Minilaparoscopic CLIPLESS Cholecystectomy: Tips, Tricks and Advanced Maneuvers.

As the world sought the 'Holy Grail' of scarless surgery, minimizing access seemed to be the natural path to follow, and minilaparoscopy (MINI) was considered to be a natural advancement of standard laparoscopy. It aims at minimizing surgical trauma by further reducing the diameter of standard instruments, without compromising range of motion, triangulation or safety. Several different terms have been coined to address this sophisticated reduced-port technique, which is characterized by the use of instruments 3 mm or less in diameter: acuscopic surgery, minilaparoscopy, needlescopic surgery and microlaparoscopy. The early adoption of MINI was mostly inhibited by the limitations of first-generation instruments, especially with respect to functionality, cost and durability. Furthermore, mini cholecystectomy demanded the use of mini optics, which suffered from poor imaging quality and a short lifetime of the scopes. Newer-generation mini instruments have mitigated these issues through the use of improved effector tips, better insulation, strength and durability, and superior optics. During the early MINI years, surgeons clipped most structures, but sturdy mini clip appliers were either unavailable or did not hold the requisite-size clips. Clipping with MINI required the use of a standard clip applier and the scope had to be changed several times during a procedure, making MINI not only more complicated but also boring and time-consuming. The development and popularization of the clipless technique allowed the surgeon to get free from the expensive and cumbersome minilaparoscopic clip appliers, and replace clips with knots. The marked improvements in instrumentation and the development of the clipless technique have occurred simultaneously with the development of NOTES, LESS and Robotic surgery, which may have contributed to a greater push towards MINI. MINI has been proven to offer more than just better cosmesis. Other advantages include better visualization of the surgical field and, with the development of precisely engineered low-friction trocars, which enhance surgical precision during dynamic and delicate tasks (knotting and suturing small structures), less stress and higher efficiency, which makes the procedure easier to perform. Furthermore, transmission of electro cautery through mini instruments has led to less lateral spread of electric current and subsequent less tissue trauma. For more than 20 years, our team has successfully used minilaparoscopy. Even with the rising popularity of robotic surgery, which still uses 8 mm instruments, minilaparoscopy remains an attractive option that is far from becoming obsolete.

Which Cholecystectomy Technique Would Surgeons Prefer on Themselves?

BACKGROUND: As the minimally invasive surgery revolution approaches 30 years, many techniques are now available for cholecystectomy: open, conventional laparoscopy, ini-laparoscopy, single incision, robotic, and natural orifice. Although much has been published about patient preferences regarding these techniques, less is known about surgeon perceptions and preferences. The aim of this study was to survey attending and trainee surgeons about which cholecystectomy technique they would prefer for themselves and what factors determine their decision. METHODS: Attending fellow and resident surgeons globally completed a Google Forms online questionnaire that was posted in 3 closed groups for surgeons on Facebook and WhatsApp. RESULTS: The online questionnaire was completed by 600 surgeons (453 attending surgeons and 147 residents/fellows). Most respondents were male individuals (87.6% of attending surgeons, 78.2% of trainee surgeons). The most common age range of respondents was 31 to 40 years. Surgeon response was global, with especially good representation from North American, Asian, and European physicians. When conventional laparoscopy, mini-laparoscopy, and robotic surgery were the options offered for cholecystectomy, 58.5% of trainees and 45.7% of surgeons chose conventional laparoscopy. When asked if they would consider a single-incision or natural orifice transluminal endoscopic surgery approach, 91.5% answered no. When asked which technique they would prefer if hypothetically all techniques were equally safe, about three-fourths chose either conventional laparoscopy (46%) or mini-laparoscopy (27%). When asked to rank which factors they considered most important in choosing a surgical technique, surgeon experience (52%) and safety of the procedure (45%) were the 2 most important factors. CONCLUSIONS: When an international sample of 600 attending and trainee surgeons were asked about undergoing a cholecystectomy on themselves, most chose either conventional laparoscopy or mini-laparoscopy as their preferred access technique. Single-incision and natural orifice transluminal endoscopic surgery approaches were unpopular. Surgeons ranked the experience of the operating surgeon and safety of the procedure as the most important factors guiding their decision.

