[Clinical reasoning: practical aspects that allow the facilitation of its development]. / Razonamiento clínico: aspectos prácticos que permiten la facilitación de su desarrollo.

Clinical reasoning is a competence that the doctor develops and that is essential for his medical practice. Clinical reasoning includes aspects related to observation, critical thinking and communication skills with the patient, since it integrates the previous knowledge that the doctor has about a disease or medical problem with obtaining information from the clinical aspects that the patient provides. and with the mental process of processing the clinical information provided by the patient to the health professional during the interrogation or anamnesis, together with the interpretation of the findings in the physical examination and, where appropriate, of the complementary tests, allowing the elaboration of a set of diagnoses likely for efficient clinical decision making. The present work intends to address the subject in the simplest way possible so that the medical teacher takes it into account and facilitates its development in the doctor in training.

El razonamiento clínico es una competencia que el médico desarrolla y que es fundamental para su práctica médica. El razonamiento clínico incluye aspectos relacionados con la observación, el pensamiento crítico y las habilidades de comunicación con el paciente, ya que integra los conocimientos previos que el médico tiene sobre una enfermedad o problema médico mediante la obtención de información de los aspectos clínicos que el paciente proporciona y con el proceso mental de procesar la información clínica proporcionada por el paciente al profesional sanitario durante el interrogatorio o anamnesis, aunado a la interpretación de los hallazgos en la exploración física y, en su caso, de las pruebas complementarias, permite elaborar un conjunto de diagnósticos probables para la eficiente toma de decisiones clínicas. El presente trabajo tiene la intención de abordar el tema de la manera más sencilla posible para que el docente médico lo tome en cuenta y facilite su desarrollo en el médico en formación.

Different doses of enoxaparin in the prevention of postoperative abdominal adhesions. Experimental study.

BACKGROUND: Postoperative abdominal adhesions (PAAs) are present in more than 90% of patients undergoing abdominal surgery. They are a cause of chronic pain, hospitalizations, multiple surgeries, and infertility in women of reproductive age. The participation of three processes have been recognized: coagulation, fibrinolysis, and inflammation. The usefulness of subcutaneous enoxaparin in their prevention has been established. The objective is to establish the safest and most efficient dose for PAA prevention by testing five different doses of subcutaneous enoxaparin (0.25, 0.5, 1, 1.5, and 2 mg/kg/day) given in one dose/day for seven days. MATERIAL AND METHODS: Fifty Sprague-Dawley rats were studied, 10 in each group. Adhesions were induced through controlled rubbing of the cecum and suturing of an incision in the terminal ileum. Two independent observers recorded the degree of adhesion formation at 14 days and histologically studied the adhesions. STATISTICAL ANALYSIS: ANOVA compared group averages. The nonparametric Kruskal-Wallis test was used to identify group differences. RESULTS: The 0.5 mg/kg/day group had greater formation of adhesions (p < 0.001). There was no significant difference between the 1.5 and 2 mg/kg/day groups, though the latter group had an incidence of 27.2% of bleeding in the abdominal cavity. The degree of adhesions in the histological sections coincided with the macroscopic findings. The interobserver agreement was kappa = 0.88 (very good). CONCLUSION: The safe and effective dose of subcutaneous enoxaparin to prevent PAA formation was 0.5-1.5 mg/kg/day for seven days.

Outpatient treatment for colostomy stenosis; report of 3 cases.

INTRODUCTION AND IMPORTANCE: Stenosis of the colostomy occurs in 2-15% of patients and, they are the cause of serious discomfort for the patient due to the difficulty in evacuation, as well as the need for new surgical interventions. The purpose of this work demonstrates an outpatient surgical treatment that can be performed in the office. CASE PRESENTATION: Three patients with definitive colostomy who suffered progressive stenosis are presented. Under local anesthesia, one or two triangular segments, with their bases on the colostomy, which included the thickened and hardened skin, are removed to expand the diameter of the stoma. The mucosa of the colon is sutured to healthy skin with Vicryl 3/0 simple stitches. This method has been used in three patients older than 60 years with permanent colostomy who presented with progressive stenosis 6-7 months after surgery. The average follow-up at 14.5 months was satisfactory, without restenosis. DISCUSSION: Stoma stenosis is a complication that occurs in up to 15% of cases and requires reconstruction, most of which are carried out in the operating room. The triangular stenoplasty presented is effective and is performed under local anesthesia in the office. CONCLUSION: Triangular-section stenoplasty of a stenosed permanent colostomy is an effective outpatient treatment.

Triggering receptor expressed on myeloid cells-1 expression on monocytes is associated with inflammation but not with infection in acute pancreatitis.

