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

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

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

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

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

High-Definition Liposculpture 18-Year Evolution: Patient Safety and Aesthetic Outcomes.

BACKGROUND: High-definition liposculpture (HDL) emerged as an innovative surgical technique that allowed plastic surgeons to achieve improved aesthetic results with a natural and athletic appearance using minimal incisions and with imperceptible scarring. Its targets are high aesthetic standards and patient safety. PURPOSE: This article summarizes the evolution of HDL by explaining upgrades to the original technique and comparing the complication rates among them. METHODS: The authors retrospectively reviewed records from four private medical centers (Evolution Medical Center, Santa Barbara Medical Center, and Dhara Clinic in Bogota and FOSCAL in Bucaramanga, Colombia) of patients who underwent HDL performed by the senior author (A.E.H) over an 18-year period (2002 through 2019). Patients were classified into three groups: suction-assisted lipoplasty (period 1), vibration amplification of sound energy at resonance-assisted HDL (period 2), and dynamic definition liposculpture (period 3). RESULTS: The authors established a cohort of 5052 patients (4300 women and 752 men): 923 in period 1, 1272 in period 2, and 2857 in period 3. The most common complications included seroma, bruising, hematoma, acute anemia, hyperchromia, wrinkled skin, wound dehiscence, and local infections. CONCLUSIONS: HDL and dynamic-definition liposculpture procedures are safe and reproducible techniques to achieve an athletic and natural body contour. Complication rates, especially those related to bleeding, decreased as the technique evolved. These procedures are aimed toward patient safety to provide higher aesthetic outcomes using extensive medical, anatomic, artistic, and technological knowledge. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Robotic surgery: financial impact of surgical trays optimization in bariatric and thoracic surgery.

The incorporation of new technologies in the surgical field, such as the robotic da Vinci System, has made it possible to offer a series of advantages to the patient and the surgeon, with important benefits for both. However, cost continues to be a limiting factor to the adoption of this technology. The development of strategies to maximize the measures that can lead to reduced expenses is a key factor to improve cost-benefit ratio. According to some studies, more than 50% of the costs of a surgical procedure are related to materials and medical supplies, which is why any measure aimed at optimizing their use is pertinent. Our institution, the Orlando Regional Medical Center (ORMC), created a working group whose main purpose is to optimize the Robotic OR process. Their first step was to optimize the surgical trays, and this was carried out in four stages: observation, modification, trial period, and cost analysis. The specialties involved in this initiative were Bariatric and Thoracic Surgeries. Once the optimization process ended, the number of laparoscopic/thoracoscopy instruments in the trays decreased by 63 and 87% for bariatric and thoracic surgery, respectively; and the number of conventional surgery instruments was also reduced by 47 and 64%, for the same specialties, respectively. The financial analysis concluded that implementing this measure will lead to an estimated six-figure savings per year.

Development of a robot-assisted thoracic surgery (RATS) program. Lessons learned after 2500 cases.

Robotic surgery provides significant advantages in terms of an optimal three-dimensional and magnified view of the surgical field, superior maneuverability of surgical instruments, removal of surgeon's tremor and excellent ergonomics. Nonetheless, the adoption of this technology in thoracic surgery has been slower than in other specialties such as urology, gynecology or digestive surgery. In this article we describe our institution's experience in robotic-assisted thoracic surgery (RATS) in the span from 2012 to 2020. During this time the average annual growth of the program has been 55%. Among the most frequently procedures performed were lobectomies, wedge resection and segmentectomies. Surgical time and length of stay decreased as the number of procedures performed increased, relative to the learning curve. Additional important elements considered relevant to the success of the program are the resources available, leadership, motivation of the surgical team, adequate and stepwise training, as well as the collection of data for periodic analysis of results. All those initiatives have led to a relevant improvement of financial variables reflecting a cost reduction.

Robot-assisted duodenal switch with DaVinci Xi: surgical technique and analysis of a single-institution experience of 661 cases.

