Outcomes of laparoscopic management of multicompartmental pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse (POP) is an increasing medical problem with complex diagnostics and controversial surgical management. It causes a series of dysfunctions in the gynecological, urinary, and anorectal organs. Numerous procedures have been proposed to treat these conditions, but in recent years, ventral mesh rectocolposacropexy (VMRCS) has emerged as the procedure of choice for the surgical treatment of POP, especially by a laparoscopic approach. This surgical technique limits the risk of autonomic nerve damage, and the colpopexy allows the correction of concomitant prolapse of the middle compartment. However, symptoms derived from anterior compartment prolapse remain a major morbidity and sometimes require an additional procedure. The aim of this study is to evaluate the results of laparoscopic prosthetic rectocolposacropexy (LRCS) and colposacropexy (LCS) procedures performed to manage combined multicompartmental POP. METHODS: Between November 2008 and December 2017, 38 patients with symptomatic POP underwent rectocolposacropexy (RCS) or colposacropexy (CS) by a laparoscopic approach. Demographics, mortality, morbidity, hospital stay, and functional outcomes were retrospectively analyzed. RESULTS: The median operating time was 200 min (IQR 160-220). Additional simultaneous surgery for POP was performed in nine cases: five suburethral slings and four hysterectomies were performed. No mortality was recorded. The conversion rate was 7.89%. There were two intraoperative complications (5.26%): one enterotomy and one urinary bladder tear. Late complications occurred in 5.26% of cases. After a mean follow-up of 20 months, constipation was completely resolved or improved in 83.33% of patients, urinary stress incontinence was resolved or improved in 52.94%, and gynecological symptomatology was resolved or improved in 93.75%. The recurrence rate was 5.26%. CONCLUSIONS: Laparoscopic mesh rectocolposacropexy and colposacropexy are safe and effective techniques associated with very low morbidity. In the medium term, they provide good results for POP and associated symptoms, but urinary symptomology has a worse outcome.

Gastric pouch carcinoma after gastric bypass for morbid obesity.

The relationship between bariatric surgery and gastric cancer is conjectural. We present a 52-year-old woman with BMI 45 operated initially by a Lap-Band procedure complicated by gastric wall erosion of the band 9 months later. She was re-operated and the band was removed. She subsequently underwent a Roux-en-Y gastric bypass. 5 years after, gastric carcinoma was discovered in the gastric pouch. Because of varied symptoms following bariatric surgery, patients may not present promptly with symptoms related to a gastric carcinoma.

Laparoscopic approach to incisional hernia.

BACKGROUND: After more than 8 years of working in the field, we thought it would be interesting to evaluate our experience in the laparoscopic repair of abdominal wall hernias, focusing attention on the lessons learned with time. METHODS: From January 1994 to November of 2000, a total of 270 patients with abdominal wall hernias were treated in our center using the laparoscopic approach. The data collected and analyzed were preoperative evaluation, operative findings, early and long-term complications, and recurrences. RESULTS: The mean follow-up time was 44 months, mean surgical time was 85 min, and mean hospital stay was 1.5 days. The average number of abdominal wall defects was 4.8 per patient. There were 9 (3.3%) small bowel perforations. Conversion to open surgery was required in 1 case (0.3%). Minor early postoperative complications occurred in 38 patients (14.07%). Twenty patients (7.4%) developed persistent postoperative abdominal pain. There was 1 case (0.3%) of small bowel incarceration through the mesh border and another case (0.3%) of small bowel leakage due to ischemia and subsequent peritonitis. The relapse rate was 4.4% (12 cases). CONCLUSION: The laparoscopic approach is a valuable option in the management of abdominal wall hernias, but it requires experience in laparoscopic surgery and there is a specific learning curve for the technique.

ERCP's role in the management of acute biliary-pancreatic pathology in the laparoscopic era.

