Pulmonary recruitment can reduce residual pneumoperitoneum and shoulder pain in conventional laparoscopic procedures: results of a randomized controlled trial.

BACKGROUND: This study is aimed to evaluate the pulmonary recruitment maneuver as a means to effectively reduce residual pneumoperitoneum and postoperative shoulder pain in patients undergoing conventional laparoscopic procedures and compare it to the instillation of intraperitoneal anesthetics. METHODS: Patients undergoing laparoscopic cholecystectomy, appendectomy or hernioplasty were randomized into two groups: pulmonary recruitment maneuver (PRM) and intraperitoneal anesthetic instillation (IAI). Six hours after surgery patients were asked to fill out a visual analog scale to identify shoulder pain and a chest X-ray was taken. Groups were analyzed for incidence of residual pneumoperitoneum and shoulder pain as well as for volume of residual subdiaphragmatic gas and intensity of pain. RESULTS: A total of 84 patients (42 per group) were included in the study. Patients in the PRM group had a lower incidence of subdiaphragmatic gas present in the chest X-ray (29% vs 55%) p = 0.01 and less volume of residual pneumoperitoneum (mean difference -.31(95%CI -7.36, 0.72), p = 0.02). They also were half as likely to present shoulder pain (24% vs 50%) p = 0.01 and showed less pain intensity than those in the IAI group (mean difference -2.04(95%CI - 3.25, - 0.84), p = 0.000). The risk of presenting shoulder pain when residual pneumoperitoneum was present showed an RR = 11.1, p = 0.0001 in the PRM group and an RR = 8.3, p = 0.000 in the IAI group. The volume of subdiaphragmatic gas was positively correlated with the intensity of shoulder pain (r = 0.54, p = 0.000). CONCLUSIONS: The pulmonary recruitment maneuver is effective in reducing the incidence and volume of residual pneumoperitoneum, as well as the incidence and intensity of shoulder pain in patients undergoing conventional laparoscopic procedures.

[Cyst of Nucks canal associated with recurrent inguinal hernia]. / Quiste del canal de Nuck asociado con hernia inguinal recurrente.

Cysts of a permeable vaginal process or cysts of Nuck are a rare entity in women and have a similar embryologic and etiologic origin as that of inguinal hernias. They should be considered a differential diagnosis when an inguinal mass is present or during a diagnostic laparoscopy in which a peritoneal defect or open inguinal ring is found. We report the case of a woman with a cyst of Nuck that presented as a recurrent inguinal hernia. Discussion is centered on the embryologic, anatomic, clinical and therapeutic aspects of this condition.

Correlación de los hallazgos endoscópicos pre y postoperatorios en pacientes sometidos a cirugía bariátrica / Correlation of pre and postoperative endoscopic findings in patients subjected to bariatric surgery

Objetivo: Establecer una correlación de los hallazgos endoscópicos preoperatorios con los síntomas gastrointestinales y hallazgos endoscópicos en el seguimiento de los pacientes sometidos a algún tipo de cirugía bariátrica. Sede: Hospital General ''Dr. Manuel Gea González''. Tercer Nivel de Atención Médica. Diseño: Estudio retrospectivo, descriptivo, transversal y comparativo. Análisis estadístico: Porcentajes como medida de resumen para variables cualitativas y χ². Pacientes y método: Pacientes que se operaron en la clínica de obesidad, de junio 2006 a junio 2010, a los cuales se les realizó endoscopia preoperatoria con un seguimiento mínimo de un año. Se identificaron las patologías gastrointestinales con mayor incidencia, hallazgos histopatológicos y la correlación de la endoscopia postoperatoria en el seguimiento de pacientes que por sus síntomas requirieron control endoscópico. Resultados: De un total de 137 pacientes que cumplieron con los criterios de inclusión (111 mujeres, 26 hombres), con edad promedio de 36.41, IMC promedio de 42.04, la patología con mayor incidencia fue gastritis inespecífica no erosiva (45.25%), el resultado histopatológico más frecuente fue gastritis asociada a Helicobacter pylori (HP) (38.6%). A un seguimiento promedio de tres años (DE ± 1.31) a 35 pacientes (25.5%) se les realizó endoscopia de seguimiento por síntomas gastrointestinales; los hallazgos endoscópicos fueron: gastritis inespecífica no erosiva (54.28%), sin alteraciones (31.42%) y estenosis de anastomosis (14.7%). Conclusión: La endoscopia preoperatoria es de gran utilidad, ya que permite identificar patologías que se pueden asociar a otras complicaciones y tomar todas las medidas para prevenirlas.

