BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT.

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT / Posição da Sociedade Brasileira de Hérnia e Parede Abdominal sobre o tratamento de grandes hérnias de hiato

Large hiatal hernias (LHH) besides being more prevalent in the elderly, have different clinical presentation: fewer reflux, more mechanical symptoms and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease (GERD-related), sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index (BMI above 35), age over 70 years and presence of comorbidity. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, case-by-case analysis of surgical risk factors such as age, obesity and comorbidities, should be taken under consideration. One should also pay attention to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual workers, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of LHH in high-volume centers, with experienced surgeons.

As grandes hérnias de hiato (HHG), além de serem mais prevalentes em idosos, têm apresentação clínica diferente: menos refluxo, mais sintomas mecânicos e maior possibilidade de complicações agudas e potencialmente fatais, como vólvulo gástrico, isquemia e perfuração mediastinal visceral. Assim, as indicações cirúrgicas são distintas das hérnias de hiato por deslizamento, relacionadas à doença do refluxo gastroesofágico (DRGE). A azia tende a ser menos intensa, enquanto os sintomas de dor no peito, tosse, desconforto e cansaço são relatados com maior frequência. Queixas de vômitos e disfagia podem sugerir a presença de volvo gástrico associado. São encontrados sinais de deficiência de ferro e anemia. A indicação cirúrgica ainda é controversa e foi anteriormente baseada na alta mortalidade relatada em cirurgias de emergência para volvo gástrico. A mortalidade pós-operatória está especialmente relacionada a três fatores: índice de massa corporal (IMC acima de 35), idade superior a 70 anos e presença de comorbidades. A cirurgia eletiva minimamente invasiva deve ser oferecida a indivíduos sintomáticos, com desempenho bom ou razoável, independentemente da faixa etária. Em pacientes assintomáticos e oligossintomáticos, além de obviamente identificar o desejo do paciente, deve-se levar em consideração a análise caso a caso dos fatores de risco cirúrgico, como idade, obesidade e comorbidades. Deve-se atentar também para situações de maior dificuldade técnica e riscos de migração aguda por aumento da pressão abdominal (abdominoplastia, trabalhos manuais, doenças espásticas). Alternativas técnicas como fundoplicatura parcial e gastropexia anterior podem ser consideradas. Ressaltamos a importância da realização de procedimentos cirúrgicos nos casos de GHH em centros de grande volume, com cirurgiões experientes.

COMPLICATIONS AND LATE FOLLOW-UP OF SCOPINARO'S SURGERY WITH GASTRIC PRESERVATION: 1570 PATIENTS OPERATED IN 20 YEARS.

AIMS: Scopinaro-type biliopancreatic diversion (BPD-S) and its variations are the surgeries that offer the best immediate results in weight loss and regain in the late follow-up. It has a high rate of immediate complications and demands control with frequent laboratory tests. The aim of this study was to analyze the late postoperative complications of 1570 patients operated by biliopancreatic diversion with gastric preservation laparoscopic video with up to 20 years of postoperative follow-up. METHODS: In a follow-up period of up to 20 years, the clinical and surgical complications of 1570 patients with grade II or III obesity were evaluated who were operated on from 2001 to 2014 with the same team of surgeons. Clavien Dindo 11 classification was used for analysis and comparison. Laboratory tests and body mass index (BMI) were used in the analysis of late metabolic outcomes. RESULTS: On the one hand, complications in 204 patients were recorded (13%), and 143 patients (9.1%) were reoperated. On the other hand, 61 patients (29.9%), who had postoperative complications were clinically treated with good evolution in 9.2 years (95%CI 8.2-10.3), with a median of 9.5 years (95%CI 6.1-12.9). Gastroileal anastomosis ulcers occurred in 44 patients (2.8%). Patients with malnutrition, severe anemia, or chronic diarrhea were operated on with common loop elongation (n=64 - 4%), conversion to gastric diversion (n=29 - 5%), or reversal of surgery (n=10 - 0.6%). One death was registered throughout casuistry (0.06%). CONCLUSIONS: Metabolic result of DBP-S was considered excellent in most patients, even referring to changes in the frequency of bowel movements, loose stools, and unpleasant odor. Complications are usually serious and most of the patients require surgical treatment. Therefore, the biliopancreatic diversion of Scopinaro should be reserved for exceptional cases, as there are safer surgical alternatives with less serious side effects.