OBJECTIVES: Laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in the management of the acute biliopancreatic pathology. Nevertheless, controversy remains about the appropriate timing for retrograde cholangiopancreatography. METHODS: A retrospective study was undertaken on a consecutive series of 117 patients with acute biliary-pancreatic pathology, who underwent laparoscopic cholecystectomy between April 1995 and April 1999. Criteria for preoperative endoscopic retrograde cholangiopancreatography were defined, and the patients were divided into 3 groups based on the presence or absence of a preoperative retrograde cholangiopancreatography indication: (1) ERCP+LC group: patients with retrograde cholangiopancreatography indicated and performed (n = 30); (2) LC group: patients without retrograde cholangiopancreatography criteria treated only by LC (n = 47); (3) LC-ERCP group: patients with retrograde cholangiopancreatography criteria but not performed (n = 40). RESULTS: The groups were similar in age, sex, ASA, and clinical diagnosis. No statistical differences occurred in operative times (73.8 min, 68 min, 67 min), major complications (3.3%, 4.25%, 12.5%), and mean postoperative stay (3.7 +/- 4; 4.7 +/- 2; 5.7 +/- 2). Postoperative retrograde cholangiopancreatography had to be used, respectively, in 0%, 10.6%, and 7.5%. The best predictive criteria for common bile duct pathology were choledocholithiasis on an ultrasound scan and the presence of cholangitis. The other criteria tested had a low predictive value. CONCLUSIONS: Preoperative endoscopic retrograde cholangiopancreatography followed by early laparoscopic cholecystectomy can be performed safely in acute biliary-pancreatic pathology, avoiding 2-stage treatment of these patients and minimizing hospital stay and inconvenience to the patients. Nevertheless, this therapeutic/diagnostic tool must be used selectively.

Laparoscopic appendectomy by ultrasonically activated scalpel in acute appendicitis: preliminary report.

BACKGROUND AND PURPOSE: Laparoscopic appendectomy (LA) is increasingly being used in treating acute appendicitis. New instruments such as the ultrasonically activated scalpel (UAS) have been introduced for most laparoscopic procedures. We evaluated the use of UAS in the performance of LA, as the potential of this instrument in this type of surgery remains to be defined. PATIENTS AND METHODS: Three patients with acute right lower abdominal pain were managed by the laparoscopic approach. Once the diagnosis of acute appendicitis was established, laparoscopic appendectomy was performed with the UAS. RESULTS: The mean operative time was 42.3 minutes (range 32-49 minutes). There were no complications related to the treatment with UAS of either the vascular pedicle or the appendicecal stump. No electrosurgical coagulation, clips, loops, or endostapler was used in any patient. CONCLUSIONS: Total LA performed with UAS is feasible. Use of the UAS may make dissection and resection of the appendix easier, helping to reduce the mean operative time.

Eventraciones y hernias ventrales: experiencia con 200 casos por abordaje laparoscópico. Técnica quirúrgica / Laparoscopic approach in abdominal wall and incisional hernias: experience in 200 cases and surgical technique

