¿Es YouTube una herramienta fiable para la enseñanza de cura de hernia inguinal asistida por robot? Una revisión crítica de los recursos disponibles / Is YouTube a reliable tool for approaching robotic assisted transabdominal preperitoneal surgery? A critical review of the available resources

Introducción: La cirugía transabdominal preperitoneal asistida por robot (rTAPP) es una técnica relativamente reciente para el tratamiento de hernia inguinal. Para alcanzar resultados óptimos se deben cumplir las 10 reglas de oro descritas. Los cirujanos en formación suelen revisar vídeos para familiarizarse con nuevas técnicas siendo YouTube una de las plataformas más utilizada. El objetivo de este estudio es realizar una evaluación de los 10 vídeos más vistos en YouTube de reparación de hernia inguinal por rTAPP para determinar si se cumplen las 10 reglas de oro. Métodos: Identificar y evaluar los 10 vídeos con mayor número de visualizaciones relacionados con la rTAPP. Tres Cirujanos con experiencia evaluaron el cumplimiento de las 10 reglas de oro utilizando una escala de Likert. Los datos fueron analizados en Excel (Microsoft) y graficados con Tableau (Tableau Inc). La consistencia entre evaluadores se determinó mediante el alfa de Cronbach, considerándose aceptable un valor > 0,7. Resultados: La evaluación general promedio fue de 3,63 con un rango de 2,6 a 4,9. Las puntuaciones relacionadas con el cumplimiento de las reglas 1, 2, 9, 10 fueron satisfactorias; en cambio, las reglas 3, 4, 5, 7 y 8 fueron débiles, en particular la regla número 7. Se observó consistencia interna entre los evaluadores con un alfa de Cronbach de 0,98. Conclusiones: La falta de cumplimiento con las 10 reglas del oro en la mayoría de los vídeos demuestra que el uso de vídeos (YouTube) no es un adecuado recurso para el aprendizaje de cura de hernia inguinal asistida por robot.(AU)

Introduction: The robotic transabdominal preperitoneal approach (rTAPP) is a relatively recent technique for the treatment of inguinal hernia. To achieve optimal results, the 10 golden rules described must be followed. Surgeons in training often review vídeos to familiarize themselves with new techniques, YouTube being one of the most used platforms. The objective of this study is to carry out an evaluation of the 10 most viewed vídeos on YouTube of inguinal hernia repair by transabdominal preperitoneal approach (rTAPP) to determine if the 10 golden rules are met. Methods: Identify and evaluate the 10 vídeos with the highest number of views related to rTAPP. Three experienced surgeons evaluated compliance with the 10 golden rules using a Likert scale. Data were analyzed in Excel (Microsoft) and plotted with Tableau (Tableau Inc.). The consistency between evaluators was determined using Cronbach's alpha, considering a value >0.7 acceptable. Results: The average overall evaluation was 3.63 with a range of 2.6–4.9. The scores related to compliance with the rules 1, 2, 9 and 10 were satisfactory; on the other hand, rules 3, 4, 5, 7 and 8 were weak, particularly rule number 7. Internal consistency was observed between raters with a Cronbach's alpha of 0.98.Conclusions: The lack of compliance with the 10 golden rules in most of the vídeos demonstrates that the use of vídeos (YouTube) is not an adequate resource for learning robot-assisted inguinal hernia cure.(AU)

Is YouTube a reliable tool for approaching robotic assisted transabdominal preperitoneal surgery? A critical review of the available resources.

INTRODUCTION: The robotic transabdominal preperitoneal approach (rTAPP) is a relatively recent technique for the treatment of inguinal hernia. To achieve optimal results, the 10 golden rules described must be followed. Surgeons in training often review videos to familiarize themselves with new techniques, YouTube being one of the most used platforms. The objective of this study is to carry out an evaluation of the 10 most viewed videos on YouTube of inguinal hernia repair by transabdominal preperitoneal approach (rTAPP) to determine if the 10 golden rules are met. METHODS: Identify and evaluate the 10 videos with the highest number of views related to rTAPP. Three experienced Surgeons evaluated compliance with the 10 golden rules using a Likert scale. Data were analyzed in Excel (Microsoft) and plotted with Tableau (Tableau Inc). The consistency between evaluators was determined using Cronbach's alpha, considering a value >0.7 acceptable. RESULTS: The average overall evaluation was 3.63 with a range of 2.6 to 4.9. The scores related to compliance with the rules 1, 2, 9, 10 were satisfactory; on the other hand, rules 3, 4, 5, 7 and 8 were weak, particularly rule number 7. Internal consistency was observed between raters with a Cronbach's alpha of 0.98. CONCLUSIONS: The lack of compliance with the 10 golden rules in most of the videos demonstrates that the use of videos (YouTube) is not an adequate resource for learning robot-assisted inguinal hernia cure.

