ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES.

BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

Acquisition of robotic surgical skills does not require laparoscopic training: a randomized controlled trial.

BACKGROUND: Robotic surgery is a valid option for minimally invasive surgery in most surgical specialties. However, the need to master laparoscopy is questionable before starting specific training in robotic surgery. We compared the development of basic robotic surgery skills between individuals randomized to train in conventional, laparoscopic, or robotic skills. METHODS: We conducted a single-centered, single-blinded randomized trial. Medical students were randomly assigned to 20 h of conventional, laparoscopic, or robotic surgical training. Students with previous surgical experience were excluded. Participants were evaluated pre- and post-training on the dV-Trainer robotic surgical simulator with the following exercises: Camera Targeting 1, Peg Board 1, Ring and Rail 1, and Ring and Rail 2. RESULTS: Sixty-six students were randomly assigned to each training group. Eight individuals did not complete the study (2 in the conventional group, 3 in the laparoscopic group, and 3 in the robotic group). All groups demonstrated significant improvement in the composite score and in each task following the training period (p < 0.001). No differences were seen between the conventional and laparoscopic groups in the composite score or individual tasks. The robotic group showed greater improvement in number of errors, economy of motion, workspace utilization, and time for completion compared to the other groups. The laparoscopic group showed improved camera manipulation skills compared to the conventional group, while the conventional group showed improved errors and economy of motion compared to the laparoscopic group. CONCLUSION: There was no difference in the acquisition of basic robotic surgical skills between individuals trained in basic conventional or laparoscopic surgical skills. We believe surgeons mastery in laparoscopy is not needed before initiating robotic surgical training. However, basic principles of laparoscopy remain applicable to robotic surgery. Future studies should compare transferability of conventional and laparoscopic training to robotic skills in the operating room.

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

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

Onlay versus sublay techniques for incisional hernia repair: 30-day postoperative outcomes / Comparação das técnicas onlay e sublay para correção de hérnia incisional: desfechos nos primeiros 30 dias pós-operatórios

ABSTRACT BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

RESUMO RACIONAL: O desenvolvimento de hérnia incisional é uma complicação comum após laparotomias. Também tem um impacto econômico importante nos sistemas de saúde e no orçamento da previdência social. O reforço com tela da parede abdominal foi um avanço importante para aumentar o sucesso dos reparos e ajudou a reduzir sua recorrência em longo prazo. Os dois locais mais comuns para colocação de tela em reparos de hérnia incisional incluem os planos pré-muscular (técnica onlay) e retromuscular (técnica sublay). Porém, até o momento, não há consenso na literatura sobre a localização ideal da tela. OBJETIVOS: Comparar as duas técnicas de reparo de hérnia incisional mais comuns (onlay e sublay) em relação à taxa de complicações nos primeiros 30 dias de pós-operatório. MÉTODO: Analisar 115 pacientes submetidos a reparos de hérnia incisional onlay ou sublay e avaliar, como desfecho, as ocorrências de sítio cirúrgico no pós-operatório de trinta dias e a recorrência precoce para cada técnica. RESULTADOS: Não encontramos diferença nos resultados entre os grupos, exceto na formação de seroma, que foi maior nos pacientes submetidos à técnica de sublay, provavelmente pela menor taxa de colocação de dreno neste grupo. CONCLUSÃO: Assim, ambas as técnicas de colocação de tela parecem ser adequadas no reparo de hérnias incisionais, sem grande diferença nos desfechos precoces, relacionados a ao sítio cirúrgico.

Simple Trick for Placement of the Robotic Single-Site Device in Obese Patients.

BACKGROUND: The creation of the da Vinci Single-Site© Surgical Platform (DVSSP) allowed robotic surgery to perform single portal procedures. Due to the characteristics of the robotic single-site system, the triangulation of the instruments was optimized, facilitating the execution of the movements. For this, the care in the placement of the portal have fundamental importance. In overweight and patients with obesity, the subcutaneous can impede the ideal positioning of the portal, affecting the movement of the robotic arms and creating discomfort for the surgeon and bringing risks to the patient. TECHNIQUE: Three points are made for subcutaneous reduction, allowing better adaptation of the device. EXPERIENCE: This technique is performed in all patients with obesity submitted to single-site robotic surgery at our service. CONCLUSION: It is a simple, fast, and low-cost method, allowing more safety to patient and comfort for the surgeon.

