Laparoscopic incisional hernia repair as a day surgery procedure: audit of 127 consecutive cases in a university hospital.

BACKGROUND: Findings have shown that laparoscopic incisional hernia repair is superior to conventional open techniques. The objective of the current study was to evaluate the results of laparoscopic surgery on incisional hernias in an outpatient surgery unit in a university hospital. METHODS: Data were gathered prospectively for all laparoscopic incisional hernia repairs from January 1997 to December 2006. A total of 127 patients were operated in an outpatient surgery unit. The patients' clinical features, hernia type, intraoperative and postoperative complications, and reasons for hospital admission are studied. RESULTS: None of the patients required readmission to hospital, 15 had no need for analgesic treatment (11.8%) and the mean requirement was 6 days. The mean time of return to normal activity was less than 10 days and all the patients expressed their satisfaction with the procedure they received. During follow-up we detected 5 recurrences (4.4%). The statistical study showed no significant differences between the hospitalized patients and those treated on an ambulatory basis with regard to morbidity and recurrence rate (P<0.05). We do find a lower intraoperative and early postoperative (<30 d) complication rate in favor of the ambulatory patients (P<0.001). CONCLUSIONS: Laparoscopic repair of incisional hernias can be performed as a highly efficient ambulatory procedure with igual morbidity and recurrences than hospitalized patients.

Síndrome del dedo azul. Evaluación y tratamiento / Blue finger syndrome. Evaluation and treatment

No disponible

[Society and surgery. Burnout and surgeons]. / Sociedad y cirugía. Burnout y cirujanos.

Burnout syndrome is a mental and emotional state of tiredness, characterised by feelings of emptiness and negative attitudes to work and life. It appears particularly in care professionals associated with human interactions, and starts progressive, affecting the professional as well as the organisation. It is currently the most common cause of absence from work. Its incidence among doctors is about 50%, but, despite being considered a high risk group, its incidence and consequences among surgeons is still unknown. The causal factors are analysed and coping strategies are offered to be able to control the problem.

Sociedad y cirugía. Burnout y cirujanos / Society and surgery. Burnout and surgeons

El síndrome de burnout (del inglés, quemado) es un estado de cansancio emocional y mental, caracterizado por sentimientos de vacío y actitudes negativas hacia el trabajo y la vida. Aparece de forma específica en las profesiones de ayuda en relación con las interacciones humanas, y se instaura de forma progresiva afectando tanto al profesional como a la organización; actualmente es la causa más frecuente de baja laboral. Su incidencia entre los médicos alcanza el 50%, pero a pesar de considerarse un grupo de alto riesgo, su incidencia y sus consecuencias entre cirujanos todavía se desconocen. Se analizan los factores causales y se ofrecen estrategias de afrontamiento para poder controlar el problema (AU)

Burnout syndrome is a mental and emotional state of tiredness, characterised by feelings of emptiness and negative attitudes to work and life. It appears particularly in care professionals associated with human interactions, and starts progressive, affecting the professional as well as the organisation. It is currently the most common cause of absence from work. Its incidence among doctors is about 50%, but, despite being considered a high risk group, its incidence and consequences among surgeons is still unknown. The causal factors are analysed and coping strategies are offered to be able to control the problem (AU)

[Treatment of non-midline ventral hernia: experience in an abdominal wall unit and literature review]. / Tratamiento de la eventración no medial: experiencia de una unidad de pared abdominal y revisión de la literatura.

