Modified Intraumbilical Versus Infraumbilical Entry Method at Laparoscopy: A Cohort Study.

BACKGROUND: There is no consensus on the optimal laparoscopic entry method. Whether a transumbilical or periumbilical incision is beneficial for the initial peritoneal access has been debated. These 2 methods have their own advocates, since each has its own benefits and disadvantages. Furthermore, the lack of consensus extends to the type of entry technique [Hasson, Veress needle (VN), direct trocar]. We have conducted a study comparing a modified intraumbilical technique (MIT), a novel method that combines a VN insertion through a modified direct-trocar access, with the standard infraumbilical VN technique. Our aim is to determine which technique is a better route for the initial umbilical trocar. MATERIALS AND METHODS: A retrospective cohort study of 406 patients from a prospectively maintained database has been performed. Two cohorts of cases have been analyzed (VN=198; MIT=208). Primary outcomes were intraoperative access-related events, entry failure, and long-term wound complications. Clinical follow-up was performed at 1 and 6 months and yearly thereafter. RESULTS: Subcutaneous emphysema, extraperitoneal insufflation, and difficult entry (>2 VN insertions) occurred more frequently in the VN group (P=0.011, 0.023, and 0.023, respectively). There were 5 (2.52%) failed entries in the VN group and none in the MIT group (P=0.085). Regarding postoperative complications, seroma of the wound occurred more frequently in the VN group (P=0.033). At a mean follow-up of 18.4 months, 13 (3.20%) trocar-site hernias were detected, equally distributed among both groups. CONCLUSIONS: MIT eliminates the risk of failed entries and some complications associated with the VN technique without an increase in umbilical wound infection and facilitates a proper closure of the umbilical incision to secure a low trocar-site hernia rate. Halfway between open and closed techniques for laparoscopic entry, MIT is a safe and feasible procedure that embodies the advantages of both methods and may constitute an advantageous alternative to the infraumbilical VN entry approach.

Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision.

Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery.

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

Hernia del orificio del trocar, ¿un problema más frecuente de lo que creemos? / Trocar site hernia: A more common problem than we believe?

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Intususcepción ileocólica en el adulto / Ileocolic intussusception in adults

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European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Uso de las redes sociales por parte de los cirujanos generales. Resultados de la encuesta nacional de la Asociación Española de Cirujanos / Use of social networks by general surgeons. Results of the national survey of the Spanish Association of Surgeons

Introducción: Se desconoce el uso y utilidad de las redes sociales (RR.SS.) entre los cirujanos generales españoles. Métodos: Entre octubre y diciembre de 2017 se realizó una encuesta online a los socios de la Asociación Española de Cirujanos, en la que se recogieron datos de perfil de uso y de opinión sobre RR. SS. Resultados: Se obtuvo respuesta de 360 cirujanos, de los cuales 310 tenían presencia en RR.SS. Las redes más populares fueron: Facebook (86%), LinkedIn (61.6%), YouTube (60,6%) y Twitter (54,2%). LinkedIn y Twitter destacaron como las RR.SS. más empleadas con fines profesionales. Los cirujanos con presencia en RR.SS. eran más jóvenes (42,4 ± 11 años frente a 51,6 ± 8 años; p < 0,001), existiendo a menor edad mayor frecuencia de acceso a las mismas. El género no mostró influencia sobre la presencia en RR.SS. La mayoría de los encuestados tiene perfil en más de una red (3,6 ± 1 cuentas) y el 73,5% comunicó acceder a ellas diariamente. El 19,7% de los servicios de cirugía al que pertenecen los encuestados tiene perfil en RR. SS. Entre las utilidades profesionales destacan las actividades formativas (87%) y el contacto con otros profesionales (84%). El 14,1% de los encuestados utilizan RR. SS. para relacionarse con los pacientes. Conclusiones: Las RR.SS. son útiles para la divulgación de información sobre eventos científicos y actividades formativas, la actualización y adquisición de conocimientos y la comunicación entre profesionales. Aspectos como la privacidad o la relación con los pacientes representan una barrera en el uso de RR. SS

Introduction: The use and utility of social media (SM) among Spanish general surgeons is unknown. Methods: Between October and December 2017 an online survey was carried out to the members of the Spanish Association of Surgeons, in which data on the profile of use and opinion on the usefulness of SM were collected. Results: 360 valid responses were obtained, 310 from surgeons who had an active SM profile. The most popular networks were: Facebook (86%), LinkedIn (61,6%), YouTube (60,6%) and Twitter (54,2%). LinkedIn and Twitter stood out as the most used SM for professional purposes. Surgeons with a SM profile were younger (42.4 ± 11 years versus 51.6 ± 8 years; P < .001). Gender did not show influence on presence in SM. The majority of respondents have profiles in more than one network (3.6 ± 1 accounts) and 73.5% reported daily access to them; 19.7% of the surgery departments to which the respondents belong have a SM account. Among SM utilities in the professional field, training activities (87%) and connectivity among professionals (84%) were the most outstanding; 14.1% of respondents use SM to interact with patients. Conclusions: SM is useful as a tool for the acquisition, updating and dissemination of scientific knowledge, also proving valuable as a new form of interaction among surgeons. Other issues such as privacy or surgeon-patient relationship represent a barrier to its use

Use of social networks by general surgeons. Results of the national survey of the Spanish Association of Surgeons. / Uso de las redes sociales por parte de los cirujanos generales. Resultados de la encuesta nacional de la Asociación Española de Cirujanos.

