Training model in abdominal wall endoscopic surgery for ventral hernias. Extended totally extra-peritoneal approach (e-tep).

PURPOSE: To develop a reproducible training program model covering the steps of the extended totally extraperitoneal approach (e-tep) technique for correction of ventral or incisional hernia repair. METHODS: Training sessions with surgeons in the laboratory using both porcine specimens and a new ethylene vinyl acetate (EVA) model simulating the operative steps of the e-tep technique. Students were interviewed and asked to answer a questionnaire pre and post the sessions to assess their performance and evaluated the course and model. RESULTS: A total of 25 trained abdominal wall surgeons was evaluated at the end of the course. It was obtained a 100% satisfaction score of the training, as well as increased confidence levels up to 9 and 10 in all technical aspects of the surgery, having 96% of the surgeons performed a surgery under supervision of the proctors after the course. CONCLUSIONS: This training model is simple, effective, low cost, and replicable in guidance on the beginning of e-tep technique adoption, and performance. As a result, surgeons can get more confident and more able to perform surgeries employing this technique.

Training model in abdominal wall endoscopic surgery for ventral hernias. Extended totally extra-peritoneal approach (e-tep)

ABSTRACT Purpose: To develop a reproducible training program model covering the steps of the extended totally extraperitoneal approach (e-tep) technique for correction of ventral or incisional hernia repair. Methods: Training sessions with surgeons in the laboratory using both porcine specimens and a new ethylene vinyl acetate (EVA) model simulating the operative steps of the e-tep technique. Students were interviewed and asked to answer a questionnaire pre and post the sessions to assess their performance and evaluated the course and model. Results: A total of 25 trained abdominal wall surgeons was evaluated at the end of the course. It was obtained a 100% satisfaction score of the training, as well as increased confidence levels up to 9 and 10 in all technical aspects of the surgery, having 96% of the surgeons performed a surgery under supervision of the proctors after the course. Conclusions: This training model is simple, effective, low cost, and replicable in guidance on the beginning of e-tep technique adoption, and performance. As a result, surgeons can get more confident and more able to perform surgeries employing this technique.

During which period should we avoid cholecystectomy in patients who underwent endoscopic retrograde cholangiopancreatography?

OBJECTIVE: To determine the period during which we should avoid cholecystectomy after endoscopic retrograde cholangiopancreatography. METHODS: A retrospective analysis of electronic medical charts of 532 patients undergoing endoscopic retrograde cholangiopancreatography, between March 2013 and December 2017. RESULTS: Approximately one-third of patients underwent the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography. The conversion rate was 3.8%. The need for abdominal drainage and the finding of biliary tract injury after surgery were observed in 15.1% and 1.9% of patients, respectively. The length of stay was significantly shorter among patients undergoing surgery more than 30 days after endoscopic retrograde cholangiopancreatography. These patients had a median length of stay of one day, whereas the median length of stay in the group undergoing the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography was 2 days. CONCLUSION: The period during which we should avoid cholecystectomy is between 4 and 30 days after endoscopic retrograde cholangiopancreatography.

Quadratus Lumborum Block As A Single Anesthetic Method For Laparoscopic Totally Extraperitoneal (Tep) Inguinal Hernia Repair: A Randomized Clinical Trial.

Minimally invasive surgery for inguinal hernia repair is advantageous in terms of return to usual activities and lower rates of chronic pain; however, it requires general anesthesia. This study sought to analyze the benefits of ultrasound guided locoregional anesthesia of the quadratus lumborum muscle (QL block) as a single anesthetic technique for endoscopic totally extraperitoneal (TEP) inguinal hernia repair with regard to postoperative pain, length of hospital stay, and hospital cost. A total of 46 patients, aged 18 to 80 years, with unilateral inguinal hernia, one group that received general anesthesia and one that received sedation and QL block for TEP inguinal hernia repair. In the 46 patients the median pain score 6 hours after surgery was significantly lower (2 versus 4) among the QL block group than among the group receiving general anesthesia. Consequently, the former group showed a briefer median hospital stay (6 versus 24 hours, respectively). The anesthesia and hospital costs were also lower for the QL block group, with median reductions of 64.15% and 25%, respectively. QL block is a safe and effective option for patients undergoing TEP inguinal hernia repair, given the observed reduction in early postoperative pain, briefer hospital stay, and decreased anesthesia and hospital costs.