INTRODUCTION: Lateral ventral hernia is an interesting surgical problem. However, few data are available on this entity. OBJECTIVE: To review current knowledge of lateral ventral hernia and present our experience of this entity in a multidisciplinary abdominal wall unit. PATIENTS AND METHOD: A. LITERATURE REVIEW: a search of Spanish (Cirugía Española) and international literature was performed through MEDLINE using the key words "lateral incisional/ventral hernia". B. Clinical study: a series of 53 patients who underwent endoscopic surgery for non-midline ventral hernia were prospectively studied. Clinical parameters, postoperative complications and the recurrence rate were evaluated. The mean follow-up was 64 months (range, 12-120 months). RESULTS: A. LITERATURE REVIEW: we found a ratio between chapters on inguinal hernia and ventral hernia of 3.8:1 and a complete absence of chapters on lateral ventral hernia. Only two articles specifically dealt with ventral hernia. B. Clinical study: the most frequent location was lumbar (34%), followed by iliac and subcostal. A total of 37.7% of patients could be treated without admission and the remaining patients had a mean length of hospital stay of 2.7 days. Hematoma (17%) predominated in iliac ventral hernias and pain was transitory in two patients with lumbar ventral hernia. There were two early recurrences due to incorrect mesh fixation in subcostal and lumbar ventral hernias. CONCLUSIONS: Non-midline ventral hernia is a little known entity. Future treatment should be individualized in each patient and should be based on common classification of the type of defect to correctly evaluate the results. The laparoscopic route provides competitive results in selected patients.

Tratamiento de la eventración no medial: experiencia de una unidad de pared abdominal y revisión de la literatura / Treatment of nonmidline ventral hernia: experience in an abdominal wall unit and literature review

Introducción. La eventración lateral es un problema quirúrgico de gran interés pero del que todavía hoy existen muy pocos datos disponibles. Objetivo. Revisar los conocimientos actuales sobre la eventración lateral y presentar una experiencia propia de una unidad multidisciplinaria de pared abdominal. Pacientes y método. A. Estudio bibliográfico: revisión de la literatura nacional (Cirugía Española) e internacional mediante MEDLINE utilizando como palabras clave "lateral incisional/ventral hernia". B. Estudio clínico: análisis prospectivo de una serie de 53 pacientes operados de eventración fuera de la línea media mediante cirugía endoscópica. Se evalúan parámetros clínicos, complicaciones postoperatorias y tasa de recidivas. El seguimiento medio ha sido de 64 meses (rango, 12-120 meses). Resultados. A. Estudio bibliográfico: hemos demostrado una relación entre los conocimientos existente de hernia inguinal y eventración del 3,8:1, una ausencia total de capítulos sobre la eventración lateral y sólo 2 artículos específicos sobre el tema. B. Estudio clínico: el grupo más frecuente fue el lumbar (34%) seguido del ilíaco y subcostal. Al 37,7% de los pacientes se pudo tratarlo sin ingreso y al resto con una estancia media de 2,7 días. El hematoma (17%) predominó en las de tipo ilíaco y el dolor fue transitorio en 2 casos de eventraciones lumbares. Se diagnosticaron 2 recidivas precoces por error en la fijación de la malla en los tipo subcostal y lumbar. Conclusiones. La eventración no medial es un problema poco conocido. Su futuro tratamiento debería pasar por individualizar a cada paciente según una clasificación común del tipo de defecto para valorar correctamente los resultados. La vía laparoscópica ofrece unos resultados muy competitivos en grupos especializados (AU)

Introduction. Lateral ventral hernia is an interesting surgical problem. However, few data are available on this entity. Objective. To review current knowledge of lateral ventral hernia and present our experience of this entity in a multidisciplinary abdominal wall unit. Patients and method. A. Literature review: a search of Spanish (Cirugía Española) and international literature was performed through MEDLINE using the key words "lateral incisional/ventral hernia". B. Clinical study: a series of 53 patients who underwent endoscopic surgery for nonmidline ventral hernia were prospectively studied. Clinical parameters, postoperative complications and the recurrence rate were evaluated. The mean follow-up was 64 months (range, 12-120 months). Results. A. Literature review: we found a ratio between chapters on inguinal hernia and ventral hernia of 3.8:1 and a complete absence of chapters on lateral ventral hernia. Only two articles specifically dealt with ventral hernia. B. Clinical study: the most frequent location was lumbar (34%), followed by iliac and subcostal. A total of 37.7% of patients could be treated without admission and the remaining patients had a mean length of hospital stay of 2.7 days. Hematoma (17%) predominated in iliac ventral hernias and pain was transitory in two patients with lumbar ventral hernia. There were two early recurrences due to incorrect mesh fixation in subcostal and lumbar ventral hernias. Conclusions. Nonmidline ventral hernia is a little known entity. Future treatment should be individualized in each patient and should be based on common classification of the type of defect to correctly evaluate the results. The laparoscopic route provides competitive results in selected patients (AU)

