Resultados iniciales del Registro Español de Hernia Incisional / Initial results of the National Registry of Incisional Hernia

INTRODUCCIÓN: El objetivo de este estudio fue analizar los datos recopilados en el Registro Nacional de Hernia Incisional (EVEREG) para conocer la situación actual del tratamiento de esta dolencia en España. MÉTODOS: EVEREG es una base de datos prospectiva online en la que, desde julio de 2012, se registraron de forma anónima los datos de las hernias incisionales intervenidas en España. RESULTADOS: Hasta marzo de 2015, se han registrado 4.501 hernias en 95 de los 113 hospitales inscritos. La edad media de los casos fue de 62,7 años, un 56,5% mujeres, con un IMC medio de 30,2 kg/m2 y un 29,8% de ellos con riesgo quirúrgico elevado (ASA III-V). Un 93,7% de las intervenciones fueron electivas, el 88,3% por cirugía abierta y el 22,2% fueron hernias recurrentes. El 66,9% correspondían a una hernia tras laparotomía media, en el 81,4% el diámetro transversal fue menor de 10 cm. Se empleó una prótesis en el 96,2% de los casos. La estancia postoperatoria fue de 5,3 días, con complicaciones en el 29,1% y con una mortalidad del 0,8%. Tras una mediana de seguimiento de 7,7 meses se ha detectado un elevado índice de recurrencias (20,7% al año), sobre todo en hernias intervenidas tras una reparación previa (18,1% primarias vs. 30,6% recidivadas; p = 0,004). CONCLUSIÓN: El registro EVEREG es una herramienta útil para conocer la situación actual del tratamiento de la hernia incisional. El análisis de los datos señala como principales elementos susceptibles de mejora el bajo índice de seguimiento y la elevada tasa de recurrencias

INTRODUCTION: The aim of this study was to the data from the National Registry of Incisional Hernia (EVEREG) to determine the reality of the treatment of this condition in Spain. METHODS: EVEREG is an online prospective database which has been functioning since July 2012; operations for incisional hernia are anonymously recorded. RESULTS: Up to March 2015, 4501 hernias from 95 of the 113 participating hospitals were registered. The mean age of the patients was 62.7, and 56.5% were women, with a mean BMI of 30.2 kg/m2; 29.8% presented a high surgical risk (ASA III-V). A total of 93.7% were scheduled surgeries, 88.3% open surgery and 22.2% were recurrent incisional hernias. There were 66.9% hernias after a midline laparotomy, and 81.4% of a transverse diameter of less than 10 cm. A mesh was used in 96.2% of cases. Postoperative stay was 5.3 days and 29.1% presented a complication, with a mortality of 0.8%. After a median follow-up of 7.7 months a high rate of recurrence was detected (20.7% per year), especially in hernias that were operated on after a previous repair (18.1% primary vs. 30.6% recurrent; P=.004). CONCLUSION: the EVEREG registry is a useful tool to know the current situation of incisional hernia treatment. Analysis of the data shows several points that could be improved: a low rate of follow-up and high recurrence rate

Initial results of the National Registry of Incisional Hernia. / Resultados iniciales del Registro Español de Hernia Incisional.

INTRODUCTION: The aim of this study was to the data from the National Registry of Incisional Hernia (EVEREG) to determine the reality of the treatment of this condition in Spain. METHODS: EVEREG is an online prospective database which has been functioning since July 2012; operations for incisional hernia are anonymously recorded. RESULTS: Up to March 2015, 4501 hernias from 95 of the 113 participating hospitals were registered. The mean age of the patients was 62.7, and 56.5% were women, with a mean BMI of 30.2kg/m2; 29.8% presented a high surgical risk (ASA III-V). A total of 93.7% were scheduled surgeries, 88.3% open surgery and 22.2% were recurrent incisional hernias. There were 66.9% hernias after a midline laparotomy, and 81.4% of a transverse diameter of less than 10cm. A mesh was used in 96.2% of cases. Postoperative stay was 5.3 days and 29.1% presented a complication, with a mortality of 0.8%. After a median follow-up of 7.7 months a high rate of recurrence was detected (20.7% per year), especially in hernias that were operated on after a previous repair (18.1% primary vs. 30.6% recurrent; P=.004). CONCLUSION: the EVEREG registry is a useful tool to know the current situation of incisional hernia treatment. Analysis of the data shows several points that could be improved: a low rate of follow-up and high recurrence rate.