Laparoscopic management of gallstone ileus: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Gallstone ileus is an uncommon complication of cholelithiasis. It is usually presented as a small bowel obstruction. Elderly patients are commonly affected. The diagnosis is challenging, since needs a high index of suspicion and imagenology is key. Surgery is the mainstay management, most commonly performed by laparotomy, but laparoscopy is summing cases. Nevertheless the approach is still controversial. We report a gallstone ileus case, that was managed totally laparoscopic in our medium complex public institution. CASE PRESENTATION: An 71 years-old male patient, with symptomatic cholelithiasis, consulted in emergency department with symptoms and signs of small bowel obstruction. Computed tomography of abdomen and pelvis showed the classical Rigler's triad. Totally laparoscopic enterolithotomy alone was performed successfully. Postoperative evolution was without incidents, being discharge at fifth day. CLINICAL DISCUSSION: Gallstone ileus represents around 0,3-0,5% of cholelithiasis complications. Mostly affect elderly women patients, with comorbidities. Mortality and morbidity is still high nowadays. The classical management of gallstone ileus is the open surgery, but the laparoscopic approach has been described and it can be done. CONCLUSION: The laparoscopic management of gallstone ileus is effective and secure procedure and seems reasonable to attempt if the conditions and skills are available.

Robot-assisted surgery and incisional hernia: a comparative study of ergonomics in a training model.

Over the years, incisional hernia repair has evolved. Currently, primary closure of the defect before placing the mesh is a critical step in incisional hernia repair and minimally invasive surgery incorporation has an important role due to great advantages. Despite its benefits, laparoscopic closure with suture intracorporeal knotting is physically demanding and technically complex. Robotic technology provides an optimal three-dimensional view, maneuverability of the instruments but no study has assessed the impact of the DaVinci system in the ergonomics which is the objective in this study. Fourteen surgeons were able to achieve surgical repair of a defect in an incisional hernia inanimate model. The task was performed with conventional laparoscopy and robotic assistance. The mental effort was registered and physical disturbances were measured with the Local Experienced Discomfort scale. The subjects expressed discomfort mainly in the dominant side (p = 0.006). In the comparative analysis between the two approaches, upper limb less disturbance (p = 0.04) and lower mental effort (p = 0.001) were reported with robotic approach. Robotic assistance decreases mental and physical effort during the primary closure of a defect in an incisional hernia inanimate model.

Colecistectomía laparoscópica subtotal como alternativa quirúrgica segura en casos complejos / Laparoscopic subtotal cholecystectomy: a surgical alternative to reduce complications in complex cases

Introducción: La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos realizados con más frecuencia a nivel mundial en el campo de la cirugía general, por lo que es fundamental que el cirujano conozca las diferentes alternativas al momento de enfrentarse con un caso complejo. Bajo esta premisa, es importante considerar la colecistectomía laparoscópica subtotal como una opción, cuando después de una adecuada disección, no se logra identificar las estructuras anatómicas y no se obtiene la visión crítica de seguridad. Este procedimiento cursa con baja morbilidad y con las ventajas ampliamente conocidas de la cirugía mínimamente invasiva. Métodos: Estudio retrospectivo de pacientes a quienes se les realizó colecistectomía laparoscópica subtotal en un periodo de 8 años. Resultados: Se realizaron 1.059 colecistectomías laparoscópicas. De estas, 22 correspondieron a colecistectomías subtotales. No se registraron lesiones de vía biliar ni conversiones. Las complicaciones más frecuentes fueron la fístula biliar (9%) y la colección intraabdominal (4,5%). No hubo mortalidad asociada al procedimiento. Durante un periodo de seguimiento promedio de 32 meses, no se observó recurrencia de sintomatología. Conclusiones: La colecistectomía laparoscópica subtotal es un procedimiento efectivo, seguro y reproducible. Debe ser considerada como una opción en casos complejos (AU)