INTRODUCTION: Acute pancreatitis (AP) is usually a mild and self-limiting disease, but some patients develop a severe form that is associated with high mortality. In AP, local inflammation is followed first by the systemic inflammatory response syndrome and then by the compensatory anti-inflammatory response syndrome, which is defined by low human leukocyte antigen (HLA)-DR expression on monocytes, increased concentration of the anti-inflammatory cytokine IL-10, and decreased monocyte function. Our aim was to measure the expression of triggering receptor expressed on myeloid cells (TREM)-1 (a proposed marker of infection or inflammation) and HLA-DR on monocytes, and the serum concentrations of IL-6 (a proinflammatory cytokine) and IL-10 in patients with AP to determine whether these markers can identify patients at high risk of developing severe AP or infection. METHODS: Fifty healthy volunteers, 18 patients with mild AP, and 11 patients with severe AP were included in this study. Samples were taken at admission and one and three days later. TREM-1 and HLA-DR expression was evaluated by flow cytometry, and soluble TREM-1, IL-6 and IL-10 concentrations were measured by ELISA. RESULTS: TREM-1 expression was higher in patients with AP than in healthy volunteers, but there was no difference between patients with mild and severe AP. TREM-1 expression was not associated with mortality or with the presence of infection. Soluble TREM-1 concentration in serum was higher in non-survivors than in survivors. HLA-DR expression was lower and IL-6 concentration higher in patients with severe AP and in infected patients. CONCLUSIONS: Increased TREM-1 expression was associated with the presence of inflammation but not infection in AP. In patients with AP, low HLA-DR expression and high IL-6 concentration could predict severity and infection in samples taken shortly after admission.

[Case study of diffuse hemangiomatosis of the liver]. / Hemangiomatosis difusa del hígado. A propósito de un caso.

In adults, diffuse haemangiomatosis of the liver is a very rare condition. The aetiology and clinical evolution are not well understood, and the literature records isolated cases with different behaviours and treatments. Here we present the case of a 45-year-old patient with haemangiomatose lesions in both lobes of the liver, causing moderate to intense abdominal pain and a bloated sensation in the presence of an abdominal mass, but with hepatic and haematological functions remaining largely intact. Conventional ultrasound and CAT scan revealed diffuse lesions in both hepatic lobes, and this required the performance of a diagnostic laparoscopy to rule out hepatic metasteses or multiple liver abscess. As the findings consisted of large blue-black spongy masses involving both lobes of the liver, radical treatment of a resective type was not possible. After two years of follow-up, the patient still complains of diffuse abdominal pain of varying intensity, which is being treated with analgesics. Liver function tests have demonstrated a gradual increase in both liver enzymes and alkaline phosphatase, but without frank clinical evidence of clinical liver insufficiency.

[Clinical characteristics and follow-up of patients with AIDS and acute abdominal pain]. / Características clínicas y evolución de pacientes con SIDA y dolor abdominal agudo.

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow-up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post-surgical and histopathological diagnosis and post-surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post-surgical complication; in five of them, six surgical re-interventions were performed. Three deaths occurred in the 30-day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

[Ultrasonography with contrast agent for diagnosis of benign retroperitoneal cyst. Case report]. / Ultrasonido con ecorrealzador para el diagnóstico de quiste retroperitoneal benigno. A propósito de un caso.

Intraabdominal tumors require precise diagnosis for patient preparation for optimal surgical procedure. For diagnosis of these lesions, the principal studies used are ultrasonography, computed axial tomography (CAT) and occasionally the use of magnetic resonance imaging, a study not always possible to accomplish in all hospitals. We present the case of a patient with a giant retroperitoneal cyst whose diagnosis was missed by means of conventional ultrasound and CAT. For this reason, we chose to use ultrasound with echography using contrast agent (Levovist) to determine if the tumor was dependent on the liver or pancreas. By means of this technique, we were able to make the diagnosis that the tumor did not depend on any organ, but rather was an independent retroperitoneal tumor. Final surgical and histopathological diagnosis was a retroperitoneal multilocular lymphangioma. We conclude that ultrasonography with contrast agent (Levovist) is an alternative method for studying intraabdominal tumors.

Características clínicas y evolución de pacientes con SIDA y dolor abdominal agudo / Clinical characteristics and follow-up of patients with AIDS and acute abdominal pain