THE ROLE OF IMMUNOINFLAMMATORY MARKERS IN THE PROGNOSIS AND RESECTABILITY OF PANCREATIC ADENOCARCINOMA.

BACKGROUND: Pancreatic adenocarcinoma has a high mortality rate. A prognostic tool is essential for a better risk stratification. The neutrophil/lymphocyte ratio and adaptations and the platelet/lymphocyte ratio seem promising for this purpose. AIM: Evaluate the prognostic value of neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio, analyze the ideal cutoff values and investigate their utility in predicting resectability. METHODS: Data were collected of patients with pancreatic adenocarcinoma in Hospital de Clínicas de Porto Alegre between 2003 and 2013. The studied ratios were determined by blood count collected at hospital admission and after two cycles of palliative chemotherapy. RESULTS: Basal neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio did not have prognostic impact in survival (p=0.394, p=0.152, p=0.177 respectively). In subgroup analysis of patients submitted to palliative chemotherapy, neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio determined after two cycles of chemotherapy were prognostic for overall survival (p=0.003, p=0.009, p=0.001 respectively). The ideal cutoff values found were 4,11 for neutrophil/lymphocyte ratio (sensitivity 83%, specificity 75%), 2,8 for derived neutrophil/lymphocyte ratio (sensitivity 87%, specificity 62,5%) and 362 for platelet/lymphocyte ratio (sensitivity 91%, specificity 62,5%), Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were not able to predict resectability (p=0.88; p=0.99; p=0.64 respectively). CONCLUSIONS: Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio are useful as prognostic markers of overall survival in patients with pancreatic adenocarcinoma submitted to palliative chemotherapy. Its use as resectability predictor could not be demonstrated.

The role of immunoinflammatory markers in the prognosis and resectability of pancreatic adenocarcinoma / O papel dos marcadores imunoinflamatórios no prognóstico e ressecabilidade do adenocarcinoma pancreático

ABSTRACT Background: Pancreatic adenocarcinoma has a high mortality rate. A prognostic tool is essential for a better risk stratification. The neutrophil/lymphocyte ratio and adaptations and the platelet/lymphocyte ratio seem promising for this purpose. Aim: Evaluate the prognostic value of neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio, analyze the ideal cutoff values and investigate their utility in predicting resectability. Methods: Data were collected of patients with pancreatic adenocarcinoma in Hospital de Clínicas de Porto Alegre between 2003 and 2013. The studied ratios were determined by blood count collected at hospital admission and after two cycles of palliative chemotherapy. Results: Basal neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio did not have prognostic impact in survival (p=0.394, p=0.152, p=0.177 respectively). In subgroup analysis of patients submitted to palliative chemotherapy, neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio determined after two cycles of chemotherapy were prognostic for overall survival (p=0.003, p=0.009, p=0.001 respectively). The ideal cutoff values found were 4,11 for neutrophil/lymphocyte ratio (sensitivity 83%, specificity 75%), 2,8 for derived neutrophil/lymphocyte ratio (sensitivity 87%, specificity 62,5%) and 362 for platelet/lymphocyte ratio (sensitivity 91%, specificity 62,5%), Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were not able to predict resectability (p=0.88; p=0.99; p=0.64 respectively). Conclusions: Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio are useful as prognostic markers of overall survival in patients with pancreatic adenocarcinoma submitted to palliative chemotherapy. Its use as resectability predictor could not be demonstrated.