Introduction: Laparoscopic cholecystectomy is a common procedure in general surgery, and in complex cases it is important for the surgeon to know all the alternatives with low associated morbidity. Laparoscopic subtotal cholecystectomy should be considered as an option when a critical view of safety cannot be obtained, because it has a low complication rate and gives the advantages of minimally invasive surgery. Methods: Retrospective study of laparoscopic subtotal cholecystectomies in an eight years period. Results: A total of 1,059 laparoscopic cholecystectomies were performed; 22 were subtotal cholecystectomies, without conversion. Biliary fistula (9%) and intraabdominal collections (4.5%) were the most common complications described. No iatrogenic bile duct injuries or deaths were reported. Our follow-up period was 32months, no recurrences were reported. Conclusions: Laparoscopic subtotal cholecystectomy is a safe and effective procedure. It should be considered as an option in complex cases (AU)

Laparoscopic subtotal cholecystectomy: a surgical alternative to reduce complications in complex cases. / Colecistectomía laparoscópica subtotal como alternativa quirúrgica segura en casos complejos.

INTRODUCTION: Laparoscopic cholecystectomy is a common procedure in general surgery, and in complex cases it is important for the surgeon to know all the alternatives with low associated morbidity. Laparoscopic subtotal cholecystectomy should be considered as an option when a critical view of safety cannot be obtained, because it has a low complication rate and gives the advantages of minimally invasive surgery. METHODS: Retrospective study of laparoscopic subtotal cholecystectomies in an eight years period. RESULTS: A total of 1,059 laparoscopic cholecystectomies were performed; 22 were subtotal cholecystectomies, without conversion. Biliary fistula (9%) and intraabdominal collections (4.5%) were the most common complications described. No iatrogenic bile duct injuries or deaths were reported. Our follow-up period was 32months, no recurrences were reported. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a safe and effective procedure. It should be considered as an option in complex cases.

Robot-assisted video endoscopic inguinal lymphadenectomy for melanoma.

Inguinal lymphadenectomy is the indicated procedure in the regional lymph node management for patients with lower limb melanoma and positive nodes. This procedure is commonly associated with surgical site complications. Video endoscopic inguinal lymphadenectomy is a minimally invasive alternative with oncological principles and lower wound-related morbidity. Incorporation of robotic surgery with optimal vision and great maneuverability would offer great advantages. A 42-year-old male patient was diagnosed with acral lentiginous melanoma and palpable inguinal nodes T2 N1 M0. The patient was scheduled for robot-assisted left inguinal video endoscopic lymphadenectomy. The working space is created using blunt-finger dissection and then extended with the endoscope by sweeping with the lens. Two 8-mm robotic trocars and a 10-mm trocar for assistant are placed. The lymphadenectomy is carried out with Maryland and scissors. The operative time was 130 min, estimated blood loss 70 ml and hospital stay 2 days. The robot-assisted inguinal video endoscopic lymphadenectomy is a safe and feasible procedure for lower limb melanoma treatment. The incorporation of the robotic system to this approach where there is a limited working space would offer advantages to the technique.

Robotic surgery training: construct validity of Global Evaluative Assessment of Robotic Skills (GEARS).

The objective of this study is to determine the ability of the GEARS scale (Global Evaluative Assessment of Robotic Skills) to differentiate individuals with different levels of experience in robotic surgery, as a fundamental validation. This is a cross-sectional study that included three groups of individuals with different levels of experience in robotic surgery (expert, intermediate, novice) their performance were assessed by GEARS applied by two reviewers. The difference between groups was determined by Mann-Whitney test and the consistency between the reviewers was studied by Kendall W coefficient. The agreement between the reviewers of the scale GEARS was 0.96. The score was 29.8 ± 0.4 to experts, 24 ± 2.8 to intermediates and 16 ± 3 to novices, with a statistically significant difference between all of them (p < 0.05). All parameters from the scale allow discriminating between different levels of experience, with exception of the depth perception item. We conclude that the scale GEARS was able to differentiate between individuals with different levels of experience in robotic surgery and, therefore, is a validated and useful tool to evaluate surgeons in training.