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1,552 cases operated in 20 years.

INTRODUCTION: Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy. OBJECTIVE: to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used. METHODS: we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device. RESULTS: 1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days. CONCLUSION: the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1, 552 cases operated in 20 years / Apendicectomia laparoscópica sem uso de materiais descartáveis - uma alternativa de baixo custo - 1. 552 casos operados em 20 anos

ABSTRACT Introduction: Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy. Objective: to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used. Methods: we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device. Results: 1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days. Conclusion: the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

RESUMO Introdução: a apendicectomia videolaparoscópica não tem protocolo único sobre sistematização técnica, vias de acesso, uso de energia e grampeadores. O custo de materiais descartáveis pode inviabilizar o emprego mais generalizado. Alternativas para diminuir o custo podem ajudar a disseminar o acesso laparoscópico para a realização de apendicectomia. Objetivo: introduzir um método para realizar a apendicectomia videolaparoscópica de baixo custo e visando bom resultado estético por meio da localização das incisões; mostrar a viabilidade por meio de aplicação em 1.552 casos de apendicectomia videolaparoscópica operados entre 2000 e 2019 com três portais, de muito baixo custo em insumos utilizados. Métodos: três punções - uma punção umbilical para introdução da câmera (de 5 ou 10mm de diâmetro), uma punção de 10mm em fossa ilíaca direita e uma punção em fossa ilíaca esquerda de 5mm. Os materiais utilizados - trocartes, pinças de apreensão, gancho, tesoura e porta-agulhas são de uso permanente, sem necessidade de qualquer material descartável. Resultados: foram operados 1.552 pacientes entre 2000 e 2019, sendo 56,25% do sexo feminino, média de idade de 32,66 anos (9 a 93 anos), tempo médio de internação de 1,74 dias (1 a 10 dias) e mediana de 1,2 dias. Conclusão: a técnica que descrevemos utiliza três trocartes metálicos e quatro instrumentos permanentes, além de um único fio de algodão. Trata-se, portanto, de procedimento laparoscópico de muito baixo custo. A aplicação demonstrou bons resultados e baixa morbidade, podendo tornar-se rotina a indicação preferencial da vídeocirurgia no tratamento da apendicite aguda.

Complications and late follow-up of scopinaro's surgery with gastric preservation: 1570 patients operated in 20 years / Complicações e acompanhamento tardios da cirurgia de scopinaro com preservação gástrica: 1.570 pacientes operados em 20 anos

ABSTRACT - BACKGROUND: Scopinaro-type biliopancreatic diversion (BPD-S) and its variations are the surgeries that offer the best immediate results in weight loss and regain in the late follow-up. It has a high rate of immediate complications and demands control with frequent laboratory tests. AIMS: The aim of this study was to analyze the late postoperative complications of 1570 patients operated by biliopancreatic diversion with gastric preservation laparoscopic video with up to 20 years of postoperative follow-up. METHODS: In a follow-up period of up to 20 years, the clinical and surgical complications of 1570 patients with grade II or III obesity were evaluated who were operated on from 2001 to 2014 with the same team of surgeons. Clavien Dindo 11 classification was used for analysis and comparison. Laboratory tests and body mass index (BMI) were used in the analysis of late metabolic outcomes. RESULTS: On the one hand, complications in 204 patients were recorded (13%), and 143 patients (9.1%) were reoperated. On the other hand, 61 patients (29.9%), who had postoperative complications were clinically treated with good evolution in 9.2 years (95%CI 8.2-10.3), with a median of 9.5 years (95%CI 6.1-12.9). Gastroileal anastomosis ulcers occurred in 44 patients (2.8%). Patients with malnutrition, severe anemia, or chronic diarrhea were operated on with common loop elongation (n=64 - 4%), conversion to gastric diversion (n=29 - 5%), or reversal of surgery (n=10 - 0.6%). One death was registered throughout casuistry (0.06%). CONCLUSIONS: Metabolic result of DBP-S was considered excellent in most patients, even referring to changes in the frequency of bowel movements, loose stools, and unpleasant odor. Complications are usually serious and most of the patients require surgical treatment. Therefore, the biliopancreatic diversion of Scopinaro should be reserved for exceptional cases, as there are safer surgical alternatives with less serious side effects.