Use of bacterial cellulose film for repair of bile duct injury in pigs.

BACKGROUND/OBJECTIVE: The aim was to evaluate the use of bacterial cellulose film and bile duct autograft in repairing critical common bile duct injury in pigs. METHODS: A prospective experimental analytical study was carried out on 20 Sus Domesticus, Piau suidae swine, divided into a control group (n = 10) and an experimental group (n = 10) divided into two subgroups: bacterial cellulose film E1 and bacterial cellulose film E2 to which bacterial cellulose film was randomly allocated. The control group underwent two complete critical common bile duct sections 10 mm apart, while the experimental group with a single critical common bile duct defect underwent a 10 mm section of the longitudinal shaft with edge resection. The defects in the control group were treated with end-to-end conventional anastomosis using polyglycolic 6-0 surgical thread and the experimental group with bacterial cellulose film by continuous suture using the same material. The animals were clinically evaluated throughout the experiment on days D150 (bacterial cellulose film E1), D225 (control group), and D330 (bacterial cellulose film E2) and by intraoperative ultrasound examination related to histopathological and biochemical findings. RESULTS: The intraoperative ultrasonography detected the changes resulting from the common bile duct anastomosis in the control group that produced a considerable incidence of ductal narrowing and obstruction to the biliary flow. In the bacterial cellulose film E2 group, there was an increase in inflammation intensity, granulomatous reaction, fibrosis, and vessels density, without producing bile duct dilation in the ultrasonography assessment. Biochemical analysis of liver enzymes yielded results in the normal range confirming preservation of liver function at the different post-surgery time points. CONCLUSION: Bacterial cellulose film, when used as a graft for bile duct repair, proved to be a biocompatible material that produced a complete healing process and biliary flow continuity.

Which Cholecystectomy do Medical Students Prefer?

INTRODUCTION: This study was undertaken to identify which minimally invasive technique medical students prefer for cholecystectomy and what factors determine their decision. METHODS: Brazilian medical students watched a video reviewing the advantages and disadvantages of six different surgical approaches to cholecystectomy: open surgery, conventional laparoscopy, mini-laparoscopy (MINI), single-incision laparoscopic surgery, natural-orifice transluminal endoscopic surgery, and robotic surgery. Respondents then answered questions about hypothetical situations in which the participants would be submitted to elective cholecystectomy. RESULTS: One hundred eleven medical students completed the survey, 60 females (54%) and 51 males (46%). Most students were 19-26 years old. When asked whether they would consider an open cholecystectomy if minimally invasive surgery (MIS) techniques were available, only 9% answered yes. Senior medical students were the least willing to consider open surgery (P = .036). When asked if they would prefer conventional laparoscopy, MINI, or robotic surgery for their cholecystectomy, 85% of the women and 63% of the men chose MINI (P = .025). When asked if they would consider a single-incision laparoscopic surgery or natural-orifice transluminal endoscopic surgery approach, 94 respondents (84%) answered no. When asked to rank which factors they consider the most important when choosing a surgical technique, they ranked safety of the procedure first (58%) and surgeon experience second (30%). CONCLUSION: When Brazilian medical students were asked to select a surgical approach for cholecystectomy, most chose MINI. The preference for MINI was strongest amongst female medical students. Both female and male medical students ranked safety as the most important factor.

Minilaparoscopy For Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: Inguinal hernia repair is among the most common procedures performed worldwide and the laparoscopic totally extraperitoneal (TEP) approach is a recognized and effective surgical technique. Although technically advantageous because of the option of no mesh fixation and no need for creation of a peritoneal flap resulting, in less postoperative pain and faster recovery, TEP has not achieved the popularity it deserves, mainly because of its complexity and steep learning curve. Minilaparoscopy was first described in the 1990s and has recently gained significantly from better instrumentation that may increase TEP's effectiveness and acceptance. We performed a prospective study, to analyze the outcomes of minilaparoscopy in pain and operative time when compared to the conventional laparoscopic technique in hernia repair. METHODS: Fifty-eight laparoscopic inguinal hernia repairs were performed: 36 by traditional laparoscopic technique and 22 by minilaparoscopic instruments (mini). A study protocol was applied prospectively for data collection. Variables analyzed were early postoperative pain (at hour 6 after procedure), pain at discharge, use of on-demand analgesics, and operative time. RESULTS: The mini group presented reduced early postoperative pain and operative time. The present study also suggests less postoperative pain at discharge with mini procedures, although this difference was not statistically significant. No difference between the groups regarding on-demand use of analgesics was found. CONCLUSIONS: This study corroborates findings in previously published papers that have shown the feasibility of minilaparoscopy in laparoscopic TEP hernia repair and its benefits regarding postoperative pain, operative time, and aesthetic outcomes.