RESUMO Racional: O adenocarcinoma pancreático apresenta alta taxa de mortalidade. Uma ferramenta que possa predizer adequadamente o seu prognóstico é fundamental para melhor estratificação de risco. A razão neutrófilos/linfócitos e suas adaptações e a razão plaquetas/linfócitos tem se mostrado promissores para este fim. Objetivo: Avaliar o valor prognóstico das razões neutrófilos/linfócitos, neutrófilos/linfócitos derivada e plaquetas/linfócitos, analisar os pontos de corte mais adequados e investigar sua utilidade como fator preditivo de ressecabilidade. Métodos: Foram coletados dados de pacientes com adenocarcinoma pancreático atendidos no Hospital de Clínicas de Porto Alegre entre 2003 e 2013. As razões estudadas foram determinadas com base nos hemogramas coletados na internação e após dois ciclos de quimioterapia paliativa. Resultados: As razões neutrófilos/linfócitos basal, neutrófilos/linfócitos derivada basal e plaquetas/linfócitos basal não tiveram impacto prognóstico na sobrevida (p=0,394, p=0,152, p=0,177 respectivamente). No subgrupo submetido a quimioterapia paliativa, as razões neutrófilos/linfócitos, neutrófilos/linfócitos derivada e plaquetas/linfócitos após dois ciclos de tratamento mostraram-se fatores prognósticos para sobrevida global (p=0,003, p=0,009 e p=0,001 respectivamente). Os pontos de corte encontrados foram 4,11 para neutrófilos/linfócitos (sensibilidade 83% e especificidade 75%), 362 para plaquetas/linfócitos (sensibilidade 91% e especificidade 62,5%) e 2,8 para neutrófilos/linfócitos derivada (sensibilidade 87% e especificidade 62,5%). As razões neutrófilos/linfócitos, neutrófilos/linfócitos derivada e plaquetas/linfócitos não se mostraram estatisticamente significativas como preditores para ressecabilidade (p=0,88; p=0,99 e p=0,64 respectivamente). Conclusões: As razões neutrófilos/linfócitos, neutrófilos/linfócitos derivada e plaquetas/linfócitos são úteis como marcadores prognósticos de sobrevida global em pacientes com adenocarcinoma pancreático submetidos à quimioterapia paliativa. Seu uso como preditor de ressecabilidade não foi demonstrado.

ROBOTIC ASSISTED SINGLE SITE FOR BILATERAL INGUINAL HERNIA REPAIR.

BACKGROUND: The inguinal hernia is one of the most frequent surgical diseases, being frequent procedure and surgeon´s everyday practice. AIM: To present technical details in making hernioplasty using robotic equipment on bilateral inguinal hernia repair with single port and preliminary results with the method. METHOD: The bilateral inguinal hernia repair was performed by using the Single-Site(c) Da Vinci Surgical Access Platform to the abdominal cavity and the placement of clamps. RESULTS: This technique proved to be effective for inguinal hernia and have more aesthetic result when compared to other techniques. CONCLUSIONS: Inguinal hernia repair robot-assisted with single-trocar is feasible and effective. However, still has higher costs needing surgical team special training.

RACIONAL: A hérnia inguinal é uma das doenças cirúrgicas mais frequentes, tornando-a procedimento frequente e do cotidiano do cirurgião. OBJETIVO: Apresentar detalhes da técnica da hernioplastia inguinal bilateral robótica por single-site e resultados preliminares com o método. MÉTODO: Foi realizada hernioplastia inguinal bilateral assistida por robô, utilizando-se da Vinci Single-Site(c) Surgical Platform para acesso a cavidade abdominal e colocação das pinças. RESULTADOS: Esta técnica demonstrou-se efetiva para correção da hérnia inguinal, além de apresentar melhor resultado estético quando comparado às outras técnicas. CONCLUSÕES: A hernioplastia inguinal assistida por robô com trocarte único é viável e eficaz. Contudo, ainda apresenta custos mais elevados e necessidade de treinamento especial por parte da equipe cirúrgica.

Robotic assisted single site for bilateral inguinal hernia repair / Hernioplastia inguinal bilateral assistida por robô com uso de trocarte único

ABSTRACT Background: The inguinal hernia is one of the most frequent surgical diseases, being frequent procedure and surgeon´s everyday practice. Aim: To present technical details in making hernioplasty using robotic equipment on bilateral inguinal hernia repair with single port and preliminary results with the method. Method: The bilateral inguinal hernia repair was performed by using the Single-Site(c) Da Vinci Surgical Access Platform to the abdominal cavity and the placement of clamps. Results: This technique proved to be effective for inguinal hernia and have more aesthetic result when compared to other techniques. Conclusions: Inguinal hernia repair robot-assisted with single-trocar is feasible and effective. However, still has higher costs needing surgical team special training.