During which period should we avoid cholecystectomy in patients who underwent endoscopic retrograde cholangiopancreatography? / Durante qual período devemos evitar a colecistectomia em pacientes que realizaram colangiopancreatografia retrógrada endoscópica?

ABSTRACT Objective: To determine the period during which we should avoid cholecystectomy after endoscopic retrograde cholangiopancreatography. Methods: A retrospective analysis of electronic medical charts of 532 patients undergoing endoscopic retrograde cholangiopancreatography, between March 2013 and December 2017. Results: Approximately one-third of patients underwent the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography. The conversion rate was 3.8%. The need for abdominal drainage and the finding of biliary tract injury after surgery were observed in 15.1% and 1.9% of patients, respectively. The length of stay was significantly shorter among patients undergoing surgery more than 30 days after endoscopic retrograde cholangiopancreatography. These patients had a median length of stay of one day, whereas the median length of stay in the group undergoing the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography was 2 days. Conclusion: The period during which we should avoid cholecystectomy is between 4 and 30 days after endoscopic retrograde cholangiopancreatography.

RESUMO Objetivo: Analisar o período durante o qual devemos evitar a colecistectomia após a colangiopancreatografia retrógrada endoscópica. Métodos: Foi realizada análise retrospectiva dos prontuários eletrônicos de 532 pacientes submetidos à colangiopancreatografia retrógrada endoscópica, no período de março de 2013 a dezembro de 2017. Resultados: Cerca de um terço dos pacientes realizaram o procedimento entre 4 e 30 dias após a colangiopancreatografia retrógrada endoscópica. A frequência de conversão do procedimento foi de 3,8%. A necessidade de dreno abdominal e o achado de lesão de via biliar após a cirurgia atingiram 15,1% e 1,9% dos pacientes, respectivamente. O tempo de internação foi significativamente menor entre os pacientes com tempo de colangiopancreatografia retrógrada endoscópica superior a 30 dias. Estes pacientes apresentaram, em mediana, um dia de internação hospitalar, enquanto o tempo mediano de internação no grupo que realizou o procedimento entre 4 e 30 dias foi de 2 dias. Conclusão: O período durante o qual devemos evitar realizar a colecistectomia após a colangiopancreatografia retrógrada endoscópica é do 4° ao 30° dia.

Giant squamous cell carcinoma of the gallbladder: A case report.

BACKGROUND: Gallbladder cancer is the most common malignant tumor of the biliary tract. The majority of cases are adenocarcinoma. Squamous cell carcinoma is the histological type present in 12% of all neoplasias accounting for approximately 12% of gallbladder neoplasms. It can occur in its pure form reaching 1%-3% of the tumors. Many patients are at an advanced stage when diagnosed and have bad therapeutic efficacy. CASE SUMMARY: A 45-year-old male patient presented with left flank pain for 1 year and irradiated to the mesogastric region. He denied fever, vomiting, and any other intestinal changes. He reported a weight loss of 10 kg in a period of 7 mo. He denied alcoholism, smoking, drug use, or prior illness. Computed tomography of the abdomen showed in the gallbladder fossa a voluminous mesogastric heterogeneous collection that had a thick and irregular capsule with liquid and gaseous contents. A predominantly hypoattenuating rounded material with partially calcified margins measuring about 2.0 cm related to gallstone was also emphasized. No lymphadenomegalies or free fluid was observed in the abdominal cavity. Patient underwent laparotomy where a huge tumor was observed affecting the transverse colon and gallbladder. This mass was resected en bloc removing gallbladder and transverse colon together with corresponding mesocolon and regional lymphadenectomy. There were no complications in the postoperative period. Although oncological treatment was performed, the patient died 6 mo after surgery. CONCLUSION: Squamous cell carcinoma represents a rare disease. Patients often present with large, bulky tumors with involvement of adjacent organs. In spite of progress in surgical techniques and adjuvant chemotherapy, the prognosis remains poor.