PREBIOUS trial: a multicenter randomized controlled trial of PREventive midline laparotomy closure with a BIOabsorbable mesh for the prevention of incisional hernia: rationale and design.

BACKGROUND: Development of an incisional hernia is one of the most frequent complications of midline laparotomies requiring reoperation. This paper presents the rationale, design, and study protocol for a randomized controlled trial, the aim of which is to evaluate the efficacy and safety of prophylactically placing a bioabsorbable synthetic mesh for reinforcement of a midline fascial closure. METHODS: The PREBIOUS trial (PREventive midline laparotomy closure with a BIOabsorbable mesh) is a multicenter randomized controlled trial in which adult patients undergoing elective or urgent open abdominal operations through a midline laparotomy incision are assigned to one of two groups based on the laparotomy closure procedure: an intervention group in which a continuous polydioxanone (PDS) suture is reinforced with a commercially available GORE® BIO-A® Tissue Reinforcement prosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA), or a control group with continuous PDS suture only. Both groups are followed over 6 months. OUTCOMES: The primary outcome is the appearance of incisional hernias assessed by physical examination at clinical visits and radiologically (CT scan) performed at the end of follow-up. Secondary outcomes are the rate of complications, mainly infection, hematoma, burst abdomen, pain, and reoperation. The PREBIOUS trial has the potential to demonstrate that suture plus prosthetic mesh insertion for routine midline laparotomy closure is effective in preventing incisional hernias after open abdominal surgery, to avoid the effects on those affected, such as poor cosmesis, social embarrassment, or impaired quality of life, and to save costs potentially associated with incisional hernia surgical repair.

Cierre de la pared abdominal después del cierre de un estoma temporal / Abdominal wall closure after a stomal reversal procedure

Revertir un estoma temporal implica 2 procedimientos quirúrgicos diferentes: la reconstrucción del tránsito intestinal y el cierre de la pared abdominal en el sitio del estoma. Este último presenta diferentes aspectos que deben ser analizados: a) la infección del sitio quirúrgico (ISQ), b) el manejo de una hernia coincidente en el sitio del estoma en el momento de su cierre, c) la prevención del desarrollo de una hernia incisional posterior, d) el cierre del estoma en el caso de que se realice la reconstrucción del tránsito por vía laparoscópica, o e) el cierre de la piel del sitio del estoma. El objetivo de este trabajo es analizar estos aspectos en relación con la reconstrucción de la pared abdominal por la que emerge un estoma temporal cuando se procede al cierre de este

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure

Abdominal wall closure after a stomal reversal procedure.

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.

Resultados de una encuesta nacional sobre el cierre de la pared abdominal / Results of a national survey on abdominal wall closure

Objetivos Evaluar los conocimientos sobre el cierre de la pared abdominal mediante una encuesta a una cohorte de cirujanos.MétodosCuestionario individual de 20 preguntas sobre laparotomía en contexto de cirugía electiva.ResultadosRespondieron 131 cirujanos de 7 hospitales (72% especialistas y 28% en formación). El 71% de los encuestados estimó la frecuencia de hernia incisional superior al 15% y un 54% consideró la técnica como factor de riesgo más importante. El 85% consideró la laparotomía media cerrada con sutura de absorción lenta (57%) en un solo plano (66%) como la técnica más adecuada. Un 67% estimó adecuados los puntos totales para la prevención. Un 50% desconocía o no sabía aplicar la técnica 4:1. El 87% consideró que una hernia incisional se puede prevenir y que la técnica es el factor más importante sobre el que se debe actuar. El 84% cree que una prótesis puede prevenir la aparición de una hernia incisional, en cambio un 40% de los encuestados no la usa nunca y solo un 38% la usan en pacientes de riesgo. Al comparar las encuestas entre especialistas y residentes, se detectaron diferencias significativas en cuanto a un mejor conocimiento de los aspectos técnicos teóricos en los cirujanos en formación.ConclusionesAunque los resultados muestran un adecuado conocimiento de la epidemiología y factores de riesgo para desarrollo de hernia incisional, algunos aspectos técnicos básicos son susceptibles de introducción de medidas de formación y consenso para obtener mejores resultados en el cierre de laparotomía (AU)