Endometriosis extragenital como causa de dolor inguinal agudo en mujer fértil / Extragenital endometriosis as a cause of acute inguinal pain in a woman of reproductive age

No disponible

[Conceptual reformulation of the double mesh repair technique: a simple solution for highly complex abdominal wall defects]. / Reformulación conceptual de la técnica de reparación doble: una solución sencilla para defectos muy complejos de la pared abdominal.

INTRODUCTION: Repair of complex abdominal wall defects remains a challenge for the general surgeon. The aim of the present study was to validate the double mesh repair technique in complex hernias. MATERIAL AND METHOD: We performed a prospective study of 15 patients with complex abdominal wall defects who underwent surgery in a university hospital. All patients were evaluated in a multidisciplinary unit. Indications consisted of incisional hernias with multiple recurrences (> 3 times), prior mesh complicated by fistula and chronic infection, giant diffuse lumbar hernia, and ventral hernia (associated with parastomal hernia or occurring after bariatric surgery with associated dermolipectomy). The surgical technique used was double intra-abdominal and supra-aponeurotic mesh repair without associated plasty techniques. Clinical, surgical and follow-up data were analyzed. RESULTS: Nine defects were lateral, three were lumbar, one was parapubic, and two were located in the mid-line (one associated with giant parastomal hernia and one occurring after bariatric surgery). Eight showed significant tissue loss, five showed trophic skin lesions, and two showed chronic suppurative infection. The mean size of the defects was 17.5 cm. Seroma occurred in three patients and limited cutaneous necrosis occurred in one patient. The mean length of hospital stay was 4.3 days (range 2-7 days). No complications, recurrences or mortality were detected during follow-up. CONCLUSION: Complex abdominal wall defects can be corrected through double repair using mesh only. This technique is simple to learn and perform and can be applied in many anatomical sites and types of defect, as well as in the presence of tissue destruction.

Reformulación conceptual de la técnica de reparación doble: una solución sencilla para defectos muy complejos de la pared abdominal / Conceptual reformulation of the double mesh repair technique: a simple solution for highly complex abdominal wall defects

Introducción. La reconstrucción de defectos complejos de la pared abdominal es todavía un reto para el cirujano general. El propósito de este trabajo es validar la técnica de reparación con doble mallas en hernias complejas. Material y métodos. Estudio prospectivo de 15 casos con defectos complejos de pared abdominal intervenidos en un hospital universitario. Todos los pacientes fueron evaluados en una unidad multidisciplinaria. Las indicaciones fueron hernias incisionales multirrecidivadas (> 3 veces), malla previa complicada con fístula e infección crónica, lumbar difusa gigante, eventración con hernia paraestomal acompañante, o tras cirugía bariátrica con dermolipectomía asociada. La cirugía empleada fue una reconstrucción con doble malla intraabdominal y supraaponeurótica sin plastias asociadas. Se analizan datos clínicos, quirúrgicos y de seguimiento. Resultados. Nueve defectos fueron laterales, 3 lumbares, 1 parapúbico y 2 de línea media (1 con hernia parestomal gigante, 1 tras cirugía bariátrica); 8 asociaban pérdida tisular importante, 5 lesiones tróficas de piel y 2 infección supurativa crónica. El tamaño medio de los defectos fue de 17,5 cm y la morbilidad, 3 casos de seroma y 1 necrosis cutánea limitada. La estancia hospitalaria media fue de 4,3 días (rango, 2-7 días) y en el seguimiento no se han detectado complicaciones, recidivas ni mortalidad. Conclusión. Los defectos complejos de la pared abdominal pueden corregirse mediante una reparación doble únicamente con mallas. Esta técnica es una opción sencilla de ejecutar y aprender, y aplicable a muchas localizaciones, tipos de defecto o presencia de destrucción tisular (AU)