The Science Behind Mini-Laparoscopic Cholecystectomy.

BACKGROUND: Mini-laparoscopy (Mini) was pioneered more than 20 years ago. Newer generation mini instruments have recently become available with improved effector tips, a choice of shaft diameters and lengths, better shaft insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument durability. Whether the use of mini instruments, particularly newer generation instruments, offers advantages for laparoscopic cholecystectomy is the subject of this review. MATERIALS AND METHODS: The literature was searched for level I data comparing mini-laparoscopic cholecystectomy (Mini LC) to standard laparoscopic cholecystectomy (Std LC). Three systematic reviews and 19 randomized clinical trials were identified and these were studied to evaluate the science behind Mini LC. RESULTS: Mini LC requires conversion to Std LC in 12.3% of patients. Mini LC and Std LC require conversion to open cholecystectomy at the same rate (2-3%). As compared to Std LC, Mini LC: (1) takes 3.4-4.9 minutes longer to perform; (2) has the same rate of intraoperative and postoperative complications; (3) may result in slightly less pain in the first 24 hours after surgery; (4) has the same duration of hospital stay, pain scores 1-28 days after surgery, time to return to activity, time to return to work, and postoperative quality of life 10 days after surgery; (5) provides a better early cosmetic result (as graded by patients and by blinded observers); and (6) provides no apparent difference in late cosmesis (as evaluated 6-12 months postop). There are minimal level I data published on the effects of newer mini instruments for laparoscopic cholecystectomy. CONCLUSION: When applied to elective laparoscopic cholecystectomy, the use of mini-laparoscopic instruments results in a slightly longer operative procedure (3-5 minutes), slightly less immediate postoperative pain (in the first 24 hours), and a better early cosmetic result, with no other apparent significant differences. Additional data are needed from large, well-conducted studies of Mini LC to resolve several unanswered questions, including the role of newer mini instruments.

Intragastric Balloon for Overweight Patients.

BACKGROUND AND OBJECTIVES: Current treatments for overweight adults include reduced-calorie diet, exercise, behavior modification, and selective use of medications. Many achieve suboptimal results with these measures and progress to obesity. Whether the intragastric balloon (IGB), a reversible device approved for treatment of obesity, is a safe and effective option in overweight adults is less well studied. We conducted a study to prospectively analyze the safety and effectiveness of IGB in overweight adults, to compare the results to a simultaneously studied cohort of obese patients, and to share procedural tips for safe IGB placement and removal. METHODS: One hundred thirty-nine patients were evaluated in this prospective, nonrandomized study. Twenty-six overweight [body mass index (BMI), 26-30)] and 113 obese (BMI > 30) patients underwent outpatient, endoscopic IGB placement under intravenous sedation. The IGB was filled with a 550-900 mL (average, 640 mL) solution of saline, radiological contrast, and methylene blue, with an approximate final proportion of 65:2:1. The patients were followed up at 1-2 weeks and then monthly for 6 months. At 6 months, they underwent IGB removal via an esophageal overtube to optimize safety, and then they were observed for 6 more months. RESULTS: IGB time was 190 ± 36 d in the overweight patients and 192 ± 43 d in the obese patients. Symptoms of IGB intolerance included nausea and pain, which were transiently present in 50-95% of patients for several days, and necessitated early IGB removal in 6% of patients. There were no procedure-related complications and no IGB-related esophagitis, erosion, perforation, or obstruction. The percentage of excess weight loss (EWL%) was 96 ± 54% in the overweight group and 41 ± 26% in the obese group (P < 0.001). CONCLUSION: In overweight adults failing standard treatments, IGB placement for 6 months had an acceptable safety profile and excellent weight loss.