Accuracy of the ultrasound examination in patients with inguinal hernia. / Avaliação da acurácia do exame ultrassonográfico em pacientes portadores de hérnia inguinal.

OBJECTIVE: to evaluate the accuracy of ultrasonography in the diagnosis of inguinal hernia in the preoperative period of patients submitted to inguinal herniorrhaphy. METHODS: we conducted a retrospective, descriptive, analytical study, based on data obtained from the charts of patients submitted to inguinal herniorrhaphy between January 2016 and December 2017 and who underwent ultrasonography in the preoperative period. The sample consisted of 232 patients, and we compared the results of the ultrasonography with the complaints, physical examination and intraoperative findings. RESULTS: ultrasonography was in agreement with inguinal hernia complaint in 52% of patients (p=0.019). There was a disagreement between the percentage of patients who presented a hernia at the physical examination not confirmed by the ultrasound examination (28.57%) and the percentage of hernias identified only by the complementary examination (8.93%), with statistical significance (p=0.0291). When comparing the ultrasound findings with the intraoperative ones, 32.70% of patients presenting with hernia had normal ultrasonography, with statistical significance for discordance (p=0.001). CONCLUSION: ultrasound was an unreliable method to help diagnosis in dubious cases of inguinal hernia, and dispensable when the diagnosis was confirmed by typical complaints and compatible physical examination.

OBJETIVO: avaliar a acurácia da ultrassonografia no diagnóstico de hérnia inguinal no pré-operatório de pacientes submetidos à herniorrafia inguinal. MÉTODOS: estudo retrospectivo descritivo, analítico, baseado em dados obtidos dos prontuários de pacientes submetidos à herniorrafia inguinal entre janeiro de 2016 e dezembro de 2017 e que realizaram ultrassonografia no período pré-operatório. A amostra foi composta por 232 pacientes e foram comparados os resultados da ultrassonografia com as queixas, exame físico e achados intraoperatórios desses pacientes. RESULTADOS: a ultrassonografia apresentou concordância com a queixa de hérnia inguinal em 52% dos pacientes (p=0,019). Houve discordância entre a porcentagem de pacientes que apresentaram hérnia ao exame físico não confirmada pelo exame ultrassonográfico (28,57%) e a porcentagem de hérnias identificadas somente ao exame complementar (8,93%), com significância estatística (p=0,0291). Quando comparados os resultados ultrassonográficos com achados intraoperatórios, 32,70% dos pacientes que apresentavam hérnia tinham ultrassonografia normal com significância estatística para discordância (p=0,001). CONCLUSÃO: a ultrassonografia mostrou-se método não confiável para auxiliar no diagnóstico em casos duvidosos de hérnia inguinal e dispensável quando o diagnóstico era confirmado por queixas típicas e exame físico compatível.

Avaliação da acurácia do exame ultrassonográfico em pacientes portadores de hérnia inguinal / Accuracy of the ultrasound examination in patients with inguinal hernia

RESUMO Objetivo: avaliar a acurácia da ultrassonografia no diagnóstico de hérnia inguinal no pré-operatório de pacientes submetidos à herniorrafia inguinal. Métodos: estudo retrospectivo descritivo, analítico, baseado em dados obtidos dos prontuários de pacientes submetidos à herniorrafia inguinal entre janeiro de 2016 e dezembro de 2017 e que realizaram ultrassonografia no período pré-operatório. A amostra foi composta por 232 pacientes e foram comparados os resultados da ultrassonografia com as queixas, exame físico e achados intraoperatórios desses pacientes. Resultados: a ultrassonografia apresentou concordância com a queixa de hérnia inguinal em 52% dos pacientes (p=0,019). Houve discordância entre a porcentagem de pacientes que apresentaram hérnia ao exame físico não confirmada pelo exame ultrassonográfico (28,57%) e a porcentagem de hérnias identificadas somente ao exame complementar (8,93%), com significância estatística (p=0,0291). Quando comparados os resultados ultrassonográficos com achados intraoperatórios, 32,70% dos pacientes que apresentavam hérnia tinham ultrassonografia normal com significância estatística para discordância (p=0,001). Conclusão: a ultrassonografia mostrou-se método não confiável para auxiliar no diagnóstico em casos duvidosos de hérnia inguinal e dispensável quando o diagnóstico era confirmado por queixas típicas e exame físico compatível.

