cesarean section in the previous pregnancy; singleton and term pregnancy; fetus in vertex presentation, with no congenital malformation; absence of placenta previa or any kind of bleeding in the third quarter of pregnancy. RESULTS: The rate of vaginal delivery was 45.6%, and 20 (5.3%) women had forceps deliveries. We found a significant association between VBAC and mothers younger than 19 years (p<0.01), Caucasian ethnicity (p<0.05), mean number of prenatal care visits (p<0.001), time of premature rupture of membranes (p<0.01), labor duration shorter than 12 hours (p<0.04), Apgar score lower than seven at 5th minute (p<0.05), fetal birth trauma (p<0.01), and anoxia (p<0.006). In the group of newborns delivered by cesarean section, we found a higher frequency of transient tachypnea (p<0.014), respiratory disorders (p<0.048), and longer time of stay in the neonatal intensive care unit (p<0.016). There was only one case of uterine rupture in the VBAC group. The rate of neonatal mortality was similar in both groups. CONCLUSIONS: Vaginal delivery in secundiparas who had previous cesarean sections was associated with a significant increase in neonatal morbidity. Further studies are needed to develop strategies aimed at improving perinatal results and professional guidelines, so that health care professionals will be able to provide their patients with better counseling regarding the choice of the most appropriate route of delivery.