Objective To assess knowledge on the abdominal wall closure through a surgeon cohort survey.MethodsA twenty question individual questionnaire on laparotomy in elective surgery.ResultsA total of 131 surgeons from seven hospitals responded (72% specialists and 28% in training). 71% of respondents estimated the frequency of incisional hernia to be higher than 15% and 54% considered the technique to be the most significant risk factor. 85% considered midline laparotomy closed with slow absorbable suture (57%) in a single layer (66%) to be the most appropriate technique. 67% believed retention sutures to be the appropriate prevention technique. 50% did not know or could not apply the 4:1 technique. 87% considered that an incisional hernia can be prevented and that the technique is the most important factor on which to act. 84% believed that a prosthesis can prevent the occurrence of incisional hernia, whereas 40% of respondents never use it and only 38% use it in patients at risk. On comparing surveys between specialists and residents, significant differences appeared in terms of a better understanding of the theoretical technical aspects in trainee surgeons.ConclusionsAlthough the results show an adequate understanding of the epidemiology and risk factors for development of incisional hernia, training and consensus measures are likely to be introduced in some basic technical aspects in order to improve results in laparotomy closure (AU)

[Results of a national survey on abdominal wall closure]. / Resultados de una encuesta nacional sobre el cierre de la pared abdominal.

OBJECTIVE: To assess knowledge on the abdominal wall closure through a surgeon cohort survey. METHODS: A twenty question individual questionnaire on laparotomy in elective surgery. RESULTS: A total of 131 surgeons from seven hospitals responded (72% specialists and 28% in training). 71% of respondents estimated the frequency of incisional hernia to be higher than 15% and 54% considered the technique to be the most significant risk factor. 85% considered midline laparotomy closed with slow absorbable suture (57%) in a single layer (66%) to be the most appropriate technique. 67% believed retention sutures to be the appropriate prevention technique. 50% did not know or could not apply the 4:1 technique. 87% considered that an incisional hernia can be prevented and that the technique is the most important factor on which to act. 84% believed that a prosthesis can prevent the occurrence of incisional hernia, whereas 40% of respondents never use it and only 38% use it in patients at risk. On comparing surveys between specialists and residents, significant differences appeared in terms of a better understanding of the theoretical technical aspects in trainee surgeons. CONCLUSIONS: Although the results show an adequate understanding of the epidemiology and risk factors for development of incisional hernia, training and consensus measures are likely to be introduced in some basic technical aspects in order to improve results in laparotomy closure.

Respuesta de los autores: Tratamiento laparoscópico de la acalasia de cardias. Análisis de resultados y reflexiones sobre la técnica / Authors’ reply: Laparoscopic treatment of achalasia of the cardia. Analysis of results and reflections on the technique

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A calcified foreign body in the bladder due to : an unusual complication after laparoscopic incisional hernia repair.