ABSTRACT Objective: to evaluate the accuracy of ultrasonography in the diagnosis of inguinal hernia in the preoperative period of patients submitted to inguinal herniorrhaphy. Methods: we conducted a retrospective, descriptive, analytical study, based on data obtained from the charts of patients submitted to inguinal herniorrhaphy between January 2016 and December 2017 and who underwent ultrasonography in the preoperative period. The sample consisted of 232 patients, and we compared the results of the ultrasonography with the complaints, physical examination and intraoperative findings. Results: ultrasonography was in agreement with inguinal hernia complaint in 52% of patients (p=0.019). There was a disagreement between the percentage of patients who presented a hernia at the physical examination not confirmed by the ultrasound examination (28.57%) and the percentage of hernias identified only by the complementary examination (8.93%), with statistical significance (p=0.0291). When comparing the ultrasound findings with the intraoperative ones, 32.70% of patients presenting with hernia had normal ultrasonography, with statistical significance for discordance (p=0.001). Conclusion: ultrasound was an unreliable method to help diagnosis in dubious cases of inguinal hernia, and dispensable when the diagnosis was confirmed by typical complaints and compatible physical examination.

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY: TECHNICAL ASPECTS AND RESULTS.

BACKGROUND: The search for less traumatic surgical procedures without compromising efficacy and safety, together with the technological advances and greater experience of the teams, led to the development of operative techniques with increasingly smaller incisions, the so-called "minimally invasive surgeries". AIM: To evaluate the technical aspects and results of single port cholecystectomy. METHOD: Were analyzed 170 patients between 18-74 years submitted to videolaparoscopic cholecystectomies by single port, regardless of elective or urgent indication, without restriction of patient selection. RESULTS: Among the 170 operations, 158 were exclusively performed by single port, and the conversion rate was 7% (inclusion of other accessory trocars or conversion to multiportal). Conversion to open surgery occurred in three cases (1.76%). The mean surgical time was 67.97 min, showing a marked decrease when was reached close to 50 cases and a stabilization after 100 surgeries. The overall complication rate was 10%, with minor complications such as: incisional pain, hematomas, granulomas, port access hernias (9.41%). CONCLUSION: Single port cholecystectomy can, after standardization and surgical team training, be a safe surgical procedure associated with a recognized aesthetic advantage.

Single port laparoscopic cholecystectomy: technical aspects and results / Aspectos técnicos e resultados da colecistectomia laparoscópica por portal único

ABSTRACT Background: The search for less traumatic surgical procedures without compromising efficacy and safety, together with the technological advances and greater experience of the teams, led to the development of operative techniques with increasingly smaller incisions, the so-called "minimally invasive surgeries". Aim: To evaluate the technical aspects and results of single port cholecystectomy. Method: Were analyzed 170 patients between 18-74 years submitted to videolaparoscopic cholecystectomies by single port, regardless of elective or urgent indication, without restriction of patient selection. Results: Among the 170 operations, 158 were exclusively performed by single port, and the conversion rate was 7% (inclusion of other accessory trocars or conversion to multiportal). Conversion to open surgery occurred in three cases (1.76%). The mean surgical time was 67.97 min, showing a marked decrease when was reached close to 50 cases and a stabilization after 100 surgeries. The overall complication rate was 10%, with minor complications such as: incisional pain, hematomas, granulomas, port access hernias (9.41%). Conclusion: Single port cholecystectomy can, after standardization and surgical team training, be a safe surgical procedure associated with a recognized aesthetic advantage.