RESUMO - RACIONAL - A derivação biliopancreática tipo Scopinaro (DBP-S) e suas variações são as cirurgias que oferecem os melhores resultados imediatos na perda de peso e de reganho de peso no acompanhamento tardio. Apresenta índice elevado de complicações imediatas e demanda controle laboratorial frequente. OBJETIVOS - Analisar as complicações pós-operatórias tardias de 1.570 pacientes operados por derivação biliopancreática com preservação gástrica videolaparoscópica com até 20 anos de acompanhamento pós-operatório. MÉTODOS - Foram avaliadas as complicações clínicas e cirúrgicas, no acompanhamento tardio de até 20 anos, de 1.570 pacientes com obesidade grau II ou III, operados no período de 2001 a 2014, por uma mesma equipe de cirurgiões. A classificação de Clavien Dindo 11 foi empregada para análise e comparação. Exames laboratoriais e índice de massa corpórea (IMC) foram utilizados na análise dos resultados metabólicos tardios. RESULTADOS - Foram registradas complicações em 204 pacientes (13%), e 143 (9,1%) foram reoperados. Por outro lado, 61 pacientes (29,9%), no período de 9,2 anos (IC 95% 8,2-10,3), com mediana de 9,5 anos (IC 95% 6,1-12,9), que tiveram complicações pós-operatórias foram tratados clinicamente, com boa evolução. A úlcera de anastomose gastroileal ocorreu em 44 pacientes (2,8%). Os pacientes com desnutrição, anemia grave ou diarreia crônica foram operados com alongamento da alça comum (n=64 - 4%), conversão para bypass gástrico (n=29 - 5%) ou reversão da cirurgia (n=10 - 0,6%). Foi registrado um óbito ao longo de toda a casuística (0,06%). CONCLUSÕES - O resultado metabólico da DBP-S foi considerado excelente na maioria dos pacientes, mesmo referindo-se a alteração da frequência de evacuações, fezes amolecidas e com odor desagradável. As complicações são geralmente graves e a maioria demanda tratamento cirúrgico. Portanto, a derivação biliopancreática de Scopinaro deve ser reservada a casos excepcionais, pois existem alternativas cirúrgicas mais seguras e com efeitos colaterais menos graves.

Does weight gain, throughout 15 years follow-up after Nissen laparoscopic fundoplication, compromise reflux symptoms control?

BACKGROUND: Gastroesophageal reflux disease is defined by the abnormal presence of gastric content in the esophagus, with 10% incidence in the Western population, being fundoplication one treatment option. AIM: To evaluate the early (six months) and late (15 years) effectiveness of laparoscopic fundoplication, the long term postoperative weight changes, as well as the impact of weight gain in symptoms control. METHODS: Prospective study of 40 subjects who underwent laparoscopic Nissen's fundoplication. Preoperatively and early postoperatively, clinical, endoscopic, radiologic, manometric and pHmetric evaluations were carried out. After 15 years, clinical and endoscopic assessments were carried out and the results compared with the early ones. The presence or absence of obesity was stratified in both early and late phases, and its influence in the long-term results of fundoplication was studied, measuring quality of life according to the Visick criteria. RESULTS: The mean preoperative ages, weight, and body mass index were respectively, 51 years, 69.67 kg and 25.68 kg/m2. The intraoperative and postoperative complications rates were 12.5% and 15%, without mortality. In the early postoperative period the symptoms were well controlled, hernias and esophagitis disappeared, the lower esophageal sphincter had functional improvement, and pHmetry parameters normalized. In the late follow-up 29 subjects were assessed. During this period there was adequate clinical control of reflux regardless of weight gain. In both time periods Visick criteria improved. CONCLUSION: Fundoplication was safe and effective in early and late periods. There was late weight gain, which did not influence effective symptoms control.