We report a rare complication caused by a displaced tack after laparoscopic incisional hernia repair. A 41-year-old woman treated 11 months earlier for a suprapubic incisional hernia (Pfannenstiel laparotomy) received a laparoscopic repair with a bilaminar mesh fixed with tacks. Seven months later, she presented miccional irritative symptoms and chronic lower abdominal pain. Leucocyturia and microhematuria were present, and computerized tomography showed 2 calcified nodules in the bladder wall. Cystoscopy confirmed 2 calcified foreign bodies in the bladder due the tack fixation. She underwent an intra-abdominal laparoscopic exploration, which showed the protrusion of a mesh in the urinary bladder. The tacks were removed and a partial laparoscopic cystectomy including mesh protrusion was performed. The patient was discharged from hospital 4 days later without postoperative complications. At follow-up 24 months after surgery, she remains well with no pain, urinary symptoms, or hernia recurrence.

Tratamiento laparoscópico de la acalasia. Análisis de resultados y reflexiones sobre la técnica / Laparoscopic treatment of achalasia: analysis of results and reflections on the technique

Introducción La miotomía de Heller por vía laparoscópica es el mejor tratamiento que podemos ofertar a los pacientes con acalasia. Al no actuar sobre la causa de la enfermedad sino que únicamente aliviamos la sintomatología la persistencia de los síntomas puede no desaparecer. Objetivo Analizar los resultados de nuestro grupo en el tratamiento de la acalasia por vía laparoscópica. Material y métodos Se revisan los resultados pre y postoperatorios de una serie de 20 pacientes intervenidos prospectivamente por vía laparoscópica de acalasia durante el período comprendido entre mayo de 2003 y abril de 2010. Para ello se ha utilizado una modificación de la escala de de gradación progresiva de los síntomas pre y postoperatorios descrita por Velanovich para el RGE (escala de 0-5). También se han recogido las complicaciones y estancia hospitalaria. Resultados Se ha practicado una miotomía de Heller amplia asociando un mecanismo anti-reflujo tipo Dor en todos los casos. No se han producido perforaciones esofágicas ni complicaciones intraoperatorias. Dos (10%) pacientes han presentado complicaciones postoperatorias. La estancia hospitalaria ha sido de 3,11±2,13 días. Tras un seguimiento medio de 55,8±14,1 meses los síntomas estudiados han disminuido significativamente tras la cirugía. Sólo 3 pacientes (15%) han presentado clínica postoperatoria de RGE. Diecinueve pacientes (95%) refirieron estar satisfechos con el resultado de la intervención. Conclusiones El tratamiento laparoscópico de la acalasia es una técnica segura, reproducible y efectiva, que consigue un control de los síntomas de la acalasia muy satisfactorio con una mínima morbilidad (AU)

Introduction Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear. Objective To analyse the results of our group in the treatment of achalasia by laparoscopy. Material and methods The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected. Results A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11±2.13 days. After a mean follow up of 55.8±14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation. Conclusions The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity (AU)

[Laparoscopic treatment of achalasia: analysis of results and reflections on the technique]. / Tratamiento laparoscópico de la acalasia. Análisis de resultados y reflexiones sobre la técnica.

INTRODUCTION: Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear. OBJECTIVE: To analyse the results of our group in the treatment of achalasia by laparoscopy. MATERIAL AND METHODS: The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected. RESULTS: A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11 ± 2.13 days. After a mean follow up of 55.8 ± 14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation. CONCLUSIONS: The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity.

Cáncer gástrico por laparoscopia: análisis de los datos del Registro Nacional de Cirugía Gástrica por Laparoscopia / Gastric cancer and laparoscopy: analysis of data from the national register of laparoscopic gastric surgery