Introduction. Repair of complex abdominal wall defects remains a challenge for the general surgeon. The aim of the present study was to validate the double mesh repair technique in complex hernias. Material and method. We performed a prospective study of 15 patients with complex abdominal wall defects who underwent surgery in a university hospital. All patients were evaluated in a multidisciplinary unit. Indications consisted of incisional hernias with multiple recurrences (> 3 times), prior mesh complicated by fistula and chronic infection, giant diffuse lumbar hernia, and ventral hernia (associated with parastomal hernia or occurring after bariatric surgery with associated dermolipectomy). The surgical technique used was double intra-abdominal and supra-aponeurotic mesh repair without associated plasty techniques. Clinical, surgical and follow-up data were analyzed. Results. Nine defects were lateral, three were lumbar, one was parapubic, and two were located in the mid-line (one associated with giant parastomal hernia and one occurring after bariatric surgery). Eight showed significant tissue loss, five showed trophic skin lesions, and two showed chronic suppurative infection. The mean size of the defects was 17.5 cm. Seroma occurred in three patients and limited cutaneous necrosis occurred in one patient. The mean length of hospital stay was 4.3 days (range 2-7 days). No complications, recurrences or mortality were detected during follow-up. Conclusion. Complex abdominal wall defects can be corrected through double repair using mesh only. This technique is simple to learn and perform and can be applied in many anatomical sites and types of defect, as well as in the presence of tissue destruction (AU)

[Adrenal incidentalomas. A disease on the increase]. / Incidentalomas suprarrenales. Una enfermedad en auge.

INTRODUCTION: Adrenal incidentalomas are unsuspected, clinically silent adrenal lesions discovered incidentally by imaging tests performed a priori for problems unrelated to the adrenal glands. The aim of this study was to present a series of incidentalomas and review the diagnostic process and treatment techniques. PATIENTS AND METHOD: Of a series of 63 patients studied and/or treated for adrenal disease, there were 34 patients with adrenal incidentalomas. The mean age of the patients with incidentaloma was 50.6 years. There were 23 women (67.6%) and 11 men (32.3%). All patients underwent hormonal investigations to rule out hyperfunction. Imaging techniques consisted of ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) to determine the size and characteristics of the lesion. In patients with an indication for surgery, the lateral transabdominal approach was used in laparoscopic surgery and the anterior approach was used in open surgery. RESULTS: Of the 34 patients, 23 patients (67.6%) (18 women and 5 men) with a mean age of 50.9 years underwent surgery. The mean tumoral diameter was 10.18 cm. Incidentalomas were located in the right adrenal gland in 16 patients and in the left adrenal gland in 7 patients. Laparoscopic surgery was performed in 9 patients (39.1%) and open surgery was performed in the remaining 14 (60.8%). The mean length of hospital stay was 8.6 days in open surgery and 4 days in laparoscopic surgery. Complications consisted of pneumonia in 2 patients (8.6%). There was no intraoperative mortality in the series. Surgery was not performed in 11 patients (32.3%) (5 women and 6 men) with a mean age of 56.3 years. The mean size of the tumor in these patients, identified by CT, was 2.5 cm. These patients underwent subsequent monitoring with a mean follow-up of 32 months. CONCLUSIONS: Due to the high resolution of ultrasonography, CT and MRI, as well as the greater number of radiological investigations performed, identification of adrenal incidentalomas has increased. In our series these tumors represented 53.9% of adrenal disease.