RESUMO Racional: A hérnia inguinal é uma das doenças cirúrgicas mais frequentes, tornando-a procedimento frequente e do cotidiano do cirurgião. Objetivo: Apresentar detalhes da técnica da hernioplastia inguinal bilateral robótica por single-site e resultados preliminares com o método. Método: Foi realizada hernioplastia inguinal bilateral assistida por robô, utilizando-se da Vinci Single-Site(c) Surgical Platform para acesso a cavidade abdominal e colocação das pinças. Resultados: Esta técnica demonstrou-se efetiva para correção da hérnia inguinal, além de apresentar melhor resultado estético quando comparado às outras técnicas. Conclusões: A hernioplastia inguinal assistida por robô com trocarte único é viável e eficaz. Contudo, ainda apresenta custos mais elevados e necessidade de treinamento especial por parte da equipe cirúrgica.

Granular cell tumor of colon: a case report

Granular cell tumor rarely affects the gastrointestinal tract. The symptoms are often unspecific and the diagnosis is reached accidentally by colonoscopy. We report the case of a 42-year-old patient diagnosed with granular cell carcinoma of the colon based on an incidental finding in colonoscopy, who was treated successfully by endoscopic excision of the tumor. (AU)

O tumor de células granulares raramente acomete o trato gastrointestinal. Os sintomas muitas vezes são inespecíficos e o diagnóstico é feito ao acaso através da colonoscopia. Nós reportamos o caso de um paciente de 42 anos diagnosticado com tumor de células granulares de cólon devido a um achado incidental da colonoscopia e tratado com sucesso com remoção endoscópica. (AU)

Staging of colorectal cancer in the private service versus Brazilian National Public Health System: what has changed after five years?

INTRODUCTION: Cancer is a disease that affects a large population, being the colorectal cancer one of the most prevalent. The early diagnosis of these neoplasms represents a better life expectancy. The high cost of diagnostic tests and the low socioeconomic status are considered factors leading to delayed diagnosis. OBJECTIVES: Assess the difference between colorectal cancer staging in patients of private clinics and patients of the Brazilian National Health Service (SUS) and assess the changes in cancer staging in the past five years. METHODS: This retrospective study was conducted with 53 patients divided in two groups (SUS and private clinic) diagnosed with colorectal cancer and treated in 2009. Staging of patients diagnosed in 2009 was compared with data from patients diagnosed in 2004, already published in 2005. RESULTS: Both groups were similar in gender and age. Regarding the staging of patients, no statistical difference was observed between the two groups (p=0.147). When comparing the staging of patients diagnosed in 2009 with that of patients studied in 2004, patients diagnosed in 2009 presented early stages (II and III) in relation to patients analyzed in 2004 (III and IV), p<0.001. CONCLUSION: No significant difference was observed in cancer staging between SUS and private clinic patients. The patients analyzed in 2009 were diagnosed with early stage tumors when compared to patients diagnosed in 2004. (AU)

INTRODUÇÃO: O câncer é uma doença que afeta grande parte da população, sendo o câncer colorretal um dos mais prevalentes. O diagnóstico precoce dessas neoplasias resulta em uma melhor expectativa de vida. O alto custo dos exames diagnósticos e o baixo nível socioeconômico são apontados como fatores que levam ao atraso no diagnóstico. OBJETIVOS: Avaliar a diferença no estadiamento de câncer colorretal no momento do diagnóstico de pacientes oriundos da clínica privada e pacientes do Sistema Único de Saúde (SUS), assim como, avaliar as mudanças no estadiamento nos últimos cinco anos. MÉTODOS: Estudo retrospectivo envolvendo 54 pacientes divididos em dois grupos (SUS e clínica privada) diagnosticados no ano de 2009. Os estadiamentos dos pacientes diagnosticados em 2009 foram comparados com os dados de pacientes diagnosticados em 2004, já publicados em 2005. RESULTADOS: Ambos os grupos eram similares em gênero e idade. Em relação ao estadiamento dos pacientes não houve diferença estatística entre os dois grupos (p=0,147). Na comparação entre os pacientes de 2009 e os pacientes estudados em 2004 se evidencia que os pacientes de 2009 apresentaram-se com estádios mais precoces (II e III) em relação aos pacientes de 2004 (III e IV), p<0,001. CONCLUSÃO: Não há diferença no estadiamento dos pacientes do SUS comparado ao estadiamento dos pacientes da clínica privada. Os pacientes tratados no ano de 2009 se apresentaram com estádios mais precoces em relação aos tratados em 2004. (AU)