Objetivo: Describir los datos enviados al Registro Nacional de Cirugía Gástrica por laparoscopia y analizar el tipo de cirugía, la reconversión, las complicaciones postoperatorias y la mortalidad. Pacientes y método: Desde marzo de 2005 a julio de 2008 han sido remitidos al registro 302 pacientes a través de un cuestionario ubicado en la página web de la Asociación Española de Cirujanos, donde se registraron datos clinicopatológicos, características de la cirugía realizada, reconversión y morbimortalidad. Resultados: Se ha intervenido a 245 pacientes por adenocarcinoma gástrico, 35 por tumores estromales y 22 por otras afecciones. En los adenocarcinomas gástricos se realizó cirugía resectiva en 232 (95%) casos. La localización predominante fue el tercio distal y el tipo de tumor más frecuente, el intestinal. El 34% fueron tumores localmente avanzados. Se realizó una linfadenectomía D2 en 117 casos, D1 en 105 y D0 en 6. Se realizó reconversión en 21 (9%), y entre las causas destacan las dificultades técnicas. Se han descrito complicaciones postoperatorias en 72 (31%) casos, entre las que destacan por su gravedad las fístulas digestivas. Hubo una mortalidad postoperatoria del 6%, y las causas más frecuentes fueron la sepsis por fuga anastomótica y las complicaciones cardiorrespiratorias. La estancia media hospitalaria en los pacientes que no presentaron complicaciones fue de 9,2±3 días. Conclusiones: La gastrectomía laparoscópica en el cáncer gástrico es un procedimiento factible que no está exento de dificultades técnicas. Una considerable tasa de complicaciones postoperatorias pueden llegar a condicionar los beneficios de la cirugía mínimamente invasiva(AU)

Objective: To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality. Patients and Method: From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed. Results: A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause . Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2±3 days.Conclusions: Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications(AU)

[Gastric cancer and laparoscopy: analysis of data from the national register of laparoscopic gastric surgery]. / Cáncer gástrico por laparoscopia: análisis de los datos del Registro Nacional de Cirugía Gástrica por Laparoscopia.

OBJECTIVE: To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality. PATIENTS AND METHOD: From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed. RESULTS: A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause. Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2 +/- 3 days. CONCLUSIONS: Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications.

Laparoscopic treatment of gastric tumors.

PURPOSE: To assess the use of different laparoscopic approaches in the management of gastric tumors based on tumor type and location. MATERIALS AND METHODS: Between March 2002 and June 2005, 23 consecutive patients with gastric lesions were treated with laparoscopy procedures. Six patients presented with stromal tumors, 5 with benign lesions, and 12 with resectable gastric cancers. RESULTS: The patients were 13 men and 10 women, mean age 66.2 +/- 11.1 years (range, 29-84 years). Five laparoscopic gastric wedge resections, 6 intragastric submucosal resections, and 12 gastrectomies (10 subtotal and 2 total) were performed. Mean operative time was 49.1 +/- 18.8 minutes (range, 30-85 minutes) in the gastrointestinal stromal tumors and 64.1 +/- 19.2 minutes (range, 45-90 minutes) in benign tumors. Gastrectomy required an average of 197.6 +/- 36.9 minutes (range, 130-260 minutes). The mean times were 142.5 +/- 9.6 minutes in the subtotal gastrectomy group with extracorporeal anastomosis and 190.8 +/- 20.1 minutes when the anastomosis was totally laparoscopic (P < 0.002). All procedures were completed laparoscopically and there were no intraoperative complications. There were four postoperative complications: one wall hematoma secondary to the introduction of a trocar, one prolonged ileus, one intra-abdominal abscess, and one esophagojejunal leakage. Gastrointestinal stromal tumor patients were discharged after a mean 5.8 +/- 1.3 days; patients with benign pathology after 5.2 +/- 0.9 days, and gastric cancer patients after 10.7 +/- 7.3 days (range, 6-28 days). The mean number of dissected lymph nodes in gastric cancer was 21.3 (range, 16-31). CONCLUSION: Laparoscopic treatment of gastric lesions is technically feasible and safe. Compared to conventional surgery, it offers the advantages of low invasiveness and improved quality of life.

Laparoscopic resection of clinically suspected gastric stromal tumors.