INTRODUCTION: The use and utility of social media (SM) among Spanish general surgeons is unknown. METHODS: Between October and December 2017 an online survey was carried out to the members of the Spanish Association of Surgeons, in which data on the profile of use and opinion on the usefulness of SM were collected. RESULTS: 360 valid responses were obtained, 310 from surgeons who had an active SM profile. The most popular networks were: Facebook (86%), LinkedIn (61,6%), YouTube (60,6%) and Twitter (54,2%). LinkedIn and Twitter stood out as the most used SM for professional purposes. Surgeons with a SM profile were younger (42.4±11 years versus 51.6±8 years; P<.001). Gender did not show influence on presence in SM. The majority of respondents have profiles in more than one network (3.6±1 accounts) and 73.5% reported daily access to them; 19.7% of the surgery departments to which the respondents belong have a SM account. Among SM utilities in the professional field, training activities (87%) and connectivity among professionals (84%) were the most outstanding; 14.1% of respondents use SM to interact with patients. CONCLUSIONS: SM is useful as a tool for the acquisition, updating and dissemination of scientific knowledge, also proving valuable as a new form of interaction among surgeons. Other issues such as privacy or surgeon-patient relationship represent a barrier to its use.

Outcomes after laparoscopic ventral hernia repair: does the number of previous recurrences matter? A prospective study.

BACKGROUND: It is not yet clearly known whether laparoscopic ventral hernia repair (LVHR) is superior to the open approach in recurrent hernias. The aim of this study is to determine the safety and efficacy of laparoscopic technique for ventral hernias and investigate whether these outcomes are affected by the number of previous failed repairs. METHODS: Data from 124 consecutive patients who underwent LVHR using a standardized technique between September 2007 and June 2014 were collected prospectively. In all repairs, a composite prosthesis was tailored to overlap the defect by at least 5 cm and fixed with a double crown of spiral tacks. Clinical follow-up visits were performed at 1 week, 1, 6, and 12 months, and yearly thereafter. Patients were classified in 3 groups (0, 1, and ≥ 2) according to the number of previous hernia repairs for further statistical analysis. RESULTS: Long-term surveillance was available in 116 (93%) patients. Of these, 96 (82.8%) were recurrent hernias. There were 2 (1.7%) conversions, both in recurrent cases, and in 3 (2.6%) patients a hybrid access was used. Mean operating time was 55 min. There was an overall postoperative complication rate of 16%, with no mortality. During a mean follow-up of 30 (range 20-90) months, 3 (2.6%) recurrences were diagnosed 6, 8, and 9 months after surgery, respectively. A univariate analysis related to demographic, clinical, and perioperative variables did not find any significant relationship between the number of previous recurrences and operating time, conversion rate, hospital length of stay, overall morbidity, or recurrence. CONCLUSIONS: This study suggests that laparoscopic approach in recurrent incisional hernias is a safe and feasible alternative to open techniques. Furthermore, our experience supports the idea that LVHR may be the best option for recurrent cases in properly selected patients, independently of the number of previous recurrences.

Primary cutaneous mucormycosis in an immunocompetent patient.

Mucormycosis is most common in immunocompromised patients, but it can also occur in healthy hosts, most frequently as primary cutaneous mucormycosis (PCM) and predominantly as a result of skin trauma. We present an uncommon case of PCM in a healthy, young man with no previous history of local trauma. Despite rapid progression of the infection, the patient was successfully treated through surgical intervention and by administering liposomal amphotericin B and posaconazole. He made a full recovery without the need for skin grafting.

Rehabilitación multimodal: práctica clínica perioperatoria de mínima agresión / Enhanced recovery: minimally aggressive perioperative practice

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Apendicitis granulomatosa: una causa infrecuente de abdomen agudo / Granulomatous appendicitis: An uncommon cause of acute abdomen

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Single-incision laparoscopic bariatric surgery: a systematic review.

BACKGROUND: Single-incision laparoscopic surgery has sparked a great deal of interest in the surgical community in recent years, including bariatric surgery. However, we still do not definitively know if this type of surgical approach provides benefits over conventional techniques without increasing morbidity and mortality. OBJECTIVE: To evaluate the safety and efficacy of single-incision laparoscopic bariatric surgery (SILBS) compared with conventional laparoscopic bariatric surgery (CLBS). MATERIALS AND METHODS: We searched the most important databases. Randomized clinical trials and observational studies comparing SILBS with CLBS were included. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. RESULTS: Fourteen studies complied with the inclusion criteria for our analysis, which included 2357 patients (1179 SILBS group versus 1178 CLBS group). The duration of surgery was longer in the SILBS group and no major intraoperative complications were observed in these series. A small improvement in postoperative pain was indicated in the SILBS group. The overall morbidity rate was 5% in the SILBS group and 4.8% in the CLBS. There was 1 perioperative death in 1 study, which occurred in an adjustable gastric banding (AGB) group, at .1% of all cases of AGB and .005% of all SILBS cases. When cosmesis was evaluated, patients in the SILBS group were more satisfied with the scar outcome. CONCLUSION: SILBS is a feasible technique to use in selected patients. However, there is insufficient evidence to recommend its widespread use compared with a conventional approach. More studies are needed to analyze the safety of this technique and its possible benefits.