Does weight gain, throughout 15 years follow-up after Nissen laparoscopic fundoplication, compromise reflux symptoms control? / O ganho do peso no seguimento de 15 anos após Nissen laparoscópico compromete o controle dos sintomas de refluxo?

ABSTRACT Background: Gastroesophageal reflux disease is defined by the abnormal presence of gastric content in the esophagus, with 10% incidence in the Western population, being fundoplication one treatment option. Aim: To evaluate the early (six months) and late (15 years) effectiveness of laparoscopic fundoplication, the long term postoperative weight changes, as well as the impact of weight gain in symptoms control. Methods: Prospective study of 40 subjects who underwent laparoscopic Nissen's fundoplication. Preoperatively and early postoperatively, clinical, endoscopic, radiologic, manometric and pHmetric evaluations were carried out. After 15 years, clinical and endoscopic assessments were carried out and the results compared with the early ones. The presence or absence of obesity was stratified in both early and late phases, and its influence in the long-term results of fundoplication was studied, measuring quality of life according to the Visick criteria. Results: The mean preoperative ages, weight, and body mass index were respectively, 51 years, 69.67 kg and 25.68 kg/m2. The intraoperative and postoperative complications rates were 12.5% and 15%, without mortality. In the early postoperative period the symptoms were well controlled, hernias and esophagitis disappeared, the lower esophageal sphincter had functional improvement, and pHmetry parameters normalized. In the late follow-up 29 subjects were assessed. During this period there was adequate clinical control of reflux regardless of weight gain. In both time periods Visick criteria improved. Conclusion: Fundoplication was safe and effective in early and late periods. There was late weight gain, which did not influence effective symptoms control.

RESUMO Racional: A doença do refluxo gastroesofágico é definida pela presença anormal do conteúdo gástrico no esôfago com incidência de 10% na população ocidental, sendo a fundoplicatura uma das opções de tratamento. Objetivo: Avaliar a efetividade precoce (seis meses) e tardia (15 anos) da fundoplicatura laparoscópica, bem como a evolução ponderal pós-operatória em longo prazo, e o impacto do ganho de peso no controle tardio dos sintomas. Métodos: Estudo prospectivo com 40 indivíduos submetidos à fundoplicatura laparoscópica pela técnica de Nissen. No pré e pós-operatório precoce, foram realizadas avaliações clínica, endoscópica, radiológica, manométrica e pHmétrica. Após 15 anos, realizaram-se avaliações clínica e endoscópica, comparando-se os resultados com os da fase precoce. Estratificou-se a presença ou ausência de obesidade nestas fases e estudou-se sua influência nos resultados em longo prazo, mensurando-se a qualidade de vida pelos critérios de Visick. Resultados: As médias de idade, peso e do índice de massa corporal pré-operatórias foram 51 anos, 69.67 kg e 25,68 kg/m2. O índice de complicações intra e pós-operatórias foram 12,5% e 15%, sem mortalidade. No pós-operatório precoce houve controle dos sintomas, remissão das hérnias e esofagites, melhora funcional do esfíncter esofágico inferior e normalização dos parâmetros pHmétricos. No seguimento tardio, 29 indivíduos foram acompanhados. Nesta fase, houve adequado controle clínico do refluxo, independente do ganho de peso. Em ambas as fases houve melhora nos critérios de Visick. Conclusão: A fundoplicatura foi segura e efetiva, precoce e tardiamente. Houve ganho de peso tardio, o que não influenciou no controle efetivo dos sintomas.

Reconstrução de extenso defeito da parede torácica anterior pós-mediastinite com retalho de omento: relato de caso / Reconstruction of an extensive anterior chest wall defect after mediastinitis with an omentum flap: a case report

Apresentamos o caso de um paciente de 70 anos de idade que evoluiu com extenso defeito cutâneo em parede torácica anterior após ter sido submetido a revascularização do miocárdio e mediastinite pós-operatória. Pela impossibilidade de utilização de retalhos cutâneos e musculares da região, fizemos a reconstrução com a rotação de retalho de omento baseado na artéria gastroepiploica esquerda e enxerto de pele em malha.