Objective: To establish a correlation between the pre-operative endoscopic findings with the gastrointestinal syndrome and endoscopic findings during follow-up of patients subjected to bariatric surgery. Setting: General Hospital ''Dr. Manuel Gea González'' (third level health care center). Design: A retrospective, descriptive, cross-sectional, comparative study. Statistical analysis: Percentages as summary measures for qualitative variables and χ². Patients and method: Patients operated in the obesity clinic from June 2006 to June 2010, in whom a preoperative endoscopy was performed with a follow-up of at least 1 years. We identified the gastrointestinal pathologies with the highest incidence, histopathological findings, and the correlation with the postoperative endoscopy during the follow-up of patients, who, due to their symptoms, required endoscopic control. Results: In a total of 137 patients that complied with the inclusion criteria (111 women and 26 men), average age of 36.41 years, average BMI of 42.04, the pathology with the highest incidence was non-specific non-erosive gastritis (45.25%), the most frequent histopathological result was gastritis associated to Helicobacter pylori (HP) (38.6%). At an average follow-up of three years (SD ± 1.31), 35 patients (25.5%) were subjected to follow-up endoscopy due to gastrointestinal symptoms. Endoscopic findings were: non-specific, non-erosive gastritis (54.28%), without alterations (31.42%), and stenosis of the anastomoses (14.7%). Conclusion: Preoperative endoscopy is very useful as it allows identifying pathologies that can be associated to other complications and taking the necessary measures to prevent them.

Resección laparoscópica de linfangioma cavernoso retroperitoneal residual / Laparoscopic resection of a residual retroperitoneal cavernous lymphangioma

Objetivo: Presentar el caso de una paciente con linfangioma cavernoso diagnosticado incidentalmente y tratado quirúrgicamente, primero por laparotomía y después, para su resolución final, mediante laparoscopia. Se discuten las ventajas de la cirugía miniinvasiva como método adyuvante en la resección del linfangioma residual después de una laparotomía extensa. Sede: Hospital de tercer nivel. Diseño: Presentación del caso y revisión de la literatura. Descripción del caso: Mujer de 43 años, en la cual se documentó masa quística aparentemente dependiente del ovario derecho, con marcadores tumorales para cáncer ovárico normales. Se programó para salpingoclasia y resección de quiste ovárico, por incisión Pfannenstiel, encontrando un quiste gigante de origen retroperitoneal, que se extendía desde el hueco pélvico hasta el abdomen superior. Fue extirpado casi en su totalidad, debido a la extensión de la tumoración, excepto en la porción pancreatoduodenal y retrohepática, ya que al intentar abordar esta zona, inició con sangrado transoperatorio y se desconocían las relaciones del tumor con estos órganos. Se difirió la resección de esta porción residual para complementar su estudio por imágenes e histopatología y llevarlo a cabo en un segundo tiempo quirúrgico. La tomografía postoperatoria no mostró dependencia pancreatoduodenal, biliar o vascular. Al mes, se programó para la resección laparoscópica del tumor residual. El reporte histopatológico fue linfangioma cavernoso en ambos casos. Conclusiones: El tratamiento para los linfangiomas retroperitoneales es la resección completa. La cirugía miniinvasiva es una alternativa útil, ventajosa y mejor aceptada por los pacientes en algunas reoperaciones planeadas, donde inicialmente se realizó cirugía abierta.