Metabolic and bariatric surgery is an effective treatment for the management of obesity and related comorbidities. Although the duodenal switch has demonstrated superior results in terms of resolution of obesity-related comorbidities and weight loss, it is one of the less performed procedures. The use of robotic surgical platforms offers many advantages in obese patients and is particularly useful in technically demanding procedures such as duodenal switch. Observational, retrospective and analytical study of cases corresponding to robot-assisted duodenal switch performed between 2016 and 2021. We describe our technique using the system DaVinci Xi. Operative and perioperative variables, postoperative complications, and readmission rate were determined. A total of 661 patients underwent duodenal switch which correspond to the 20.7% of the total bariatric procedures performed in this period. A clear decrease in surgical time and length of stay was observed as the number of cases progressively increased. The complication rate during the first 30 days was 9.1%. Among these, only 1.9% corresponded to major complications, being strictures the most frequent (0.9%), followed by leaks (0.45%). Readmission rate in this period was 6.1%. Between 30 and 90 days postoperatively, the complication rate was 0.91%. Robotic-assisted duodenal switch is a safe surgery with a low complication rate. This procedure is highly effective in terms of durable weight loss in obese and super-obese patients. Robotic DaVinci Xi system allows surgeons to achieve a high level of proficiency and master technique resulting in reduction of surgical time and length of stay.

H-Wing Neoumbilicoplasty: A New Technique for Advanced Abdominoplasty and Umbilical Zones by Gender.

BACKGROUND: Multiple umbilicoplasty techniques have been described, even more after the advent of full tummy tuck procedures and the neoumbilicoplasty (X-shaped incision) described by the authors in a previous report. The authors decided to upgrade the technique (H-wing incision) because the former procedure is associated with relatively common complications. The authors report a case series of an upgraded technique for neoumbilicoplasty (H-wing technique), comparing its outcomes with their previous standard procedure (X-shaped incision). METHODS: The authors reviewed their records for neoumbilicoplasties performed between January of 2014 and December of 2019. The authors divided the procedures according to the surgical technique and performed a detailed analysis regarding timing, complications, uses, and quality standards according to patients' opinion through a nonstandardized survey. RESULTS: A total of 407 procedures were distributed between two techniques: X-shaped incision, 179 procedures; and H-wing technique, 228 procedures. The former was performed from January of 2014 to October of 2016 and the latter from September of 2016 to December of 2019. High satisfaction indexes were found for both procedures; however, fewer complications were seen in the H-wing group. The X-shaped incision is thought to generate a greater force of tension over the flaps compared to that from the H-wing technique, which consequently increased the risk of flap necrosis and flattening. CONCLUSIONS: The H-wing technique for neoumbilicoplasty decreases the risk of postoperative complications such as dehiscence, skin necrosis, and navel flattening, and maintains high aesthetic standards and satisfaction indexes among patients. The technique can be used after either lipoabdominoplasty or secondary procedures.

Decision-Making Algorithm for Advanced Excisional Body Contouring: Dynamic Definition Solutions for Skin Laxity.

BACKGROUND: Excisional body contour surgery is the cornerstone treatment for skin laxity. Decision-making can be challenging when selecting the procedure. Dynamic definition liposculpture allows the surgeon to carve the underlying anatomy and provide more natural results, in which umbilical shape and position play a crucial role. The authors describe their experience using a decision-making algorithm as a tool to ease surgical planning for advanced excisional body contouring. METHODS: Following the algorithm designed by the senior author regarding excisional body contouring procedures, the authors searched their database for patients who were classified according to skin laxity and navel location to undergo one of the following procedures: mixed technologies plus umbilical mobilization, mixed technologies plus sliding mini-abdominoplasty, mini-tummy tuck with muscular plication, full abdominoplasty, reverse bridge abdominoplasty, or reverse full abdominoplasty. RESULTS: A total of 563 women were consecutively operated on from February of 2014 to January of 2020. The six-procedure model algorithm helped the authors achieve very good results with low complication rates in patients with some grade of abdominal skin laxity. Most complications were reported as minor (9.6 percent). Major complications (3.9 percent) included three localized infections, four abnormal skin retractions, two cases of skin flap necrosis, and 13 cases of postoperative anemia. CONCLUSIONS: This algorithm helped the authors choose the best excisional technique based on patients' anatomical features by following skin geometry to enhance aesthetic outcomes. Further studies are needed to support the algorithm validation and aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of Tranexamic Acid in Liposculpture: A Double-Blind, Multicenter, Randomized Clinical Trial.

