Hollow viscus perforation in blunt abdominal trauma: A 14-year experience from a trauma center.

BACKGROUND: Isolated perforations of hollow viscus (HV) represent less than 1% of injuries in blunt abdominal trauma (BAT). When they do present, they are generally due to high-impact mechanisms in the segments of the intestine that are fixed. The aim of this study is to determine the incidence of major HV injuries in BAT at the "Dr. Domingo Luciani" General Hospital (HDL), and address the literature gap regarding updated HV perforations following BAT, especially in low-income settings. METHODS: A retrospective review was conducted on the medical records of patients admitted to our trauma center with a diagnosis of complicated BAT with HV perforation over 14 years. RESULTS AND DISCUSSION: Seven hundred sixty-one patients were admitted under the diagnosis of BAT. Of them, 36.79% underwent emergency surgical resolution, and 6.04% had HV perforation as an operative finding. Almost half (44.44%) of these cases presented as a single isolated injury, while the remaining were associated with other intra-abdominal organ injuries. The most common lesions were Grade II-III jejunum and Grade I transverse colon, affecting an equal proportion of patients at 13.33%. In recent years, an increased incidence of HV injuries secondary to BAT has been observed. Despite this, in many cases, the diagnosis is delayed, so even in the presence of negative diagnostic studies, the surgical approach based on the trauma mechanism, hemodynamic status, and systematic reevaluation of the polytraumatized patient should prevail.

Customized Denonvilliers' Fascia Excision: An Advanced Total Mesorectal Excision Technique for Anteriorly Located Rectal Cancer.

BACKGROUND: The role of Denonvilliers' fascia in achieving a negative circumferential resection margin during anterior total mesorectal excision has been controversial. Opinions on whether to dissect in the anterior or posterior surgical plane varies among researchers. IMPACT OF INNOVATION: We performed total mesorectal excision with selective en bloc resection of Denonvilliers' fascia based on preoperative MRI staging, preoperative clinical tumor stage, and tumor level in selected patients with anterior rectal tumors adherent to Denonvilliers' fascia. TECHNOLOGY MATERIALS AND METHODS: Between March and August 2021, 5 patients who underwent robotic (n = 4) and laparoscopic (n = 1) total mesorectal excision for anteriorly located low rectal adenocarcinomas after neoadjuvant chemoradiotherapy were enrolled in this study. Transabdominal total mesorectal excision dissection is performed by changing to a plane anterior to Denonvilliers' fascia, with partial or total excision tailored to the tumor level and depth of invasion as a further step in circumferential resection margin clearing. Customized excision of Denonvilliers' fascia was performed by dissecting through the extramesorectal plane. This anterior plane permits resection of Denonvilliers' fascia, exposing the prostate and seminal vesicles. PRELIMINARY RESULTS: Two tumors were located at the seminal vesicle level and 3 were found at the prostate level. The mean distance from the anal verge to the distal margin of the tumor was 4.8 ± 0.9 cm. Denonvilliers' fascia was preserved in 1 patient and partially excised in 4. Customized Denonvilliers' fascia excision was performed in 3 robotic ultralow anterior resections with coloanal anastomosis, 1 laparoscopic ultralow anterior resection with coloanal anastomosis, and 1 robot-assisted abdominoperineal resection. The circumferential resection margins in all patients were negative. CONCLUSIONS AND FUTURE DIRECTIONS: Anterior dissection in front of Denonvilliers' fascia can be selectively performed during total mesorectal excision based on preoperative planning, tumor location, and clinical tumor stage. Preoperative MRI and magnified operative views in minimally invasive platforms provide access to more precise surgical planes for clear circumferential resection, achieving optimal functional outcomes and oncological safety.