We report the case of a 70-year-old patient who developed an extensive skin defect in the anterior chest wall after undergoing myocardial revascularization and postoperative mediastinitis. Owing to the impossibility of using cutaneous and muscular flaps on the region, we performed the reconstruction with an omentum flap based on the left gastroepiploic artery and meshed skin graft.

Robotic Transversus Abdominis Release (TAR): is it possible to offer minimally invasive surgery for abdominal wall complex defects?

We describe the preliminary national experience and the early results of the use of robotic surgery to perform the posterior separation of abdominal wall components by the Transversus Abdominis Release (TAR) technique for the correction of complex defects of the abdominal wall. We performed the procedures between 04/2/2015 and 06/15/2015 and the follow-up time was up to six months, with a minimum of two months. The mean surgical time was five hours and 40 minutes. Two patients required laparoscopic re-intervention, since one developed hernia by peritoneal migration of the mesh and one had mesh extrusion. The procedure proved to be technically feasible, with a still long surgical time. Considering the potential advantages of robotic surgery and those related to TAR and the results obtained when these two techniques are associated, we conclude that they seem to be a good option for the correction of complex abdominal wall defects.

Descrevemos a experiência preliminar nacional na utilização da cirurgia robótica para realizar a separação posterior de componentes da parede abdominal pela técnica transversus abdominis release (TAR) na correção de defeitos complexos da parede abdominal e seus resultados precoces. As cirurgias foram realizadas entre 02/04/2015 e 15/06/2015 e o tempo de acompanhamento dos resultados foi de até seis meses, com tempo mínimo de dois meses. O tempo cirúrgico médio foi de cinco horas e 40 minutos. Dois pacientes necessitaram reintervenção por laparoscopia, pois um desenvolveu hérnia por migração peritoneal da tela e um teve escape da tela. A cirurgia provou ser factível do ponto de vista técnico, com um tempo cirúrgico ainda elevado. Tendo em vista as vantagens potenciais da cirurgia robótica e aquelas relacionadas ao TAR e os resultados obtidos ao se associar essas duas técnicas, conclui-se que elas parecem ser uma boa opção para a correção de defeitos complexos da parede abdominal.

Robotic Transversus Abdominis Release (TAR): is it possible to offer minimally invasive surgery for abdominal wall complex defects? / Transversus Abdominis Release (TAR) Robótico: é possível oferecer cirurgia minimamente invasiva para os defeitos complexos da parede abdominal?

ABSTRACT We describe the preliminary national experience and the early results of the use of robotic surgery to perform the posterior separation of abdominal wall components by the Transversus Abdominis Release (TAR) technique for the correction of complex defects of the abdominal wall. We performed the procedures between 04/2/2015 and 06/15/2015 and the follow-up time was up to six months, with a minimum of two months. The mean surgical time was five hours and 40 minutes. Two patients required laparoscopic re-intervention, since one developed hernia by peritoneal migration of the mesh and one had mesh extrusion. The procedure proved to be technically feasible, with a still long surgical time. Considering the potential advantages of robotic surgery and those related to TAR and the results obtained when these two techniques are associated, we conclude that they seem to be a good option for the correction of complex abdominal wall defects.

RESUMO Descrevemos a experiência preliminar nacional na utilização da cirurgia robótica para realizar a separação posterior de componentes da parede abdominal pela técnica transversus abdominis release (TAR) na correção de defeitos complexos da parede abdominal e seus resultados precoces. As cirurgias foram realizadas entre 02/04/2015 e 15/06/2015 e o tempo de acompanhamento dos resultados foi de até seis meses, com tempo mínimo de dois meses. O tempo cirúrgico médio foi de cinco horas e 40 minutos. Dois pacientes necessitaram reintervenção por laparoscopia, pois um desenvolveu hérnia por migração peritoneal da tela e um teve escape da tela. A cirurgia provou ser factível do ponto de vista técnico, com um tempo cirúrgico ainda elevado. Tendo em vista as vantagens potenciais da cirurgia robótica e aquelas relacionadas ao TAR e os resultados obtidos ao se associar essas duas técnicas, conclui-se que elas parecem ser uma boa opção para a correção de defeitos complexos da parede abdominal.

Pioneer Robotic Serra-Doria Operation for Recurrent Achalasia After Heller's Cardiomyotomy: A "New Quondam" Procedure.