RESUMO Racional: A busca de procedimentos cirúrgicos menos traumáticos, esteticamente melhores, sem comprometimento da eficácia e segurança, em conjunto com os avanços tecnológicos e maior experiência das equipes, levaram ao desenvolvimento de técnicas operatórias com incisões cada vez menores, as denominadas "cirurgias minimamente invasivas". Objetivo: Avaliar os aspectos técnicos e resultados da colecistectomia por portal único. Método: Foram analisados 170 pacientes entre 18-74 anos submetidos à colecistectomias videolaparoscópicas por portal único, independente da indicação eletiva ou de urgência, sem restrição de seleção dos pacientes. Resultados: Das 170 operações, 158 foram exclusivamente realizadas por portal único, sendo que a taxa de conversão foi de 7% (inclusão de outros trocárteres acessórios ou conversão para multiportal). Já a conversão para laparotomia ocorreu em três casos (1,76%). A média de tempo cirúrgico foi de 67,97 min, mostrando decréscimo acentuado quando chegou-se perto dos 50 casos, e estabilização após a centésima operação. A taxa de complicação global foi de 10% sendo que em sua maior parte foram complicações leves como: dor incisional, hematomas, granulomas, hérnias no portal de acesso (9,41%). Conclusão: A colecistectomia por portal único consegue, após padronização técnica e treinamento da equipe cirúrgica, ser procedimento cirúrgico seguro, associado à vantagem estética reconhecida.

Risk factors associated with complications of acute appendicitis.

OBJECTIVE: to identify the main risk factors associated with the development of complications in patients with acute appendicitis. METHODS: we conducted a case-control study of 402 patients with acute appendicitis hospitalized in a secondary hospital, divided into two groups: the control group, with 373 patients who progressed without postoperative complications (Group 1) and the study group, with 29 patients who presented complications (Group 2). We evaluated demographic data, signs and symptoms of the disease, imaging tests and hospitalization data. RESULTS: factors associated with complications were fever, radiological and sonographic changes, abrupt positive decompression and diarrhea. Migration of pain, nausea, vomiting and abrupt positive decompression were the findings that were significantly more frequent in both groups (p = 0.05). The duration of signs and symptoms in days in group 2 was significantly higher than in group 1, with a median of three days for the group with complications (p = 0.05). CONCLUSION: alterations in imaging, fever, diarrhea, positive abrupt decompression, duration of symptoms and lower age are associated with a higher frequency of complications in acute appendicitis, which reinforces the importance of anamnesis, physical examination and indication of complementary exams in the approach of these patients.

Risk factors associated with complications of acute appendicitis / Fatores de risco associados às complicações de apendicite aguda

ABSTRACT Objective : to identify the main risk factors associated with the development of complications in patients with acute appendicitis. Methods: we conducted a case-control study of 402 patients with acute appendicitis hospitalized in a secondary hospital, divided into two groups: the control group, with 373 patients who progressed without postoperative complications (Group 1) and the study group, with 29 patients who presented complications (Group 2). We evaluated demographic data, signs and symptoms of the disease, imaging tests and hospitalization data. Results: factors associated with complications were fever, radiological and sonographic changes, abrupt positive decompression and diarrhea. Migration of pain, nausea, vomiting and abrupt positive decompression were the findings that were significantly more frequent in both groups (p = 0.05). The duration of signs and symptoms in days in group 2 was significantly higher than in group 1, with a median of three days for the group with complications (p = 0.05). Conclusion: alterations in imaging, fever, diarrhea, positive abrupt decompression, duration of symptoms and lower age are associated with a higher frequency of complications in acute appendicitis, which reinforces the importance of anamnesis, physical examination and indication of complementary exams in the approach of these patients.