BACKGROUND: Intraoperative hemostasis should be performed with great caution because bleeding is a huge enemy of patient safety during surgery. Tranexamic acid is a lysine synthetic derivate that inhibits fibrinolysis and diminishes the bleeding by blocking the five lysine-binding sites for plasminogen. The authors compare the efficacy of tranexamic acid versus placebo as a hemostatic agent in liposculpture procedures. METHODS: The authors conducted a multicenter, double-blind, randomized, controlled clinical trial in patients who were scheduled for liposculpture in three plastic surgery centers (Colombia and Mexico) between January of 2019 and February of 2020. One hundred forty-one patients were randomly assigned into three groups: intravenous (1 g of tranexamic acid), subcutaneous (1 g of tranexamic acid), and placebo (normal saline). Forty-seven patients were assigned to each group. There were 30 male patients and 111 female patients. The main outcome was to evaluate the amount of postoperative bleeding between groups. The primary outcome was measured by the hemoglobin point loss at day 1 (preoperative hemoglobin minus hemoglobin at day 1 postoperatively) and the hemoglobin (in milligrams per deciliter) point loss at day 5 (preoperative hemoglobin minus hemoglobin at day 5 postoperatively). RESULTS: The authors found the intravenous intervention group to have a greater hemoglobin level than the other two groups on both the first postoperative day ( p = 0.0001) and the fifth postoperative day ( p = 0.001). There were no statistical differences in hemoglobin values between the placebo and the subcutaneous intervention groups. CONCLUSION: Intravenous tranexamic acid is a good therapeutic choice to implement on liposculpture procedures to decrease postoperative bleeding. CLINICAL RELEVANCE STATEMENT: The preoperative use of intravenous tranexamic acid not only decreases the bleeding rate after liposuction procedures, but also allows greater lipoaspirate volumes when performing high-definition liposculpture. Further studies are required to support the effectiveness of tranexamic acid within the infiltration solution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

TULUA Male High-Definition Abdominoplasty.

BACKGROUND: Abdominoplasty is a surgical technique for body contouring that has been shown to improve the patient's quality of life. It has become more common among male patients, so clear differences between procedures for men and women have to be stated. The authors present their experience with high-definition lipoabdominoplasty with transverse plication in men. METHODS: Records of male patients undergoing transverse plication full abdominoplasty in addition to high-definition liposculpture were analyzed. A total of 24 consecutive cases were found between January of 2017 and June of 2019. Patient ages ranged from 24 to 60 years. Patients aged 18 years or younger were excluded. Body mass index ranged from 25 to 33 kg/m2. Photographic records were taken before and during follow-up at 2 days and 1, 3, 6, and 12 months after surgery. RESULTS: Male TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) with high-definition lipoabdominoplasty was successfully achieved in 24 cases. No major complications were reported. Six minor complications were reported (25 percent). Rectus abdominis diastases are less common in men compared to women, as pregnancy is the most determining factor in its development. Fat distribution is also a key difference when performing lipoabdominoplasty for the male or the female patient. The authors recommend a transverse plication of the abdominal wall, instead of a vertical one, as flap viability is preserved and enhanced muscular definition can be accomplished. CONCLUSIONS: Combining transverse plication with high-definition lipoabdominoplasty (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar plus high-definition lipoabdominoplasty) is a safe and reproducible technique for the male patient. It offers higher aesthetic results in line with modern beauty ideals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cardiomiopatía hipertrófica: experiencia de 5 años / Hypertrophic cardiomyopathy: 5 year experience

Resumen Introducción: La cardiomiopatía hipertrófica se define como el engrosamiento de la pared ventricular izquierda que no es explicado por condiciones anormales de la carga y que impone un riesgo de: arritmias, falla cardiaca y muerte súbita. Objetivo: identificar prevalencia, las características clínicas y el tratamiento de los pacientes con cardiomiopatía hipertrófica atendidos en nuestra institución. Materiales y métodos: Se extrajeron y analizaron los registros de pacientes con cardiomiopatías hipertróficas, definiendo las características generales y explorando las diferencias entre subgrupos, todos los contrastes estadísticos asumieron una confianza del 95%. Resultados: Se evaluaron 22 casos de la cardiomiopatía hipertrófica, el sexo femenino aportó el 40,9% del total de los casos, la edad promedio fue 54 años. El 77,27% presentaron insuficiencia mitral, el 63,64% reportaron dolor torácico, el 68,18% se encontraban en tratamiento inhibidor de renina y el 95,45% tenían betabloqueador, el grosor promedio del septum fue del 22,77 mm, la prevalencia de fibrilación auricular fue del 22,7% y la de enfermedad coronaria del 18%. Conclusiones: La prevalencia de la cardiomiopatía hipertrófica en el período 2009-2013 fue del 2,35%, relacionado principalmente con la insuficiencia mitral y tenían antecedente de dolor torácico, la prevalencia de la fibrilación auricular en pacientes con cardiomiopatía hipertrófica en el presente estudio fue del 22,7% y la de enfermedad coronaria del 18%.