INTRODUCTION: Recurrence of achalasia may occur in 10%-20% of cases operated by Heller's cardiomyotomy. Most of these patients will require further surgery to relieve symptoms. Major technical difficulties can be found in these reoperations. CASE REPORT: A 50-year-old female patient with relapsed idiopathic achalasia after Heller's technique was treated with an unusual procedure, for the first time in the literature, by minimally invasive access with robotic assistance. CONCLUSIONS: The Serra-Doria operation allows preserving the esophagus and alleviating dysphagic symptoms with low rates of postoperative complications. The use of robotic technology is perfectly feasible and allows minimally invasive access in complex cases and reoperations.

Two port video-assisted gastrostomy and jejunostomy: technical simplification and clinical results.

BACKGROUND: Patients presenting upper gastrointestinal obstruction, difficulty or inability in swallowing, may need nutritional support which can be obtained through gastrostomy and jejunostomy. AIM: To describe the methods of gastrostomy and jejunostomy video-assisted, and to compare surgical approaches for video-assisted laparoscopy and laparotomy in patients with advanced cancer of the esophagus and stomach, to establish enteral nutritional access. METHODS: Were used the video-assisted laparoscopic techniques for jejunostomy and gastrostomy and the same procedures performed by laparotomies. Comparatively, were analyzed the distribution of patients according to demographics, diagnosis and type of procedure. RESULTS: There were 36 jejunostomies (18 by laparotomy and 17 laparoscopy) and 42 gastrostomies (21 on each side). In jejunostomy, relevant data were operating time of 132 min vs. 106 min (p = 0.021); reintroduction of diet: 3.3 days vs 2.1 days (p = 0.009); discharge: 5.8 days vs 4.3 days (p = 0.044). In gastrostomy, relevant data were operative time of 122.6 min vs 86.2 min (p = 0.012 and hospital discharge: 5.1 days vs 3.7 days (p = 0.016). CONCLUSION: The comparative analysis of laparotomy and video-assisted access to jejunostomies and gastrostomies concluded that video-assisted approach is feasible method, safe, fast, simple and easy, requires shorter operative time compared to laparotomy, enables diet start soon in compared to laparotomy, and also enables lower length of stay compared to laparotomy.

Two port video-assisted gastrostomy and jejunostomy: technical simplification and clinical results / Gastrostomia e jejunostomia videoassistidas com dois portais: simplificação técnica e resultados clínicos

BACKGROUND: Patients presenting upper gastrointestinal obstruction, difficulty or inability in swallowing, may need nutritional support which can be obtained through gastrostomy and jejunostomy. AIM: To describe the methods of gastrostomy and jejunostomy video-assisted, and to compare surgical approaches for video-assisted laparoscopy and laparotomy in patients with advanced cancer of the esophagus and stomach, to establish enteral nutritional access. METHODS: Were used the video-assisted laparoscopic techniques for jejunostomy and gastrostomy and the same procedures performed by laparotomies. Comparatively, were analyzed the distribution of patients according to demographics, diagnosis and type of procedure. RESULTS: There were 36 jejunostomies (18 by laparotomy and 17 laparoscopy) and 42 gastrostomies (21 on each side). In jejunostomy, relevant data were operating time of 132 min vs. 106 min (p=0.021); reintroduction of diet: 3.3 days vs 2.1 days (p=0.009); discharge: 5.8 days vs 4.3 days (p= 0.044). In gastrostomy, relevant data were operative time of 122.6 min vs 86.2 min (p= 0.012 and hospital discharge: 5.1 days vs 3.7 days (p=0.016). CONCLUSION: The comparative analysis of laparotomy and video-assisted access to jejunostomies and gastrostomies concluded that video-assisted approach is feasible method, safe, fast, simple and easy, requires shorter operative time compared to laparotomy, enables diet start soon in compared to laparotomy, and also enables lower length of stay compared to laparotomy. .