Objetivo. El tratamiento laparoscópico de eventraciones y hernias ventrales ha sido poco usado, aunque estas hernias se pueden tratar muy bien por vía laparoscópica. El objetivo de este estudio ha sido revisar nuestra experiencia en el abordaje laparoscópico para el tratamiento de las hernias ventrales e incisionales. Material y métodos. Entre enero de 1994 y noviembre de 1999 una serie de 200 pacientes fueron intervenidos por hernias ventrales e incisionales por medio de cirugía laparoscópica con una media de 36 meses de seguimiento postoperatorio. La media del número de defectos de pared fue de 4,3 por paciente y la superficie media a corregir de 138 cm2. Un total de 15 hernias fueron menores de 5 cm, 105 de tamaño medio (5 a 10 cm) y 80 fueron hernias grandes (> 10 cm). El origen de los defectos de pared fue primario en 33 casos y posquirúrgico en 167. Se usaron tres puertas de entrada en todas ellas describiendo el resto de la técnica quirúrgica. Los defectos herniarios fueron cubiertos con malla de PTFE Dual Mesh de 26 × 18 cm en 10 pacientes, 19 × 15 en 187 y 10 × 15 en 65 casos. En 65 pacientes se usó una malla adicional. En los últimos 130 casos fue empleada una malla PTFE Dual Mesh Plus multiperforada. Resultados. El tiempo medio quirúrgico fue de 64 min. Sólo una intervención fue reconvertida a cirugía abierta (0,5 por ciento) y únicamente un paciente requirió una segunda intervención en el postoperatorio inmediato. Las complicaciones menores incluyeron 2 pacientes con enfisema subcutáneo, 4 casos con hematomas subcutáneos, 28 pacientes con pequeños seromas no complicados y 16 casos que refirieron dolor postoperatorio. No hubo infecciones en los orificios de los trocares ni tampoco infecciones de ninguna malla. Cuatro pacientes desarrollaron hernia recidivada (2 por ciento) en el primer mes postoperatorio y fueron reintervenidos con una técnica laparoscópica similar. La ingesta oral y la movilización se realizó a las pocas horas de la cirugía con una estancia media hospitalaria de 28 h. Conclusiones. La técnica laparoscópica permite evitar grandes incisiones, así como la no utilización de drenajes con un bajo número de complicaciones, infecciones y recidivas. El abordaje laparoscópico acorta considerablemente el tiempo quirúrgico y la estancia hospitalaria postoperatoria (AU)

Diverticulitis aguda y enfermedad diverticular del colon: una satisfactoria indicación de cirugía laparoscópica / Acute diverticulitis and diverticular disease of the colon: a safe indication for laparoscopic surgery

INTRODUCCIÓN: analizar y estudiar la experiencia obtenida con el tratamiento quirúrgico de la diverticulitis y enfermedad diverticular del colon sintomática utilizando la vía de abordaje laparoscópica. MÉTODOS: entre enero de 1994 y octubre de 1999 un grupo de 52 pacientes con criterios de enfermedad diverticular sintomática en el colon sigmoide y descendente fueron operados por vía laparoscópica con un porcentaje de media de 40 cm de resección de colon enfermo. La anastomosis colorrectal se realizó intrabdominalmente con sutura mecánica transanal. La utilización de tijeras armónicas ha simplificado y mejorado la técnica laparoscópica y los tiempos quirúrgicos. RESULTADOS: la morbilidad operatoria total fue del 15 por ciento. Dos casos con diverticulitis aguda y sepsis difusa fueron reconvertidos a cirugía abierta. Cuatro enfermos presentaron rectorragia postoperatoria que cedió espontáneamente y tres pacientes tuvieron infección en la minilaparotomía de extracción de la pieza. No hubo complicaciones a distancia salvo una hernia incisional en orificio de trócar. La hospitalización postoperatoria fue de 3-8 días (media: 5,5) y el tiempo operatorio medio de 130 minutos (rango: 70-240), comenzando la alimentación oral entre el segundo y el tercer día del postoperatorio. DISCUSIÓN: a pesar de haber tenido que superar la curva de aprendizaje para esta compleja cirugía, las muy aceptables cifras de morbimortalidad con el abordaje laparoscópico, especialmente para estos pacientes de alto riesgo quirúrgico (edad > 65 años, HTA, EPOC, etc.), indican la necesidad de poder ofrecer esta opción quirúrgica con criterios de efectividad y seguridad, mejorando los resultados de la cirugía convencional. Sin embargo, aquellos pacientes con enfermedad diverticular complicada precisan cirujanos con amplia experiencia en cirugía laparoscópica del colon (AU)

Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients.