Mini-Laparoscopy: Instruments and Economics.

Mini-laparoscopy (Mini) was pioneered more than 20 years ago, initially with instruments borrowed from other specialties and subsequently with tools designed specifically for Mini. Early adoption of Mini was inhibited though by the limitations of these first-generation instruments, especially functionality and durability. Newer generation Mini instruments have recently become available with improved effector tips, a choice of shaft diameters and lengths, better shaft insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument durability. Improvements are also occurring in imaging and advanced energy for Mini. The current status of mini-laparoscopy instruments and economics are presented.

Low-Friction Minilaparoscopy Outperforms Regular 5-mm and 3-mm Instruments for Precise Tasks.

BACKGROUND AND OBJECTIVES: Therapeutic laparoscopy was incorporated into surgical practice more than 25 y ago. Several modifications have since been developed to further minimize surgical trauma and improve results. Minilaparoscopy, performed with 2- to 3-mm instruments was introduced in the mid 1990s but failed to attain mainstream use, mostly because of the limitations of the early devices. Buoyed by a renewed interest, new generations of mini instruments are being developed with improved functionality and durability. This study is an objective evaluation of a new set of mini instruments with a novel low-friction design. METHOD: Twenty-two medical students and 22 surgical residents served as study participants. Three designs of laparoscopic instruments were evaluated: conventional 5mm, traditional 3 mm, and low-friction 3 mm. The instruments were evaluated with a standard surgical simulator, emulating 4 exercises of various complexities, testing grasping, precise 2-handed movements, and suturing. The metric measured was time to task completion, with 5 replicates for every combination of instrument-exercise-participant. RESULTS: For all 4 tasks, the instrument design that performed the best was the same in both the medical student and surgical resident groups. For the gross-grasping task, the 5-mm conventional instruments performed best, followed by the low-friction mini instruments. For the 3 more complex and precise tasks, the low-friction mini instruments outperformed both of the other instrument designs. CONCLUSION: In standard surgical simulator exercises,low-friction minilaparoscopic instruments outperformed both conventional 3- and 5-mm laparoscopic instruments for precise tasks.

Analysis of subcutaneous and visceral fat after gastric balloon treatment.

BACKGROUND AND OBJECTIVES: This project is a continuation of a larger project entitled "Treatment with intragastric balloon (IGB) in patients with overweight and obesity in Recife" developed by Professor Dr. Gustavo Lopes de Carvalho. It is a project studying the effectiveness of treatment with IGB evaluating the loss of weight and body mass index and its impact on blood pressure, blood glucose, triglycerides, total cholesterol and fractions. It also assesses the lifestyle of patients studying whether treatment with IGB interferes in smoking, alcohol consumption, eating habits and physical exercises performed by patients. The present study added a larger project, the separate evaluation of the different types of abdominal fat-visceral fat and subcutaneous cell tissue fat - and was conducted to discover which of the 2 types of fat undergoes the greater reduction after IGB treatment. To measure these 2 types of fat, we used the ultrasonography technique, because it has been shown to be accurate and noninvasive. METHODS: Twenty-five patients were evaluated before and after 6 months of IGB treatment. RESULTS: The patients' ages ranged from 20 to 61 years, with 60% being 40 years of age or older. The majority (72%) were women. All variables (weight, body mass index [BMI], VF, and SCTF) showed a significant reduction (P < .05) in mean values after treatment. The difference was highest in the SCTF (17.5%) and ranged from an 11.4% to an 11.6% reduction in all other variables. The average loss of SCTF was highest among the patients who had lost up to 10.0% of their initial weight (19.2% for the ≤10.0% group vs 15.9% for the >10.0% group); however, the difference was not significant (P = .66). The average loss of VF was higher in the subgroup of patients who had lost >10.0% of their initial weight (16.2% vs 6.3%; P = .003). The Pearson correlation between the reductions in SCTF vs VF was negative, low, and nonsignificant (-0.17; P = .41). CONCLUSIONS: After 6 months of IGB treatment, there was no significant difference between the reduction in abdominal SCTF and VF, but the results signify a possible correlation between the percentage of body weight loss and the type of abdominal fat reduced, as the impact on the VF was higher when the patients lost >10.0% of their initial weight.

Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches.

INTRODUCTION: Endoscopic surgical repair of inguinal hernia is currently conducted using 2 techniques: the totally extraperitoneal (TEP) and the transabdominal (TAPP) hernia repair. The TEP procedure is technically advantageous, because of the use of no mesh fixation and the elimination of the peritoneal flap, leading to less postoperative pain and faster recovery. The drawback is that TEP is not performed as frequently, because of its complexity and longer learning curve. In this study, we propose a hybrid technique that could potentially become the gold standard of minimally invasive inguinal hernia surgery. This will be achieved by combining established advantages of TEP and TAPP associated with the precision and cosmetics of minilaparoscopy (MINI). MATERIALS AND SURGICAL TECHNIQUE: Between January and July 2011, 22 patients were admitted for endoscopic inguinal hernia repair. The combined technique was initiated with TAPP inspection and direct visualization of a minilaparoscopic trocar dissection of the preperitoneum space. A10-mm trocar was then placed inside the previously dissected preperitoneal space, using the same umbilical TAPP skin incision. Minilaparoscopic retroperitoneal dissection was completed by TEP, and the surgical procedure was finalized with intraperitoneal review and correction of the preperitoneal work. DISCUSSION: The minilaparoscopic TEP-TAPP combined approach for inguinal hernia is feasible, safe, and allows a simple endoscopic repair. This is achieved by combining features and advantages of both TAPP and TEP techniques using precise and sophisticated MINI instruments. Minilaparoscopic preperitoneal dissection allows a faster and easier creation of the preperitoneal space for the TEP component of the procedure.

The use of an improved intragastric balloon technique to reduce weight in pre-obese patients--preliminary results.

BACKGROUND: In this study, a new safer and faster intragastric balloon procedure was also employed to treat pre-obese patients (body mass index (BMI) < 30). METHODS: From June 2006 to June 2009, 20 such patients were submitted to the Silimed Gastric Balloon treatment, as a part of a multidisciplinary program involving clinical, psychological, and behavioral approaches. For the 16 patients who had completed the 5-6-month treatment, the initial mean weight and mean BMI were 74 kg and 27.5 kg/m(2), respectively. RESULTS: After the treatment, the mean weight and BMI values decreased significantly to 65.9 kg and 24.5 kg/m(2), respectively. There were only minor complications--nausea and vomiting--with the exception of two cases of spontaneous deflation of the devices which were successfully removed by gastric endoscopy. CONCLUSIONS: Thus, preliminary data suggest that this new intragastric balloon procedure might also be a safe and effective treatment for weight loss in pre-obese patients.

Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases.

BACKGROUND: The advent of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), surgery without skin scarring, is now challenging every surgeon to improve the esthetic results for patients. Minilaparoscopic cholecystectomy (MLC) represents a refinement in laparoscopic surgery, potentially as cosmetically effective as NOTES. Nevertheless, because of the increased cost and difficulty in managing the equipment, it has not been widely accepted among surgeons. OBJECTIVE: To report modifications of the minilaparoscopic technique that make it possible to conduct needlescopic procedures safely and effectively, thereby, considerably reducing costs and promoting the dissemination of this operation. METHOD: One thousand consecutive patients who underwent MLC were analyzed, from January 2000 to May 2009 (78.7% women; average age 45.9 y). SURGICAL TECHNIQUE: after performing the pneumoperitoneum at the umbilical site, 4 trocars were inserted; 2 of 2 mm, 1 of 3 mm, and 1 of 10 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag made with a glove wrist, through the 10-mm umbilical site. RESULTS: The operative time was 43 minutes. The average hospital stay was 16 hours. There was no conversion to open surgery; 2.8% of patients underwent conversion to standard (5 mm) laparoscopic cholecystectomy because of difficulties with the procedure; there were 1.9% minor umbilical site infections and 1.0% umbilical herniations. There was no mortality; no bowel injury, no bile duct injury, and no postoperative hemorrhage, only 1 patient with Luschka's duct bile leakage needed a reoperation. CONCLUSIONS: The MLC technique shows no differences in risks as compared with other laparoscopic cholecystectomy procedures. It also entails a considerable reduction in cost, and, as it does not use the 3-mm laparoscope or disposable materials, it is possible to perform MLC on a larger number of patients. Owing to the near invisibility of scars, MLC may also be considered as cosmetically effective as NOTES and SILS.