Incidentalomas suprarrenales. Una enfermedad en auge / Adrenal incidentalomas. A disease on the increase

Introducción. Se considera incidentaloma suprarrenal la lesión adrenal no sospechada, clínicamente silente, descubierta casualmente por estudios de imagen realizados a priori, por problemas no relacionados con las glándulas suprarrenales. Nuestro objetivo es presentar nuestra serie de incidentalomas, revisando el proceso diagnóstico y las técnicas de tratamiento. Pacientes y método. Presentamos 34 casos catalogados como incidentalomas de una serie de 63 pacientes estudiados y/o tratados por enfermedad suprarrenal. La edad media de los pacientes con incidentaloma fue de 50,6 años, 23 de los cuales fueron mujeres (67,6%) y 11, varones (32,3%). A todos se les realizó un estudio hormonal para descartar hiperfunción. Como técnica de imagen se les realizó ecografía, tomografía computarizada (TC) y/o resonancia magnética (RM) para precisar el tamaño y las características de la lesión. En los casos en que se indicó cirugía, la técnica utilizada, en caso de cirugía laparoscópica, fue la vía transabdominal lateral y, en caso de cirugía abierta, la vía anterior. Resultados. De los 34 casos, hemos intervenido a 23 pacientes (67,6%) (18 mujeres y 5 varones) con una edad media de 50,9 años. El tamaño medio de los tumores es de 10,18 cm de diámetro. En la suprarrenal derecha se localizaron 16 casos y en la izquierda, 7. Se realizó cirugía laparoscópica en 9 casos (39,1%) y en los 14 casos restantes (60,8%) se practicó cirugía abierta. La estancia media en caso de cirugía abierta fue de 8,6 días y en cirugía laparoscópica, de 4 días. Como complicaciones ha habido 2 casos de neumonía (8,6%). No hay mortalidad intraoperatoria en la serie. No se han intervenido 11 casos (32,3%) (5 mujeres y 6 varones), con una edad media de 56,3 años. El tamaño medio del tumor en estos pacientes, según la TC, es de 2,5 cm. Estos pacientes se han sometido a controles posteriores con un seguimiento medio de 32 meses. Conclusiones. La alta resolución de la ecografía, la TC y la RM, así como el mayor número de exploraciones radiológicas realizadas, ha incrementado el número de incidentalomas suprarrenales, como ocurre en nuestra serie, donde suponen el 53,9% de la patología suprarrenal (AU)

Introduction. Adrenal incidentalomas are unsuspected, clinically silent adrenal lesions discovered incidentally by imaging tests performed a priori for problems unrelated to the adrenal glands. The aim of this study was to present a series of incidentalomas and review the diagnostic process and treatment techniques. Patients and method. Of a series of 63 patients studied and/or treated for adrenal disease, there were 34 patients with adrenal incidentalomas. The mean age of the patients with incidentaloma was 50.6 years. There were 23 women (67.6%) and 11 men (32.3%). All patients underwent hormonal investigations to rule out hyperfunction. Imaging techniques consisted of ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) to determine the size and characteristics of the lesion. In patients with an indication for surgery, the lateral transabdominal approach was used in laparoscopic surgery and the anterior approach was used in open surgery. Results. Of the 34 patients, 23 patients (67.6%) (18 women and 5 men) with a mean age of 50.9 years underwent surgery. The mean tumoral diameter was 10.18 cm. Incidentalomas were located in the right adrenal gland in 16 patients and in the left adrenal gland in 7 patients. Laparoscopic surgery was performed in 9 patients (39.1%) and open surgery was performed in the remaining 14 (60.8%). The mean length of hospital stay was 8.6 days in open surgery and 4 days in laparoscopic surgery. Complications consisted of pneumonia in 2 patients (8.6%). There was no intraoperative mortality in the series. Surgery was not performed in 11 patients (32.3%) (5 women and 6 men) with a mean age of 56.3 years. The mean size of the tumor in these patients, identified by CT, was 2.5 cm. These patients underwent subsequent monitoring with a mean follow-up of 32 months. Conclusions. Due to the high resolution of ultrasonography, CT and MRI, as well as the greater number of radiological investigations performed, identification of adrenal incidentalomas has increased. In our series these tumors represented 53.9% of adrenal disease

Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department.