Objective: To present the case of a woman with cavernous lymphangioma incidentally diagnosed and surgically treated, first through laparotomy and later, for its final resolution, through laparoscopy. We discuss the advantages of mini-invasive surgery as an adjuvant method for the resection of a residual lymphangioma after extensive laparotomy. Setting: Third level health care hospital. Design: Case presentation and review of the literature. Case description: A 43-year-old woman, in whom a cystic mass, apparently depending on the right ovary was documented; tumor markers for ovarian cancer were normal. She was programmed to undergo salpingoplasty and resection of the ovarian cyst, through Pfannenstiel incision. During surgery a giant cyst of retroperitoneal origin was found, which extended from the pelvic hole to the upper abdomen. It was resected almost totally due to the extension of the tumor, except for the pancreatoduodenal and retrohepatic region, because, when attempting to approach this area, transoperative bleeding started and we did not know the relations of the tumor with these organs. The resection of this residual portion was deferred to be able to complement the diagnosis with imaging and histopathology studies and perform the resection at a second surgical time. Postoperative tomography revealed no pancreatoduodenal, biliary, or vascular dependence. After 1 month, the patient was programmed for laparoscopic resection of the residual tumor. The histopathological report corresponded to cavernous lymphangioma in both situations. Conclusions: Treatment of retroperitoneal lymphangiomas consists of complete resection. Mini-invasive surgery is a useful, valuable option and a better accepted alternative by patients in some planned re-operations where initially open surgery had been performed.

Mejoría en el score de riesgo cardiovascular por la cirugía bariátrica / Improvement in the cardiovascular risk score due to bariatric surgery

Introducción: La obesidad se ha considerado como un factor de riesgo para desarrollar eventos coronarios agudos. Los principales factores para desarrollar este tipo de enfermedades están presentes en la mayoría de los pacientes sometidos a cirugía bariátrica. Objetivo: Evaluar el riesgo cardiovascular de los pacientes sometidos a cirugía bariátrica en forma preoperatoria y postoperatoria tras un seguimiento a dos años. Sede: Hospital General ''Dr. Manuel Gea González''. Diseño: Estudio retrospectivo, longitudinal, observacional y comparativo. Material y métodos: Pacientes de la clínica de cirugía bariátrica, operados con la técnica de bypass gástrico, calculando el riesgo cardiovascular de forma preoperatoria y posteriormente a dos años de seguimiento. Resultados: Se incluyeron 64 pacientes (13 hombres y 51 mujeres). La edad promedio de los hombres fue 42 años su índice de masa corporal promedio fue 49.44 kg/m², la puntuación del riesgo cardiovascular preoperatoria fue: 5.15 (2-9). Al seguimiento a dos años su índice de masa corporal promedio disminuyó a 36.23 kg/m², la puntuación del riesgo cardiovascular fue: 2.38 (0-5). En las mujeres la edad promedio fue de 36 años, su índice de masa corporal promedio previo a la cirugía fue 45.32 kg/m², la puntuación del riesgo cardiovascular fue: 4.3 (-10 a 13). A un seguimiento de dos años su índice de masa corporal promedio fue 28.64 kg/m² (20.1-42.1), la puntuación del riesgo cardiovascular fue -4.1 (-11 a 8). Conclusión: La cirugía bariátrica no sólo ha demostrado ser un método eficaz y seguro para la disminución del peso corporal en pacientes con obesidad mórbida, también aquí se demuestra que disminuye el riesgo cardiovascular que poseen estos pacientes.