Lipoma retroperitoneal gigante (MDM2 negativo) en una paciente joven / Giant retroperitoneal lipoma (MDM2 negative) in a young patient

Las lesiones sólidas mesenquimales del retroperitoneo son infrecuentes representando menos del 1 %. De los sarcomas retroperitoneales el 10 a 15 % corresponde a liposarcomas, los cuales representan el primer diagnóstico diferencial de lipomas benignos. La realización de inmunohistoquímica, específicamente el MDM2,dará el diagnóstico histológico certero, donde su negatividad se traduce en benignidad. El tratamiento quirúrgico de elección es la resección R-0. Caso clínico: Presentamos el caso de paciente femenino de 24 años de edad quien refiere 5 meses previos al ingreso aumento de la circunferencia abdominal y dolor a predo-minio de flanco izquierdo. Exámenes clínicos y paraclínicos indican el diagnóstico presuntivo de un tumor de aspecto graso retroperitoneal. Se realiza laparotomía exploradora con los hallazgos de tumor de aspecto graso, de superficie lisa, de gran tamaño ubicado a nivel de retroperitoneo. Se realiza resección R-0 de la lesión sin complicaciones. Tiempo operatorio: 110 minutos, sangrado estima-do: 150 cc. Tumor de aspecto graso de 11 Kg y 55 cm. Paciente es dado de alta a las 48 horas tolerando vía oral. La biopsia reporta tejido adiposo maduro sin atipias. Inmunohistoquímica reporta tumor lipomatoso, MDM2 Negativo, descartando de esta manera el diagnóstico de liposarcoma. Conclusión: Podemos concluir que los lipomas gigantes a nivel de retroperitoneo corresponden a una patología poco frecuente. Donde la resolución quirúrgica se basa en la resección R-O. La realización del MDM2 permitirá un diag-nóstico histológico confiable y por ende le brindará al cirujano la capacidad de decidir el tratamiento post-operatorio(AU)

The mesenchymal solid retroperitoneal lesions are uncommon, representing less than 1%. Liposarcomas constitute 10 to 15% of the retroperitoneal sarcomas, which represent the first differential diagnosis of benign lipomas. The immunohistochemistry, specifically the MDM2, give the accurate histological diagnosis, where their negativity translates into benignity. The treatment of choice is surgical R-0 resection. Clinical case: We report the case of 24 years old female patient who refers five months before admission increased abdominal girth and pain, predominantly at the left flank. Clinical and laboratory tests indicate presumptive diagnosis of retroperitoneal fatty tumor. Exploratory laparotomy is done with the findings of large retroperitoneal lipomatous tumor. R-0 resection of the lesion is performed without complications. Operating time: 110 minutes, estimated blood loss: 150 cc. Fatty tumor aspect of 11 kg and 55 cm. The patient's progress was satisfactory and he was discharged on the second postoperative day. Mature adipose tissue biopsy reports without atypia. Lipomatous tumor immunohistochemistry reports, MDM2 negative, discarding liposarcoma diagnosing.Conclusion:We conclude that the giant retroperitoneal lipomas corresponds a rare condition. The surgical resolution is based on R-0 resection, and the MDM2 allow a reliable histological diagnosis and thus will provide the surgeon with the capacity to decide the postoperative treatment(AU)

Gastrectomía total laparoscópica asistida por sistema da vinci en el tratamiento de la enfermedad de ménétrier / Laparoscopic total gastrectomy assisted by da vinci system in the management of ménétrier's disease

La enfermedad de Ménétrier es una enfermedad poco frecuente que se caracteriza por presentar hipertrofia gástrica asociada con hipoproteinemia. Objetivo:Presentación de caso clínico y revisión de la literatura, de un paciente con el diagnóstico de enfermedad de Ménétrier, tratado en el servicio de Cirugía III del Hospital Universitario de Caracas. Métodos:Se presenta el caso de un apaciente femenina de 65 años de edad, quien acude por presentar,dolor en epigastrio posterior a las comidas, intolerancia a la vía oral y pérdida de peso. Se realiza una endoscopia digestiva superior donde se evidencia lesión infiltrativa estenosante del cuerpo gástrico que produce reducción de la luz en 100 %, la biopsia concluye hiperplasia foveolar reactiva y cambios reactivos en el epitelio glan-dular, sugestivos de enfermedad de Ménétrier. Resultados: Lapaciente es llevada a mesa operatoria donde se procede a la reali-zación de gastrectomía total más esófago-yeyuno anastomosis por abordaje laparoscópico asistido por robot, evolucionando de manera satisfactoria, egresando al octavo día del postoperatorio. Conclusión: El abordaje laparoscópico asistido por el sistema Da Vinci es una opción factible y segura. La incorporación de la tecnología robótica facilita la realización de procedimientos complejos mediante cirugía mínimamente invasiva(AU)