Primary spontaneous pneumothorax is a common abnormality for which there is a variety of treatments. This study presents the results of a year's evaluation of a clinical pathway (CP). A series of 34 patients treated during 1 year before CP development was analyzed to identify the weak points. To address these weak points, the CP includes associated protocols. In the CP, 31 patients were evaluated during 1 year; the results were compared with those of the pre-CP series. The mean length of stay of the pre-CP patients and the CP patients was 7.3 days and 5.0 days, respectively. The number of radiographs fell from 4.3 to 3.2. The rate of complications and readmissions is similar in both groups. The mean cost per process dropped from 1863 [UNKNOWN] to 1168 [UNKNOWN]. The CP for pneumothorax successfully manages to reduce both the variability in care patterns and hospital costs, justifying the work involved in its development and implementation.

Vía clínica para el tratamiento del neumotórax espontáneo primario en un servicio de cirugía general / Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department

Introducción. El neumotórax espontáneo primario (NEP) es una enfermedad frecuente que se trata de forma variable en los diferentes sistemas sanitarios e incluso entre los médicos dentro de un mismo servicio. En nuestro servicio de cirugía general se atiende a entre 30 y 40 pacientes al año con NEP y hay una significativa variabilidad en su asistencia, lo que motivó la iniciativa de elaborar una vía clínica (VC) basada en el análisis del proceso, la búsqueda de estudios con la mayor evidencia científica y el consenso de los profesionales. El objetivo de este trabajo es presentar los resultados tras 1 año de evaluación de la VC. Pacientes y método. Se analizó una serie previa de 34 enfermos tratados durante el año previo a la elaboración de la vía para identificar los puntos débiles y las áreas de mejora. Para dar respuesta y solución a los puntos débiles identificados, la VC incluye protocolos asociados y documentos principales de la VC. Durante un año se ha atendido a 31 pacientes incluidos en la VC, cuyos resultados se han comparado con los de la serie previa. Resultados. La estancia media de los pacientes antes de la implantación de la vía ha sido de 7,3 días y los pacientes incluidos en la vía tuvieron una estancia de 5,0 días. El número de radiografías ha disminuido también de 4,3 a 3,2. La tasa de complicaciones y reingresos es similar en ambos grupos. El coste medio por proceso ha disminuido de 1.863 a 1.168 €. Conclusión. La VC del neumotórax puede disminuir la variabilidad de las actuaciones profesionales y los costes hospitalarios, lo que justifica el esfuerzo de su elaboración e implantación (AU)

Introduction. Primary spontaneous pneumothorax (PSP) is a common entity. Treatment varies widely across different health systems and even among doctors in the same department. In our general surgery department 30 to 40 patients with PSP are treated each year and there is significant variability in care delivery. This prompted the development of a clinical pathway (CP) based on analysis of the process, a search for studies with the greatest scientific evidence and professional consensus. The aim of this study was to present the results after 1 year's evaluation of the CP. Patients and method. A series of 34 patients treated in the year prior to the design of the pathway was analyzed to identify weak points and areas for improvement. To address these weak points the CP included associated protocols and principal documents. Thirty-one patients included in the CP were treated over 1 year and the results were compared with those of the pre-pathway series. Results. The mean length of stay in the pre-pathway patients was 7.3 days compared with 5.0 days in the pathway patients. The number of radiographs also fell from 4.3 to 3.2. The rate of complications and re-admissions was similar in both groups. The mean cost per process decreased from 1863 € to 1168 €. Conclusion. The CP for pneumothorax reduced both variability in professional care patterns and hospital costs, justifying the work involved in its development and implementation (AU)

Evaluation of the clinical pathway for laparoscopic cholecystectomy.