Gastrointestinal stromal tumors (GISTs) account for 5% of all gastric tumors. Preoperative diagnosis is relatively difficult because biopsy samples are rarely obtained during fibergastroscopy. Surgical radical resection is the gold standard treatment, allowing pathologic study for both diagnosis and prognosis. Laparoscopic resection has become an alternative to the open approach, but long-term results are not well known. The aim of this study is to report experience with laparoscopic resection, placing special emphasis on preoperative diagnosis and describing long-term results. A retrospective analysis was made of all patients undergoing a laparoscopic resection for clinically suspected gastrointestinal stromal tumors between November 1998 and August 2006 at 2 tertiary hospitals. The medical records of all participants were reviewed regarding surgical technique, clinicopathologic features, and postoperative long-term outcome. Laparoscopic gastric resection was attempted in 22 patients (13 women and 9 men) with a mean age of 66.7 years (range, 29-84 years). One patient had 2 gastric tumors. Tumor localization was upper gastric third in 6 patients, mid-gastric third in 7, and distal third in 10. Surgical techniques were transgastric submucosal excision (n = 1), wedge resection (n = 13), partial gastrectomy with Y-en-Roux reconstruction (n = 6), and total gastrectomy with Y-en-Roux reconstruction (n = 2). Two patients (9.1%) required conversion to the open procedure because of tumor size. Postoperative morbidity was delayed gastric emptying in 3 patients. Median postoperative stay was 6 days (range, 4-32 days). Pathologic and immunohistochemical study confirmed gastrointestinal stromal tumors in 18 cases. The other 4 cases were adenomyoma, hamartoma, plasmocytoma, and parasitic tumor (anisakis). Median tumor size was 5.6 cm (range, 2.5-12.5 cm) in cases of gastrointestinal stromal tumors. Malignant risk of gastrointestinal stromal tumors assessed according to mitotic index and size was low (n = 8), intermediate (n = 6), or high (n = 4). After a median follow-up of 32 months (range, 1-72 months), there was 1 case of recurrence of GIST. Definitive preoperative diagnosis of gastric submucosal tumors is frequently difficult. The laparoscopic approach to surgical treatment of these tumors seems safe and is associated with acceptable intermediate-term results, especially in cases of gastrointestinal stromal tumors.

The development of laparoscopic surgery in Spain.

AIM: To assess degree of development and level of acceptance of laparoscopic surgery in Spain. METHOD: A questionnaire was sent to all members of the Spanish Association of Surgeons in April 2003. It included 32 questions, 9 of which were general, and 23 referred to specific clinical situations, techniques, and standard practice. RESULTS: Eight hundred and fifty-eight (33.1%) surgeons replied. Only 211 (25%) surgeons reported performing advanced laparoscopic procedures. Four hundred and twenty (49%) surgeons believed that the results obtained with laparoscopic surgery were better than those obtained with conventional surgery, and 325 (40%) surgeons believed that laparoscopy would become a superspecialty. Laparoscopic surgery was considered the method of choice in the treatment of gallbladder stones (99%), gastroesophageal reflux disease (94%), acute cholecystitis (81%), in selected cases of inguinal hernia repair, and in procedures to be performed in spleen and adrenals, benign colon disease, and obesity. Three hundred and ninety-eight (47%) surgeons considered laparoscopic surgery the preferred approach for colon cancer, 292 (34%) for appendicitis, and 155 (18%) for incisional hernia. Five hundred and five (59%) surgeons considered that the use of laparoscopic surgery had grown less than expected. CONCLUSIONS: The vast majority of surgeons advocated laparoscopic surgery for the treatment of gallbladder stones and gastroesophageal reflux disease. Although most hospitals had the appropriate technical facilities for performing advanced laparoscopic procedures, few surgeons actually did so.

Impacto de la cirugía laparoscópica en el manejo del dolor abdominal agudo en la mujer joven. ¿Indicación de apendicectomía selectiva? / Impact of laparoscopic surgery in the management of acute abdominal pain in young women. Indication for selective appendicectomy?