Introduction: Obesity has been considered a risk factor for acute coronary events. The main factors to develop this type of diseases are present in most of the patients subjected to bariatric surgery. Objective: To assess the cardiovascular risk of patients subjected to bariatric surgery preoperatively and at 2-years follow-up. Setting: General Hospital ''Dr. Manuel Gea González''. Design: Retrospective, longitudinal, observational, and comparative study. Patients and methods: Patients from the bariatric surgery clinic, operated with the gastric bypass technique, calculating the cardiovascular risk preoperatively and at 2-year follow-up. Results: The study included 64 patients (13 men and 51 women). Average age of men was 42 years, their average body mass index was 49.44 kg/m², preoperative cardiovascular risk score was 5.15 (2-9). At 2-year follow-up, their BMI diminished to 36.23 kg/m², the cardiovascular risk score was 2.38 (0-5). In women, average age was of 36 years, their body mass index before surgery was of 45.32 kg/m², the cardiovascular risk score was 4.3 (-10 a 13). At 2-year follow-up, their average body mass index reduced to 28.64 kg/m² (20.1-42.1), and the cardiovascular risk score was -4.1 (-11 to 8). Conclusion: Bariatric surgery has not only been demonstrated as an efficacious and safe method to reduce body weight in patients with morbid obesity but also to diminish the cardiovascular risk depicted by these patients.

[Case report. Post cesarean section laparoscopic cholecystectomy for hydrocholecystitis]. / Colecistectomía laparoscópica poscesárea por hidrocolecisto. Reporte de un caso.

BACKGROUND: Acute cholecystitis is the second most common surgical emergency in pregnant women. Although laparoscopic cholecystectomy has been described previously in these cases, there is still controversy regarding the most appropriate moment in which to perform the procedure. OBJECTIVE: To describe the clinical presentation and management of a female with 36.6 weeks of pregnancy and clinical signs of acute cholecystitis. Cesarean section to deliver a healthy newborn was immediately followed by laparoscopic cholecystectomy without complications. A 10 year literature review complements the analysis and discussion of the case. CLINICAL CASE: A 33 year-old female with 36.6 weeks of gestation presented a history of 24 hours with right upper quadrant and epigastric abdominal pain, nausea and vomiting. Symptoms were precipitated by cholecystokinetics and did not subside after expectant and pharmacologic medical treatment. The medical group decided with the patient's consent to interrupt the pregnancy via Cesarean section immediately followed by laparoscopic cholecystectomy. RESULTS: After Cesarean section through a Pfannenstiel incision, laparoscopic trocars were placed and cholecystectomy performed without complications. The postsurgical course was favorable and both patient and newborn were discharged on day four. CONCLUSIONS: Laparoscopic surgery cholecystectomy during pregnancy and in the immediate puerperium is feasible and safe. These combined procedures: rapid pregnancy interruption followed by a minimal invasive approach gives the benefits of laparoscopic surgery in these patients.

[Pelvic solitary fibrous nodule, incidental finding and laparoscopic resection. Case report]. / Nódulo fibroso solitario pélvico, hallazgo incidental y resección laparoscópica. Reporte de un caso.

The solitary fibrous nodule is a rare clinical disease that mainly affects the pleura, but has been occasionally described in other anatomical sites. This type of tumors can have malignant components and therefore it is important to differentiate them from other retroperitoneal masses. We describe the case of a patient with ectopic pregnancy in whom a solitary fibrous nodule with laparoscopy was found. A peritoneal pelvic tumor with smooth surface, 20,2 g, firm was detected. The mass was independent of colon, uterus, ovaries or salpinx and was very near to the iliac vessels on the right side. A small fragment was biopsied and sent to trans surgical histopathology study and the rest of the mass was removed completely without complications. The histopathologic report described that the tumor contained sclerosed cells with collagenous bands and sings of hemorrhage and calcification, compatible with a benign pelvic solitary fibrous tumor. The solitary fibrous nodule is a rare, benign disease, but with malignant potential. These tumors must be resected when they are incidentally found during other surgical procedures or if diagnosed preoperatively. The laparoscopic approach has advantages in the identification and resection these tumors.