RACIONAL: Enfermos que apresentam obstrução digestiva alta, com dificuldade ou impossibilidade de deglutição, podem necessitar suporte nutricional provisório ou permanente16, que pode ser obtido através de gastrostomias e jejunostomias. OBJETIVO: descrever os métodos de gastrostomia e jejunostomia videoassistidas, bem como comparar os acessos cirúrgicos por laparotomia e por laparoscopia videoassistida, em pacientes portadores de neoplasias avançadas de esôfago e estômago, para estabelecimento de acesso nutricional enteral. MÉTODOS: Foram utilizadas as técnicas laparoscópics video-assistidas para a jejunostomia e gastrostomia e os mesmo procedimentos realizados por laparotomia. Foram analisados comparativamente a distribuição dos pacientes quanto à demografia, diagnóstico e tipo de procedimento. RESULTADOS: Foram 36 jejunostomias (18 por laparotomia e 17 por laparoscopia) e 42 gastrostomias (21 de cada lado). Na jejunostomia os dados relevantes foram: tempo operatório de 132 min vs 106 min (p=0,021); reintrodução da dieta: 3,3 dias vs 2,1 dias (p=0,009); alta hospitalar: 5,8 dias vs 4,3 dias (p=0,044). Na gastrostomia os dados relevantes foram: tempo operatório de 122,6 min vs 86,2 min (p=0,012 e alta hospitalar: 5,1 dias vs 3,7 dias (p=0,016). CONCLUSÃO: A análise comparativa das vias de acesso laparotômica e videoassistida para jejunostomias e gastrostomias conclui que a via videoassistida é método factível, segura, rápida, simples e fácil, necessita menor tempo operatório em relação à laparotomia, possibilita início de dieta mais rapidamente na jejunostomia em relação à laparotomia, e possibilita menor tempo de internação em relação à laparotomia. .

Robotic Roux-en-Y gastric bypass: operative results in 100 patients.

BACKGROUND: Laparoscopic gastric bypass is gold-standard for morbid obesity treatment. AIM: To describe the results of robotic gastric bypass for morbid obesity patients. METHOD: Were operated on 100 morbidly obese patients through totally robotic gastric bypass between 2013 and 2014. They were 83% female. The age ranged from 20 to 65 years old (medium 48,5 years); the body mass index varied between 38-67 (medium 42,3 kg/cm2). The procedure was designed with 3 cm long gastric pouch, 1 m biliopancreatic limb, 1,2 m alimentary limb, manual or stapled anastomosis. There were four super-super-obese patients and four revisional surgeries. RESULTS: Docking time varied from 1 to 20 min (medium 4 min). Console time varied from 40-185 min (medium 105 min). There were no intra operative complications or mortality. There were two lower limb deep venous thrombosis. There was no readmission in the first 30 days. CONCLUSION: Totally robotic gastric bypass is safe and reproduceable, with excellent results even during the initial experience with regular surgeries, revisional surgeries or in super-obese patients. Adequate training may shortens or obviates the learning curve.

Three port laparoscopic appendectomy technique with low cost and aesthetic advantage.

INTRODUCTION: Despite dating more than 30 years after the first laparoscopic appendectomy, ileocecal appendix resection is still performed by laparotomy in more than 90% of cases, in our country. AIM: To describe a technique for laparoscopic removal of the ileocecal appendix with three portals, at low cost and very good aesthetic appearance. TECHNIQUE: Three incisions, one umbilical and two suprapubic are made; permanent material used comprises: grasping forceps, hook, scissors, needle holders, three metal trocars and four other usual instruments, and a single strand of cotton. There is no need to use of operative extractors bags, clips, endoloops, staples or bipolar or harmonic energy instruments. Allows triangulation and instrumentation in the conventional manner. CONCLUSION: The proposed technique is safe and reproducible, easily teachable, at very low cost and can be applied in general hospitals with conventional laparoscopic equipment.