Los síntomas abdominales son frecuentes en el SIDA y el dolor abdominal es un reto diagnóstico que puede requerir cirugía electiva o urgente aunque la información acerca de esta última es pobre. En este estudio analizamos los hallazgos clínicos y evolución de pacientes con SIDA y dolor abdominal agudo. En un periodo de dos años, recolectamos variables demográficas y de laboratorio, síntomas clínicos, diagnóstico inicial, hallazgos quirúrgicos, diagnóstico postquirúrgico, hallazgos histopatológicos y complicaciones postoperatorias de pacientes con SIDA y dolor abdominal agudo. De 232 pacientes hospitalizados, 34 tuvieron dolor abdominal agudo: 32 hombres y 2 mujeres (mediana de edad = 32 años; intervalos 26 a 58). Veintidós pacientes requirieron manejo quirúrgico. Ocho pacientes presentaron complicaciones postquirúrgicas; cinco requirieron seis segundas intervenciones. Ocurrieron tres muertes en los 30 días luego de la cirugía inicial. La supervivencia para los pacientes tratados médicamente fue 4 meses (1 a 17), contra 6.5 meses (1 a 20) del grupo quirúrgico. El médico debe estar alerta acerca de las posibilidades diagnósticas del enfermo con SIDA y dolor abdominal agudo. Demorar la cirugía puede ser letal. La cirugía tiene un papel importante en el tratamiento integral del paciente con SIDA.

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post surgical and histopathological diagnosis and post surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post surgical complication; in five of them, six surgical re interventions were performed. Three deaths occurred in the 30 day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

[Mesenteric cyst as a cause of acute abdomen. Report of 3 cases]. / Quiste de mesenterio como causa de abdomen agudo. A propósito de tres casos.

Mesenteric cyst is a tumor of multiple origins that surely are found more frequently than the literature report, at any rate, this tumor is uncommon. Because of absence of characteristic clinical findings, diagnosis cumbersome, until these cysts are of such a size that palpation becomes possible or when they cause compression to nearby viscera. Occasionally, diagnosis is made during surgery, even when it was emergency surgery. The present paper reports on three patients with mesenteric cyst found during surgery as emergency treatment. Histopathologic reports showed lymphangioma in two cases and leiomyosarcoma in one case, quite uncommon in this kind of lesion.

Mesh prosthesis versus triangular flap from the anterior sheath of the abdominal rectus muscle in primary inguinal hernia repair.

A study was carried out to compare the use of two different tension-free surgical techniques, for the repair of primary inguinal hernia in cases without complications. The study was carried out on 91 consecutive patients who presented with primary and uncomplicated inguinal hernia. The patients were randomly divided into two groups. Group I consisted of 42 patients whose inguinal hernia was repaired by means of the application of a triangular flap rotated from the anterior sheath of the abdominal rectus muscle and then sutured to the inguinal ligament with non-continuous and nonabsorbable suture 00. Group II consisted of 49 patients whose inguinal hernia was repaired by tension-free hernioplasty, placing a mesh umbrella plug in the deep inguinal orifice and, if necessary, mesh reinforcement to the floor of the inguinal canal (the Gilbert technique). There were no statistically significant differences with regard to age, sex, hernia evolution time, trans- or postoperative complications, or hernia recurrence during an average follow-up time of 3 years. Patients in the flap group required significantly more surgery time and postoperative analgesics. Cost analysis showed that patients receiving a muscle sheath flap spent less money on the actual surgical procedure, given the saving on the purchase of a prosthetic mesh. However, when taking into account the greater need for analgesia and the longer time in the operating theater, there was no difference in overall cost between the two procedures. Inguinal hernia repair using a triangular flap from the anterior sheath of the abdominal rectus muscle is an additional surgical procedure that can be utilized in cases where prosthetic mesh repair is not feasible.

[An useful classification for acute appendicitis]. / Una clasificación útil en apendicitis aguda.

OBJECTIVE: To analyze clinical aspects of acute appendicitis at a teaching hospital, and to present a simple classification for acute appendicitis according to surgical findings, a classification that will indicate what postoperative treatment should be. MATERIALS AND METHODS: The study included 3,112 adult patients who had undergone surgery between September 1994 and February 2000 and who had been diagnosed preoperatively with acute appendicitis. Faced with the need to simplify description of surgical findings and to relate them to treatment, the following classification was instituted: Grade 0: No appendicitis; incidental appendectomy was carried out and antimicrobians were stopped. Grade Ia: Oedematous, ingurgitated appendix. Grade Ib: Abscessed or phlegmonous appendix, presents fibrin membranes and seropurulent liquid around appendix. Grade Ic: Necrosed appendix with no perforation. In these grades, there is very little or no presence of bacteria in periappendicular liquid or in fibrin membranes. Hence, treatment consisted of appendectomy and perioperative antimicrobians (metronidazol 500 mg and amikacine 500 mg within 2 h prior to surgery, followed by two further doses every 8 h postoperatively). Grade II: Perforated appendix with localized abscess. Treatment consisted of appendectomy and antimicrobians begun preoperatively and continuing for 3 days. A Saratoga or Penrose drain was inserted if internal tissue bed remaining after excision was raw or bloody, and might have predisposed to collection of fluid. Grade III: Complicated appendicitis with generalized peritonitis. In these cases, appendectomy was carried out with lavage to abdominal cavity. Antimicrobians were administered beginning preoperatively and were continued until patient's general condition was good, the patient had remained afebrile for 48 h and white cell count had fallen. RESULTS: Patients ranged in age from 16 to 83 years, with 62% of patients men and 38%, women. Grade I appendicitis was found to be the most common, affecting 74% of patients. Hospital stay for grade I appendicitis was 2 days; for grade II appendicitis, from 2 to 7 days; and for grade III appendicitis, from 3 to 14 days. No significant difference was noted in presence of surgical wound infection among grade I appendicitis cases, incidence being 1.1%. In grade II appendicitis cases, incidence was 17.1% and 36% in grade III cases. CONCLUSIONS: Classification of acute appendicitis as herein proposed made it possible to standardize management and treatment carried out and to predict possible complications.