OBJECTIVE: The laparoscopic treatment of eventrations and ventral hernias has been little used, although these hernias are well suited to a laparoscopic approach. The objective of this study was to investigate the usefulness of a laparoscopic approach in the surgical treatment of ventral hernias. METHODS: Between January 1994 and July 1998, a series of 100 patients suffering from major abdominal wall defects were operated on by means of laparoscopic techniques, with a mean postoperative follow-up of 30 months. The mean number of defects was 2.7 per patient, the wall defect was 93 cm2 on average. There were 10 minor hernias (<5 cm), 52 medium-size hernias (5-10 cm), and 38 large hernia (>10 cm). The origin of the wall defect was primary in 21 cases and postsurgical in 79. Three access ports were used, and the defects were covered with PTFE Dual Mesh measuring 19 x 15 cm in 54 cases, 10 x 15 cm in 36 cases, and 12 x 8 cm in 10 cases. An additional mesh had to be added in 21 cases. In the last 30 cases, PTFE Dual Mesh Plus with holes was employed. RESULTS: Average surgery time was 62 minutes. One procedure was converted to open surgery, and only one patient required a second operation in the early postoperative period. Minor complications included 2 patients with abdominal wall edema, 10 seromas, and 3 subcutaneous hematomas. There were no trocar site infections. Two patients developed hernia relapse (2%) in the first month after surgery and were reoperated with a similar laparoscopic technique. Oral intake and mobilization began a few hours after surgery. The mean stay in hospital was 28 hours. CONCLUSIONS: Laparoscopic technique makes it possible to avoid large incisions, the placement of drains, and produces a lower number of seromas, infections and relapses. Laparoscopic access considerably shortens the time spent in the hospital.

Acute diverticulitis and diverticular disease of the colon: a safe indication for laparoscopic surgery.

AIM: We analyzed our experience with a laparoscopic method for the treatment of acute diverticular disease. METHODS: Between January 1994 and October 1999 a group of 52 patients who fulfilled the criteria for symptomatic diverticular disease in the descending and sigmoid colon underwent laparoscopy with resection of an average of 40 cm of the bowel. Intraabdominal mechanical anastomosis completed the procedure. RESULTS: The use of ultrasonic scissors made the laparoscopic technique easier and shortened operative time. Operative morbidity was 15%. Two patients with acute diverticulitis and associated sepsis were reconverted to open surgery, and 4 patients presented postoperative rectal bleeding which ceased spontaneously. No long-term complications were found except in 1 patient who developed an incisional hernia through an entry port. Oral intake began between the second and third day. Postoperative hospitalization was 3-8 days (mean: 5.5 days) and mean operative time was 130 min (range: 70-240 min). CONCLUSIONS: Despite the steep learning curve for this type of surgery, the good morbidity and mortality rates with the laparoscopic method, especially with high-risk groups of patients (age > 65 years, high blood pressure, etc.) suggest that this surgical option can be used efficiently and safely, and that it achieves better results than with open surgery. However, we feel that the treatment of patients with acute complications of diverticular colon disease requires extensive experience with laparoscopic colorectal surgery.

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh.

BACKGROUND: Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques. METHODS: A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays. RESULTS: The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05). CONCLUSIONS: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay.

Surgical treatment of the acute cholecystitis in the laparoscopic age. A comparative study: laparoscopy against laparatomy.

OBJECTIVE: The aim of this study was to assess the complications and results of the laparoscopic opposite to open treatment of the acute cholecystitis. METHODS: A retrospective randomized study with two groups of 30 patients each one. The parameters tested were age, sex, risk factors, surgical time, hospital stay, cholecystitis type, and early or late complications. RESULTS: In the two groups there were no significant differences in age, sex, risk factors, type of cholecystitis and surgical time. The average of hospital stay was significantly longer for open cholecystectomy (9.5) than for laparoscopic technique (2.30) (p < 0.001). The complication rate was higher (7.30%) in open cholecystectomy. CONCLUSIONS: The laparoscopic cholecystectomy should be the standard procedure for the treatment of the acute cholecystitis.

Decrease in plasma levels of vasoactive intestinal polypeptide in short bowel syndrome: experimental study.