Robotic Roux-en-Y gastric bypass: operative results in 100 patients / Bypass gástrico em Y-de-Roux por via robótica: resultados de 100 pacientes operados

BACKGROUND: Laparoscopic gastric bypass is gold-standard for morbid obesity treatment. AIM: To describe the results of robotic gastric bypass for morbid obesity patients. METHOD: Were operated on 100 morbidly obese patients through totally robotic gastric bypass between 2013 and 2014. They were 83% female. The age ranged from 20 to 65 years old (medium 48,5 years); the body mass index varied between 38-67 (medium 42,3 kg/cm2). The procedure was designed with 3 cm long gastric pouch, 1 m biliopancreatic limb, 1,2 m alimentary limb, manual or stapled anastomosis. There were four super-super-obese patients and four revisional surgeries. RESULTS: Docking time varied from 1 to 20 min (medium 4 min). Console time varied from 40-185 min (medium 105 min). There were no intra operative complications or mortality. There were two lower limb deep venous thrombosis. There was no readmission in the first 30 days. CONCLUSION: Totally robotic gastric bypass is safe and reproduceable, with excellent results even during the initial experience with regular surgeries, revisional surgeries or in super-obese patients. Adequate training may shortens or obviates the learning curve. .

RACIONAL: O bypass gástrico laparoscópico é operação consagrada no tratamento da obesidade mórbida. OBJETIVO: Apresentar resultados da cirurgia robótica na realização do bypass gástrico para controle da obesidade mórbida. MÉTODO: Foram operados 100 pacientes com obesidade mórbida totalmente por via robótica entre 2013 e 2014. Dos pacientes 83% eram mulheres. A idade variou de 20-65 anos (média de 48,5 anos). O índice de massa corpórea variou entre 38-67 (média de 42,3 kg/cm2). O modelo da operação constou de um coto gástrico de 3 cm de extensão, alça biliopancreática de 1 m, alça alimentar de 1,2 m, anastomose manual ou com grampeador linear. Quatro pacientes eram super-super-obesos, e houve quatro casos de operações revisionais. RESULTADOS: O tempo de acoplamento do robô variou de 1 a 20 min, com média de 4. O tempo de console variou de 40 a 185 min, com média de 105. Não houve complicações intra-operatórias. Houve duas tromboses venosas profundas de membros inferiores. Não houve mortalidade ou re-internação nos primeiros 30 dias. CONCLUSÃO: O bypass gástrico robótico mostrou-se seguro e apresentou excelentes resultados mesmo na fase inicial da experiência nas operações primárias, revisionais e em pacientes super-obesos. Adequado treinamento pode encurtar ou obviar a curva de aprendizado. .

Three port laparoscopic appendectomy technique with low cost and aesthetic advantage / Técnica de apendicectomia laparoscópica com três portais de baixo custo e benefício estético

INTRODUCTION: Despite dating more than 30 years after the first laparoscopic appendectomy, ileocecal appendix resection is still performed by laparotomy in more than 90% of cases, in our country. AIM: To describe a technique for laparoscopic removal of the ileocecal appendix with three portals, at low cost and very good aesthetic appearance. TECHNIQUE: Three incisions, one umbilical and two suprapubic are made; permanent material used comprises: grasping forceps, hook, scissors, needle holders, three metal trocars and four other usual instruments, and a single strand of cotton. There is no need to use of operative extractors bags, clips, endoloops, staples or bipolar or harmonic energy instruments. Allows triangulation and instrumentation in the conventional manner. CONCLUSION: The proposed technique is safe and reproducible, easily teachable, at very low cost and can be applied in general hospitals with conventional laparoscopic equipment. .

INTRODUÇÃO: Apesar de datar mais de 30 anos da primeira apendicectomia videolaparoscópica, a apendicectomia ainda é realizada por laparotomia em mais de 90% dos casos em nosso país. OBJETIVO: Descrever uma técnica para retirada laparoscópica do apêndice ileocecal com três portais, com muito baixo custo em insumos e de muito bom aspecto estético. TÉCNICA: São feitas três punções, uma umbilical e duas suprapúbicas; o material permanente utilizado compreende: pinça de apreensão, gancho, tesoura, porta-agulhas, três trocárteres metálicos e outros quatro instrumentos usuais, além de um único fio de algodão. Não há necessidade do uso de bolsas extratoras da peça operatória, clipes, alças, grampeadores ou instrumentos de energia especial, bipolar ou harmônica. Permite triangulação e instrumentação da forma convencional. CONCLUSÃO: A técnica proposta é segura e reprodutível, facilmente ensinada, de muito baixo custo podendo ser aplicada em hospitais gerais com equipamento laparoscópico convencional. .