RESUMO Objetivo: identificar os principais fatores de risco associados ao desenvolvimento de complicações em pacientes portadores de apendicite aguda. Métodos: estudo caso controle de dados dos prontuários de 402 pacientes internados com apendicite aguda em um hospital de nível secundário, separados em dois grupos: grupo controle, com 373 pacientes que evoluíram sem complicações pós-operatórias (Grupo 1) e grupo estudo, com 29 pacientes que apresentaram complicações (Grupo 2). Foram avaliados dados demográficos, sinais e sintomas da doença, exames de imagem e dados da internação. Resultados: os fatores associados às complicações foram febre, alterações radiológicas e ultrassonográficas, descompressão brusca positiva e diarreia. Migração da dor, náuseas, vômitos e descompressão brusca positiva foram os achados significativamente mais frequentes nos dois grupos (p=0,05). Já a duração dos sinais e sintomas, em dias, no grupo 2 foi significativamente maior que no grupo 1, com mediana de três dias para o grupo com complicações (p=0,05). Conclusão: alterações nos exames de imagem, febre, diarreia, descompressão brusca positiva, tempo de duração de sintomas e menor faixa etária estão associados à maior frequência de complicações na apendicite aguda, o que reforça a importância da anamnese, do exame físico e da indicação de exames complementares na abordagem desses pacientes.

Isolated rupture of the gallbladder following blunt abdominal trauma: case report.

Gallbladder rupture following blunt abdominal trauma is a rare event recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis and treatment. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma.

Isolated rupture of the gallbladder following blunt abdominal trauma: case report / Ruptura isolada de vesícula biliar após trauma abdominal fechado: relato de caso

Gallbladder rupture following blunt abdominal trauma is a rare event recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis and treatment. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma.

A ruptura da vesícula biliar após trauma abdominal fechado é um evento raro, identificada apenas durante laparotomia para avaliar e tratar outras lesões viscerais. A ruptura isolada da vesícula biliar secundária a traumatismo abdominal fechado é ainda mais rara. A apresentação clínica da lesão da vesícula biliar é variável, resultando em um atraso no diagnóstico e tratamento. Relata-se um caso de ruptura isolada da vesícula biliar devido a um trauma abdominal fechado.

Hemoperitôneo secundário a GIST gástrico c-KIT negativo e anticorpo anti-DOG1 positivo / Hemoperitoneum secondary to gastric GIST negative for c-KIT and positive for antibody anti-DOG1

Os tumores estromais do trato gastrintestinal, embora relativamente raros, compreendem a maioria dos tumores mesenquimais do trato digestivo e constituem 5% de todos os sarcomas. Quanto à apresentação clínica, os sintomas mais comuns são dor, hemorragia digestiva e massa palpável. Este trabalho relatou o caso de um paciente jovem que desenvolveu hemoperitôneo por ruptura de neoplasia gástrica e necessitou de tratamento cirúrgico de urgência. A análise patológica e imunoistoquímica revelou tratar-se de um caso raro epidemiologicamente: tipo celular epitelioide e c-KIT negativo.

Although relatively rare, the gastrointestinal stromal tumors comprise most mesenchymal tumors of the digestive tract and account for 5% of all sarcomas. The most common symptoms are pain, gastrointestinal bleeding and palpable mass. This study reported the case of a young patient who developed hemoperitoneum due to gastric neoplasm rupture and required urgent surgical treatment. Pathology and immunohistochemistry analysis showed an epidemiologically rare case: epithelioid and c-KIT negative tumor.

Hemoperitoneum secondary to gastric GIST negative for c-KIT and positive for antibody anti-DOG1.

Although relatively rare, the gastrointestinal stromal tumors comprise most mesenchymal tumors of the digestive tract and account for 5% of all sarcomas. The most common symptoms are pain, gastrointestinal bleeding and palpable mass. This study reported the case of a young patient who developed hemoperitoneum due to gastric neoplasm rupture and required urgent surgical treatment. Pathology and immunohistochemistry analysis showed an epidemiologically rare case: epithelioid and c-KIT negative tumor.