An improved intragastric balloon procedure using a new balloon: preliminary analysis of safety and efficiency.

BACKGROUND: The authors developed a new intragastric balloon procedure with the objective of making it safer, faster, and less expensive than the established ones. The proposed procedure uses a new gastric balloon with technical improvements in the placement and removal procedures. METHODS: From June 2006 to July 2007, 52 patients were submitted to the new treatment with the Silimed Gastric Balloon (SGB), as part of a multidisciplinary program involving clinical, psychological, and behavioral approaches. RESULTS: The new placement and removal procedures of the SGB were effective and safe in all the cases. Due to simplicity and shortened duration of the procedures, all the patients left the outpatient clinic in less than 1 h after the placement or removal of the SGB. For the 14 patients who had completed the 6-month treatment, the initial mean weight, mean body mass index (BMI), and mean excess of weight (EW) were, respectively, 100.7 kg, 35.7 kg/m(2), and 30.0 kg. After the 6-month treatment, these values decreased significantly: 89.4 kg, 31.8 kg/m(2), and 19.6 kg. CONCLUSIONS: Preliminary data suggest that the procedure with the new balloon comes forth as a safe and effective alternative to the treatment of weight loss in patients with appropriate indication of use.

Laparoscopic repair of a ureter damaged during inguinal herniorrhaphy.

BACKGROUND: Laparotomy has been used generally to deal with ureteral injury. Recently, a few papers have reported the repair of gynecologic ureteral injuries by laparoscopy, with encouraging results; however, successful repair of a ureter damaged during an open inguinal herniorrhaphy fully performed by laparoscopy has not been reported yet. PATIENT: A 49-year-old obese man (body mass index=35) in the 10 years before surgery began to note a protrusion in the scrotal region. The protrusion evolved asymptomatically for 8 years, and began to cause pain in the lumbar spine to the right and paresthesia of the right leg. METHOD: An open right inguinal herniorrhaphy was performed. When the exeresis of the fatty tissue around the spermatic cord was being carried out, resection of a 12-cm tubular structure, supposedly the appendix, was performed. Wall defect was closed by a polypropylene mesh. Acute abdominal pain developed immediately in the postoperative period and investigation using laparoscopy was undertaken. After confirmation of ureteral injury, laparoscopic repair was performed, and the ureter was anastomosed without tension over a double-J catheter. A suction drain was left near the anastomosis. RESULT: Postoperative period was uneventful. The vesical catheter was withdrawn on the eighth postoperative day and the drain on the twelfth postoperative day. The histopathologic report confirmed that the resected structure was the ureter. The patient has remained asymptomatic for 2 years since the surgery.

Cisto de colédoco associado à agenesia da vesícula biliar / Choledochal cyst associated with gallbladder agenesis

Dilataçöes císticas congênitas do colédoco (CC) säo malformaçöes, pouco frequentes, que possuem risco de desenvolvimento de: coledocolitiase, colestase crônica, pancreatite recorrente e câncer da via biliar. O presente trabalho relata o caso de uma paciente de 51 anos com história prévia de dor abdominal e intolerância a alimentos gordurosos, que teve erroneamente firmado o diagnóstico de colecistite litiásica ao ultra-som de abdome. Foi submetida a tentativa de colecistectomia por videolaparoscopia. Durante o procedimento, foi detectado: agenesia da vesícula biliar e presença de um cisto do colédoco tipo IVA, repleto de cálculos, o qual foi tratado, após ressecçäo videolaparoscópica, mediante conversäo para cirurgia aberta, com uma hepático-jejuno-anastomose em "Y de Roux". A paciente evoluiu sem problemas recebendo alta hospitalar no sexto dia pós operatório