La simulación como herramienta de enseñanza y aprendizaje quirúrgico / Surgical simulation as a teaching and learning tool

La simulación es la técnica de replicar un proceso o situación. El objetivo de la simulación quirúrgica es transferir de manera efectiva las habilidades adquiridas en el laboratorio al quirófano, reduciendo las curvas de aprendizaje y los costos operativos. Objetivos : Describir la utilización, ventajas, desventajas, y estado actual de la práctica basada en simulación como método de enseñanza y aprendizaje para la capacitación de residentes y cirujanos en los programas de formación quirúrgica, según lo reportado en la literatura científica actual. Métodos : Se realizó una búsqueda en la literatura utilizando palabras claves. Se sintetizaron los hallazgos de cada estudio en una revisión narrativa. Resultados : La simulación quirúrgica es una herramienta educativa que confiere ventajas únicas. Permite el desarrollo de programas de formación flexibles e individualizados, enfatiza el aprendizaje basado en problemas, basado en competencias y basado en destrezas, y acelera el proceso de aprendizaje al ofrecer entornos seguros para practicar procedimientos quirúrgicos complejos. Además, respalda la retroalimentación y el análisis posterior, fomenta la formación multidisciplinaria y facilita la investigación y la innovación, mejorando en última instancia la calidad de la atención médica. Conclusiones : Las ventajas prácticas de los programas de formación estructurados han convertido a la educación basada en la simulación en un método de enseñanza factible, confiable y altamente atractivo. La simulación no solo contribuye al desarrollo profesional de los residentes, sino que también mejora la seguridad del paciente y la calidad general de los servicios de salud(AU)

Simulation is the act of replicating a process or situation. The objective of surgical simulation is to effectively transfer the skills acquired in the laboratory to the operating room, reducing the learning curves and operational costs. Objectives: To describe the use, advantages, disadvantages, and current state of simulation-based practice as a method of teaching and learning for the training of residents and surgeons in surgical training programs, as reported in the current scientific literature. Methods: A literature search was conducted using keywords. The findings of each study were synthesized in a narrative review. Results: Surgical simulation is an educational tool that offers unique advantages. It allows for the development of flexible and individualized training programs, emphasizes problem-based, competency-based, and skill-based learning, and accelerates the learning process by providing safe environments to practice complex surgical procedures. Furthermore, it supports feedback and post-analysis, encourages multidisciplinary training, and facilitates research and innovation, ultimately enhancing the quality of healthcare. Conclusions: The practical benefits of structured training programs have made simulation-based education a feasible, reliable, and highly attractive teaching method. Simulation not only contributes to the professional development of residents but also improves patient safety and the overall quality of healthcare services(AU)

Situación actual de la enseñanza quirúrgica por simulación en Venezuela / Current status of surgical training with simulation in Venezuela

La simulación constituye un instrumento beneficioso para la adquisición de destrezas quirúrgicas. Su disponibilidad en países en vías de desarrollo representa un obstáculo importante en la educación quirúrgica contemporánea.Objetivo : Identificar centros de capacitación quirúrgica en Venezuela que utilicen la simulación para el entrenamiento de habilidades técnicas y conocer la opinión de los miembros de la Sociedad Venezolana de Cirugía (SVC) acerca de su uso para desarrollar habilidades en cirugía abierta.Métodos : Estudio transversal y descriptivo. Se enviaron encuestas por correo electrónico a todos los miembros activos de la SVC. Se utilizó estadística descriptiva para el análisis y presentación de los datos.Resultados : De 1115 encuestas enviadas, 111 fueron completadas; 67,6 % de los participantes no tienen conocimientos sobre la existencia de centros de entrenamiento basados en simulación quirúrgica; el 99,1 % están de acuerdo con implementar la simulación como método de capacitación complementario y consideran importante el entrenamiento de habilidades en cirugía abierta; 94,6 % manifestó que el entrenamiento debe estructurarse y ejecutarse en módulos que inicien con tareas básicas para luego avanzar hacia procedimientos más complejos; 75 % de los procedimientos avanzados que deben practicarse con mayor frecuencia corresponden al sistema gastrointestinal, destacando las anastomosis intestinales (74,7 %).Conclusión : la gran mayoría de los cirujanos en las Instituciones de salud de Venezuela no tienen acceso a la simulación como herramienta educativa, a pesar de estar de acuerdo con que su implementación es altamente potenciadora para el desarrollo de habilidades técnicas(AU)