Ménétrier's disease is a rare disease characterized by gastric hypertrophy associated with hypoproteinemia. Objective: Presentation of clinical case and literature review of a patient with diagnosis of Ménétrier's disease managed at Service of Surgery III, Hospital Universitario de Caracas. Methods: We present a case of a 65 years old female patient who presented epigastric pain after meals, e oral intolerance and weight loss. Upper endoscopy is performed where is evidenced gastric mucosa with prominent folds in gastric body along with stenosis at antrum-pylorous, biopsy was taken and reported foveolar reactive hyperplasia and reactive glandular epithelium changes suggestive of Ménétrier's disease. Results: A robot-assisted laparoscopic total gastrectomy and an esophagusjejunum anastomosis was performed, patient's evolution was satisfactory and is discharged at the eighth postoperative day. Conclusion: The robot-assisted laparoscopic gastrectomy is a feasible and safe option that facilitates the performance of complex procedures(AU)

Miotomía de heller asistida por robot Vs. Miotomía de heller laparoscópica Para el tratamiento de la acalasia / Heller's myotomy assisted by robot Vs laparoscopic heller's myotomy For the treatment of achalasia

La cirugía mínimamente invasiva se ha convertido en el tratamiento estándar para la acalasia. La incorporación de la tecnología robótica permite superar limitaciones de la cirugía laparoscópica aportando una óptima visión tridimensional, aumentando los grados de libertad de los movimientos a la vez que evita el efecto fulcrum e incrementa la ergonomía. Objetivo: determinar las ventajas de la miotomía de Heller asistida por robot sobre la miotomía de Heller laparoscópica en el tratamiento de la acalasia. Métodos: fueron incluidos cuarenta y ocho (48) pacientes con diagnóstico de acalasia confirmado con esofagograma y manometría. Las molestias principales en ambos grupos eran disfagia y pérdida de peso. Resultados: veinticinco (25) pacientes fueron tratados con miotomía de Heller laparoscópica y veintitrés (23) pacientes fueron tratados con miotomía de Heller asistida por robot. No hubo diferencia en el promedio de tiempo quirúrgico (73 ±13 vs 77 ± 18 min, p:0,39). Los eventos intraoperatorios adversos fueron menos frecuentes en los procedimientos asistidos por robot (8% vs. 0%), sin embargo, ésta no representa una diferencia estadísticamente significativa (p: 0.17). La efectividad de la cirugía es comparable en ambos abordajes Conclusión: la miotomía de Heller asistida por robot es un procedimiento seguro y eficaz. El tiempo operatorio no es mayor que la miotomía de Heller laparoscópica, pero es necesario evaluar la técnica en ensayos clínicos aleatorios para determinar sus ventajas en términos de eventos intraoperatorios adversos(AU)

Minimally invasive surgery has become the gold standard for the treatment of achalasia. The incorporation of robotic technology overcomes the limitations of laparoscopic surgery, providing optimum three-dimensional vision, increasing the degrees of freedom of movement while preventing the fulcrum effect and increases ergonomics. Objective: the aim of this study was to compare robotic-assisted laparoscopic Heller myotomy with laparoscopic Heller myotomy in terms of efficacy and safety. Methods: forty-eight (48) patients with diagnosis of achalasia confirmed by esophagogram and manometry were included. Dysphagia and weight loss were the main complaints in both groups. Results: twenty-five (25) patients were treated with laparoscopic Heller myotomy and twenty-three (23) patients were treated with robotic-assisted Heller myotomy. There was no difference in mean operative time (73 ± 13 vs 77 ± 18 min, p:0.39). Intraoperative adverse events were less frequent in the robotassisted procedures (8% vs. 0%), however, this was a nonsignificant difference (p:0.17). The effectiveness of the surgery is comparable in both approaches. Conclusion: Heller myotomy robot assisted is safe and effective. The operating time is not longer than laparoscopic Heller myotomy, but is necessary to evaluate the technique in randomized clinical trials to determine its advantages in terms of intraoperative adverse events(AU)