Abstract Introduction: Hypertrophic cardiomyopathy is defined as the thickening of the left ventricular wall that is not explained by abnormal loading conditions, imposing a risk for arrhythmias, heart failure and sudden death. We attempt to identify the prevalence, clinical features and treatment of patients with hypertrophic cardiomyopathy assisted within our institution. Material and methods: Records of patients with hypertrophic cardiomyopathy were pulled and analysed, defining general features and exploring differences among subgroups; all statistical contrasts assumed a confidence of 95%. Results: 22 cases of hypertrophic cardiomyopathy were assessed, 40.9% of whom were female, average age was 54. 77.27% showed mitral insufficiency, 63.4% reported chest pain, 68.18% were receiving renin inhibitor therapy and 95.45% were taking beta blockers. Average septum thickness was 22.77 mm, prevalence of atrial fibrillation was 22.7% and coronary disease 18%. Conclusion: Prevalence of hypertrophic cardiomyopathy during the 2009-2013 period was of 2.35%, mostly related to mitral insufficiency and previous history of chest pain; prevalence of atrial fibrillation in patients with hypertrophic cardiomyopathy in our study was of 22.7%,and 28% for coronary disease.

El ultrasonido: desde el murciélago hasta la cardiología no invasiva / Ultrasound: from bats to non-invasive cardiology

Resumen Introducción: El sonido se propaga en un medio aprovechando las propiedades elásticas del mismo. El presente estudio describe la evolución de la ultrasonografía cardiaca y su aplicación en la cardiología. Materiales y métodos: Revisión descriptiva en bases documentales, se exploraron conceptos en textos electrónicos de física y fisiología, ampliando los conceptos por método de Snowball. Resultados: Siglo xviii y xix: Spallanzani reconoció la existencia de la ecolocalización en el modelo animal (murciélagos), se descubre la piezoelectricidad. Siglo xx: aplicación de la ecolocalización en el sistema SONAR y la detección de tumores cerebrales, cuerpos extraños en tejidos orgánicos y lesiones malignas en el intestino y el tejido mamario. Década de los años 50 y 60, se identificaron masas en la aurícula izquierda, inicia la descripción de la enfermedad valvular mitral; se describen los primeros ecardiogramas en modo M (movimiento). En los años 60, un transductor de elemento único permitió los ecocardiogramas intracardiacos; luego un transductor de rotación lenta permitió obtener imágenes en 2 D. En los años 80, nace la ecocardiografía transesofágica para evaluar pacientes con pobre ventana acústica; en los años 90, se introdujeron los traductores omniplanares y biplanares con capacidad Doppler y flujo en color. En los últimos años, los desarrollos de la ecocardiografía han ampliado el alcance hasta la cirugía mínimamente invasiva. Conclusiones: Grandes avances se han logrado en consecuencia con la evolución del ultrasonido en medicina, su inicio en la ecolocalización descrita en los murciélagos hasta la ultrasonografía cardiaca en 3 D, han permitido el desarrollo de nuevas no invasivas en la medicina cardiovascular.

Abstract Introduction: Sound propagates in a medium taking advantage of its elastic properties. This study describes the evolution of cardiac ultrasonography and its application in cardiology. Material and methods: Descriptive review of data bases, concepts were explored in electronic physics and physiology texts, expanding the concepts by means of the Snowball method. Results: 18th and 19th century: Spallanzani recognised the existence of echolocation in the animal model (bats); piezoelectricity is discovered. 20th century: applying echolocation in the SONAR system and brain tumour detection, foreign bodies in organic tissue and intestinal and breast tissue malignancies. 50s and 60s: masses in the left atrium were identified, mitral valve disease description begins, first M-mode echocardiograms are described. In the 60s a single element transducer allowed for intracardiac echocardiograms, later on a slow rotating transducer displayed 2 D images. In the 80s transthoracic echocardiogram is born to assess patients with a poor acoustic window; in the 90s omniplane and biplane transducers with Doppler ability and colour flow were introduced. Over the last years, development of echocardiograms have broadened their scope towards minimally invasive surgery. Conclusion: Big steps have been taken in parallel with progress of ultrasounds in the medical field, their onset in echolocation described in bats until 3 D cardiac ultrasonography have contributed to the development of new non-invasive techniques in cardiovascular medicine.