Simulation represents a beneficial tool for acquiring surgical skills. Its availability in developing countries poses a significant obstacle in contemporary surgical education.Objective : To identify surgical training centers in Venezuela that use simulation for technical skills training, and to understand the opinion of members of the Venezuelan Society of Surgery (SVC) regarding its use for developing open surgical skills.Methods : A cross-sectional, descriptive study. Surveys were sent via email to all active SVC members. Descriptive statistics were used for data analysis and presentation.Results : Of the 1,115 surveys sent, 111 were completed. 67.6% of the participants were unaware of the existence of simulation-based surgical training centers. 99.1% agreed with implementing simulation as a complementary training method and considered training in open surgery skills important. 94.6% stated that training should be structured and conducted in modules starting with basic tasks and progressing to more complex procedures; 75% of the advanced procedures that should be practiced more frequently were related to the gastrointestinal system, with intestinal anastomoses (74.7%) being particularly highlighted.Conclusion : The majority of surgeons in Venezuelan healthcare institutions do not have access to simulation as an educational tool, despite agreeing that its implementation is highly beneficial for the development of technical skills(AU)

Exposure of the Middle Rectal Artery and Lateral Ligament of the Rectum Following the Gate Approach during Total Mesorectal Excision.

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.

Double-layered hand-sewn anastomosis: a valuable resource for the colorectal surgeon.

Hand-sewn anastomosis is an essential and fundamental skill for surgeons dealing with any gastrointestinal anastomosis. Despite the advances in minimally invasive surgery and stapling devices, there are still complex surgical circumstances when the surgeon's surgical know-how are necessary. Therefore, a safe hand-sewn technique for bowel anastomosis is required to establish a tension-free, well-perfused, and sealed anastomosis that allows gastrointestinal continuity with no unexpected complications. We describe a step-by-step procedure for hand-sewn double-layered anastomosis that reflects these principles and is practical for small and large bowel anastomosis.

A case of caecal "PECOMA": An uncommon entity.

INTRODUCTION AND IMPORTANCE: World Health Organization (WHO) defines PEComa as a mesenchymal tumor composed of histologically and immunohistochemically distinctive perivascular epithelioid cells. The symptoms and clinical signs of PEComa patients are nonspecific. Hence, diagnosis is usually difficult. Since it's a rare diagnosis, further research might help in understanding the disease better. CASE PRESENTATION: The patient in this study was an asymptomatic patient, who did colonoscopy as part of a regular check-up. A submucosal cecal tumor was detected in colonoscopy, and apart from that, all other investigative parameters were within normal limits. CLINICAL DISCUSSION: Laparoscopic Ileocecectomy was performed, and the histopathology report was suggestive of Pecomatosis (PEComa - Perivascular epithelioid cell tumor). The PEComas, neoplasms with perivascular epithelioid cell differentiation, are mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells (PEC). The characteristic features of PEC are the positivity of melanocytic markers and smooth muscle markers. CONCLUSION: Perivascular epithelioid tumors are mostly rare in the gastrointestinal tract, and even more unusual to be detected in Cecum. Surgery is the mainstay of the treatment, although, adjuvant therapy has been tried in recent times. The patients have to be kept in close follow-up, as there are reported cases of recurrences and distant metastasis.

Surgical Treatment of Low-Lying Rectal Cancer: Updates.

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

Postoperative bleeding in essential thrombocytosis patients with colorectal cancer: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by increased platelet count and a high risk of bleeding or thrombotic events due to platelet dysfunction. Patients with ET are treated according to their risk of complications with cytoreductive or anti-aggregant treatment. Neither guidelines for oncologic patients nor perioperative management of patients with ET have been determined. CASE PRESENTATION: A 41-year-old female patient with ET who had alternating constipation and diarrhea was referred after a screening colonoscopy diagnosing a locally advanced rectosigmoid junction colon adenocarcinoma with liver metastases. Systemic preoperative chemotherapy was indicated. The patient underwent laparoscopic low anterior resection plus volume-preserving right lobectomy of the liver. Postoperative bleeding of the internal iliac artery (IIA) associated with hematoma at the lower pelvic cavity was diagnosed and treated by interventional radiology; the patient was discharged without other complications 16 days after surgery. CLINICAL DISCUSSION: ET has been related to the development of hematologic complications or second non-hematologic malignancies. A systematic review was conducted to seek guidance for the management of such patients in the perioperative period. Special perioperative care must be taken, and complications management should avoid further hemorrhages or cloth formation. CONCLUSION: Under oncologic and hematological guidance, minimally invasive surgery and non-invasive management of complications are advised in the lack of published perioperative management guidelines of ET patients with colorectal cancer.