To investigate the behaviour of the vasoactive intestinal polypeptide (VIP) in short bowel syndrome (SBS), an experimental model of massive intestinal resection (MIR) was developed. For this purpose, 20 'minipigs' were divided into two experimental groups: A (control) and B (MIR). The parameters determined were the mean plasma levels of VIP and the degree of steatorrhea at four different times: T1 (basal), T2 (one week after surgery), T3 (two weeks after surgery), and T4 (24 weeks after surgery). The results indicated that, after MIR, a progressive decrease in the mean plasma levels of VIP takes place, with statistical significance in T3 (p < 0.05) and T4 (p < 0.01). This situation seems to be a direct result of the massive loss of intestinal tissue, and could lead to the use of this peptide to mark the evolution of the intestinal adaptation process.

Intragastric migration of laparoscopic adjustable gastric band (Lap-Band) for morbid obesity.

The appearance of fistulas and the posterior intragastric inclusion of the adjustable silicone Lap-Band prothesis have been described, representing a severe complication of the Lap-Band procedure. A 45-year-old patient with severe obesity, weighing 115 kg, and having BMI (body max index) of 45 kg/m2 was assigned to a protocol to place a Lab-Band in her. An infection in the reservoir after 9 months indicated the beginning of the appearance of fistulas. The entire adjustable silicone gastric band device eroded inside the stomach between months 9 and 14 after its placement, resulting in reoperation. The gastric inclusion of the Lap-Band device represents a severe complication that requires reoperation, and raises concerns about the safety of this new alternative weight reduction operation.

Vertical ring gastroplasty (VRG) in the treatment of the serious clinical obesity. Results and complications.

OBJECTIVE: The morbid obesity is a serious polysystematic disease to which it is necessary to offer a surgical solution when the conservative alternatives fail. METHODS: In a period of five years, 50 patients with vertical ring gastroplasty (VRG) have been evaluated and protocolized in the program of surgery of the morbid obesity, with an average weight of 134.3 kg corresponding to an overweight and body mass index (BMI) average respectively, of 69.7 kg and 49.8 kg/m2. RESULTS: The early morbidity has been scarce and the postoperative average stay of 7 days. The decrease of the percentage of weight, overweight and BMI was maximum 2 years later, with losses of 52 kg, with a percentage of loss of average overweight of 76.8% and a fall of 21 points in the BMI; however there was a partial recovery of the indexes in the following years. The accompanying pathology was solved in the period of studied time, although 84% of the patients referred vomits and practically 100% dietary limitations. CONCLUSIONS: The gastroplasty is a quick, simple technique and of scare morbimortality, although it is being subjected to criticism for the restrictions in the diet, quality of life and disruptions of the line of clamped. However, nowadays there is not a consensus on the ideal bariatric solution, and as a surgical alternative, the vertical gastroplasty can represent one of the techniques of choice for certain selected types of serious obesity.

[Gastrointestinal hormones during minimal enteral feeding of sick premature infants]. / Hormonas gastrointestinales en la estimulación enteral mínima en neonatos prematuros enfermos.

OBJECTIVE: To measure gastrointestinal hormonal response (GHR) with minimal enteral feeding (MEF) in sick premature infants. METHODS: Forty-one babies birth weight < 1800 g receiving total parenteral nutrition or intravenous solutions entered the study. They were distributed in two groups: group I: 26 infants (early enteral feeding < or = 5 d) and group II = 15 infants (late enteral feeding = 10-14 d). A diluted special formula was used as MEF starting with 1 mL hourly with daily increments of 1 mL up to 120 mL. Basal and final determinations of GHR were done before and after the MEF. RESULTS: Both groups were similar in birth weight, postnatal age, and trophism. There were intragroup differences between basal and final GHR for all hormones in both groups. Subgroups by gestational age (< or = 32 vs > 32 weeks) and trophism (< or = 1250 vs > 1250 g) also showed basal-final differences. There were no complications related to the MEF. CONCLUSIONS: MEF favors secretion of gastrointestinal hormones in sick premature infants. Early MEF seems to be preferable to late one since it allows a faster secretion related to volume of the formula. MEF did not increase abdominal complications in our infants.