Introducción. El objetivo de este estudio es analizar la utilidad de la laparoscopia en las mujeres en edad fértil con dolor agudo en la fosa ilíaca derecha (FID), a fin de mejorar su diagnóstico y proceder a su tratamiento adecuado.Pacientes y método. Estudio prospectivo realizado entre enero de 1999 y octubre de 2003 en mujeres de edad fértil con sospecha clínica de apendicitis aguda. En los casos en que el diagnóstico era claro clínicamente se procedía a la intervención quirúrgica por vía convencional (grupo abierto). Cuando el diagnóstico clínico era dudoso y la clínica era susceptible de exploración quirúrgica, se indicaba una laparoscopia diagnóstica; no se practicaba una apendicectomía sistemática si la paciente no presentaba una apendicitis aguda (grupo laparoscópico).Resultados. Durante este período se intervino a un total de 159 mujeres en edad fértil con sospecha clínica de apendicitis aguda, 89 en el grupo laparoscópico y 70 en el grupo abierto. En el primer grupo, 68 casos (76,4 por ciento) presentaron una apendicitis aguda, mientras en los 21 restantes la causa fue diferente de esta entidad clínica; el motivo más frecuente fue la enfermedad ginecológica en 16 casos (18 por ciento). En estas 21 pacientes que no presentaban una apendicitis aguda no se practicó apendicectomía y ninguna de ellas precisó reintervención por apendicitis aguda en un seguimiento medio de 3 meses (ningún falso negativo).En el grupo abierto se halló una apendicitis aguda en 60 casos (85,7 por ciento) y el índice de apendicectomías blancas fue del 12,8 por ciento. En el grupo laparoscópico no hubo ningún caso de apendicectomía blanca (p < 0,02).Conclusiones. En mujeres de edad fértil con sospecha de apendicitis aguda, la laparoscopia aumenta la precisión diagnóstica y puede disminuir el índice de apendicectomías innecesarias. Cuando la laparoscopia descarta el diagnóstico de apendicitis aguda, resulta seguro dejar el apéndice en la cavidad abdominal, una vez evaluado como normal (AU)

Recurrent inguinal hernia: a ten-year review.

BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.

La cirugía laparoscópica en España. Resultados de la encuesta nacional de la Sección de Cirugía Endoscópica de la Asociación Española de Cirujanos / Laparoscopic surgery in spain. Results of the national survey of the endoscopic surgery section of the spanish association of surgeons

Objetivo. Conocer la opinión de los cirujanos miembros de la Asociación Española de Cirujanos (AEC) sobre la cirugía laparoscópica (CL) y su implantación en nuestros hospitales. Material y métodos. Dos encuestas de opinión. Una remitida a todos los miembros de la AEC en abril de 2003. Incluía aspectos generales y situaciones clínicas. La otra se remitió a todos los servicios de cirugía del país e incluía aspectos sobre dotación e implantación de la CL. Resultados. Han contestado 106 servicios (40 por ciento) y 855 cirujanos (32,3 por ciento). Sólo 209 (25 por ciento) cirujanos realizan procedimientos avanzados. El 49 por ciento de cirujanos creen que los resultados de la CL son mejores que los de la cirugía convencional y 324 (40 por ciento) creen que la CL acabará siendo una superespecialidad. La CL se considera de primera elección en el tratamiento de la colelitiasis (99 por ciento), reflujo gastroesofágico (RGE) (94 por ciento) y colecistitis aguda (81 por ciento). En otras afecciones como la hernia inguinal, las enfermedades del bazo, patología benigna de colon, la obesidad y enfermedades suprarrenales se utilizaría en casos seleccionados. El cáncer de colon, la apendicitis y la eventración tienen una baja aceptación como primera indicación en la CL. El 59 por ciento de cirujanos considera que la CL no ha tenido el crecimiento esperado. Conclusiones. La CL, en nuestro medio y para un amplio colectivo de cirujanos, es ampliamente aceptada para el tratamiento de la colelitiasis y el RGE. A pesar de que nuestros hospitales tienen medios técnicos suficientes para realizar la CL avanzada, ésta se practica por pocos cirujanos. Aspectos como la formación en CL y la superespecialización aún quedan por perfilar en un futuro (AU)