Clinical pathways are comprehensive systematized patient care plans for specific procedures. The clinical pathway for laparoscopic cholecystectomy was implemented in our department in March 2002. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. A study was conducted on all the patients included in the clinical pathway since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year prior to implementation of the clinical pathway. As our hospital has a system of cost management, we analyzed the mean cost per procedure before and after clinical pathway implementation. Evaluation was made of a series of 160 consecutive patients who underwent surgery during the period 1 year prior to development of the clinical pathway and met the accepted inclusion criteria. The mean length of hospital stay was 3.27 days, and the mean cost per procedure before pathway implementation was 2149 (+/-768) euros. One year after implementation of the pathway, 140 patients were included (i.e., an inclusion rate of 100%). The mean length of hospital stay of the patients included in the clinical pathway was 2.2 days. The degree of compliance with stays was 66.7 per cent. The most frequent reasons for noncompliance were staff-dependent, followed by patient-dependent causes (oral intolerance, pain, etc.). The mean cost in the series of patients included in the clinical pathway was 1845 (+/-618) euros. Laparoscopic cholecystectomy is an ideal procedure for commencing the systemization of clinical pathways. Results show that it has significantly reduced the length of hospital stay and mean cost per procedure with no increased morbidity and with a high degree of patient satisfaction.

Reparación laparoscópica de las hernias lumbares secundarias: cirugía abierta frente a laparoscópica. Estudio prospectivo no aleatorizado / Laparoscopic repair of secondary lumbar hernias: open vs. laparoscopic surgery. A prospective, non randomized study

Introducción. La hernia lumbar es un defecto de la pared abdominal posterior poco frecuente y su tratamiento quirúrgico es todavía controvertido. El objetivo del estudio es valorar la utilidad de la vía laparoscópica frente a la cirugía abierta. Pacientes y método. Estudio prospectivo no aleatorizado con 16 pacientes intervenidos por hernia lumbar secundaria entre enero de 1997 y enero de 2003: 9 mediante vía laparoscópica y 7 por vía abierta. Las variables analizadas fueron: datos clínicos y hospitalarios (tiempo quirúrgico y estancia), bienestar del paciente (consumo de analgésicos y retorno a su actividad habitual) y recurrencias. Se realiza un análisis del coste hospitalario del proceso. Resultados. No encontramos diferencias entre ambos grupos en cuanto a la edad y los antecedentes, aunque el tamaño de los defectos operados por laparoscopia fue menor. El tiempo quirúrgico medio, la morbilidad postoperatoria, la estancia hospitalaria media, el consumo de analgésicos y el retorno a la actividad habitual fueron significativamente menores en el grupo laparoscópico (p < 0,01). El coste hospitalario del proceso no presentó diferencias estadísticas en función del abordaje quirúrgico, pero sí el coste final tras incluir los gastos por reingreso y recidiva (p < 0,01). Conclusiones. En nuestra serie, la vía laparoscópica puede ser empleada en la reparación de las hernias lumbares secundarias con una mayor eficacia y rentabilidad que la vía abierta tradicional y con el mismo coste (AU)

Introduction. Lumbar hernia is an uncommon defect of the posterior abdominal wall and its surgical treatment remains controversial. The aim of the present study was to evaluate the utility of laparoscopy versus open surgery. Patients and method. We performed a prospective, nonrandomized study of 16 patients with secondary lumbar hernias who underwent surgery between January1997 and January 2003. Nine patients underwent laparoscopy and 7 underwent open surgery. The variables analyzed were clinical features, hospital data (operating time and length of hospital stay), patient comfort (analgesic consumption and return to normal daily activity) and recurrences. Hospital costs were also analyzed. Results. No differences were found between the two groups in age or history, although the size of laparoscopically-repaired defects was smaller. Mean operating time, postoperative morbidity, mean length of hospital stay, analgesic consumption, and return to daily activities were significantly lower in the laparoscopic group (P<.01). No statistically significant differences in the cost of the process were found according to surgical approach but significant differences were found in final cost after including the cost of readmissions and recurrences (P<.01). Conclusions. In our series, the laparoscopic approach was more effective than traditional open surgery in the repair of secondary lumbar hernias while the cost of the two procedures was the same (AU)

[Laparoscopic repair of secondary lumbar hernias: open vs. laparoscopic surgery. A prospective, nonrandomized study]. / Reparación laparoscópica de las hernias lumbares secundarias: cirugía abierta frente a laparoscópica. Estudio prospectivo no aleatorizado.

INTRODUCTION: Lumbar hernia is an uncommon defect of the posterior abdominal wall and its surgical treatment remains controversial. The aim of the present study was to evaluate the utility of laparoscopy versus open surgery. PATIENTS AND METHOD: We performed a prospective, nonrandomized study of 16 patients with secondary lumbar hernias who underwent surgery between January 1997 and January 2003. Nine patients underwent laparoscopy and 7 underwent open surgery. The variables analyzed were clinical features, hospital data (operating time and length of hospital stay), patient comfort (analgesic consumption and return to normal daily activity) and recurrences. Hospital costs were also analyzed. RESULTS: No differences were found between the two groups in age or history, although the size of laparoscopically-repaired defects was smaller. Mean operating time, postoperative morbidity, mean length of hospital stay, analgesic consumption, and return to daily activities were significantly lower in the laparoscopic group (P<.01). No statistically significant differences in the cost of the process were found according to surgical approach but significant differences were found in final cost after including the cost of readmissions and recurrences (P<.01). CONCLUSIONS: In our series, the laparoscopic approach was more effective than traditional open surgery in the repair of secondary lumbar hernias while the cost of the two procedures was the same.

[Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department]. / Vía clínica para el tratamiento del neumotórax espontáneo primario en un servicio de cirugía general.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a common entity. Treatment varies widely across different health systems and even among doctors in the same department. In our general surgery department 30 to 40 patients with PSP are treated each year and there is significant variability in care delivery. This prompted the development of a clinical pathway (CP) based on analysis of the process, a search for studies with the greatest scientific evidence and professional consensus. The aim of this study was to present the results after 1 year's evaluation of the CP. PATIENTS AND METHOD: A series of 34 patients treated in the year prior to the design of the pathway was analyzed to identify weak points and areas for improvement. To address these weak points the CP included associated protocols and principal documents. Thirty-one patients included in the CP were treated over 1 year and the results were compared with those of the pre-pathway series. RESULTS: The mean length of stay in the pre-pathway patients was 7.3 days compared with 5.0 days in the pathway patients. The number of radiographs also fell from 4.3 to 3.2. The rate of complications and re-admissions was similar in both groups. The mean cost per process decreased from 1863 Euro to 1168 Euro. CONCLUSION: The CP for pneumothorax reduced both variability in professional care patterns and hospital costs, justifying the work involved in its development and implementation.

Vía clínica del carcinoma colorrectal. Elaboración a partir del análisis del proceso / Clinical pathway for colorectal carcinoma. Design based on an analysis of the process

Objetivo: Las vías clínicas son herramientas para la gestión de la calidad que establecen protocolos para determinados procesos. El carcinoma colorrectal es el tumor digestivo más frecuentemente tratado en los servicios de cirugía de nuestro país, y en su atención hay numerosos factores que producen una gran variabilidad. El objetivo de este trabajo es exponer el proceso de elaboración de la vía clínica del tratamiento del carcinoma colorrectal en cirugía programada. Metodología: Para su elaboración se seleccionó un grupo de trabajo formado por los representantes de los profesionales implicados en su asistencia. Se analizó una serie de 60 pacientes intervenidos con el diagnóstico de carcinoma colorrectal previo a la elaboración de la vía clínica para la identificación de los puntos débiles. Resultado: Se identificaron como principales puntos débiles los siguientes: estudio incompleto de extensión preoperatorio, falta de información a los pacientes portadores de ostomías, protocolos quirúrgicos y patológicos con déficit de información relevante y ausencia de protocolo de seguimiento oncológico estandarizado. Para dar respuesta satisfactoria a los mencionados puntos débiles, se elaboraron los documentos principales de la vía clínica y unos protocolos asociados. Conclusiones: La elaboración de una vía clínica en el proceso de carcinoma colorrectal está plenamente justificada por el número de pacientes atendidos en nuestro hospital y la elevada variabilidad en su asistencia. El análisis del proceso, la revisión bibliográfica y el consenso de los participantes son las bases fundamentales en las que se ha apoyado su elaboración (AU)