[Mesenteric cyst. A review]. / Quiste de mesenterio. Revisión.

The mesenteric cyst is a tumor of multiple origins, that undoubtedly presents with greater frequency than that referred in published series. Nevertheless, it continues to be a rare entity. Due to absence of characteristic signs and symptoms, diagnosis is only made once these lesions have reached a size, sufficiently large to be palpable or when they cause compression on organs or neighboring structures. The cyst can present with chronic manifestations such as diffuse abdominal pain imprecisely located but associated with palpable mass, or due to complications of the cyst or due to compression of adjacent structures. Diagnosis is confirmed by imaging studies, such as the different ultrasound modalities, computed tomography (CT) scan, and magnetic resonance imaging (MRI). A differential diagnosis must be made to exclude other intra-abdominal or retro-peritoneal tumors. Optimum treatment is extirpation of the cyst. On occasion it is also necessary to remove the adjacent organ due to the impossibility of enucleating cyst. marsupialization of the cyst or drainage into peritoneal cavity, have high incidence of recurrence. Surgical treatment can be carried out by minimal invasion techniques.

Colgajo del recto abdominal: tratamiento de la hernia inguinal recidivante / Recto-abdominal flap: recurrent inguinal hernia

Se presenta una opción de técnica quirúrgica para la reparación de la hernia inguinal recidivante que necesita malla protésica para reforzar el piso de la región inguinal. Usamos un colgajo de la vaina anterior del músculo recto del abdomen para reparar la hernia. Fueron incluidos cincuenta pacientes consecutivos con primera recidiva de hernia inguinal no complicada. Se obtuvo colgajo triangular de la vaina anterior del músculo recto, a nivel del área conjunta, el cual fuel rotado y cuyo bordo libre suturado con monofilamento no absorbible 00 al ligamento inguinal, quedando en situación similar a la malla protésica. El seguimiento posoperatorio promedio fue de 20 meses. Esta técnica fue posible en 35 pacientes (70 por ciento); en el resto no, principalmente por adherencia firmes de la región. Un paciente presentó recidiva (2.8 por ciento) a los 14 meses de la reparación. No hubo complicaciones mayores. Concluimos que se requiere un mayor número de pacientes y tiempo de seguimiento para evaluar la eficacia de esta técnica, sin embargo, el colgajo triangular de la vaina del músculo recto del abdomen es útil en el refuerzo del piso de la región inguinal, con baja tensión y puede sustituir a la malla protésica debido a que ambas estructuras se dejan en la misma posición

Tumor insospechado en el colon / Unsuspected large bowel tumor

Antecedentes: En alguna ocasión el cirujano encuentra un tumor colónico insospechado, y por sus características le puede ser difícil diferenciar si es de origen benigno o maligno; en ese mismo momento debe decidir si lo reseca o cierra el abdomen y realiza biopsia y estudios complementarios con lo que pueda ofrecerle al paciente el tratamiento más adecuado de acuerdo con el diagnóstico definitivo: objetivo: Presentar y analizar el curso clínico de pacientes con operación abdominal que presentaron tumores insospechados en colon. Método: Revisamos 8,703 expedientes de pacientes con operación abdominal, de los cuales 21 (0.24 por ciento) presentaron un tumor insospechado en el colon. Se dividieron en dos grupos: al grupo I no se le realizó resección inmediata y se estudiaron integralmente, el grupo II incluyó a pacientes que fueron tratados con resección inmediata. Resultados: De los pacientes del grupo I (n= 16), 11 requirieron resección definitiva a los 12 días promedio, sin complicaciones en el tiempo transcurrido ente la operación inicial y la definitiva; en los cinco pacientes restantes el diagnóstico fue ameboma y respondieron bien al tratamiento con metronidazol, no requirieron resección colónica. De los pacientes del grupo II (n= 5), tres presentaron complicaciones posoperatorias: Conclusiones: En nuestro medio, el ameboma debe ser considerado en el diagnóstico diferencial de tumores colónicos insospechados y no requiere de resección, por lo que el hallazgo inesperado de un tumor en el colon durante una operación, justifica no resecarlo y realizar estudios diagnósticos complementarios.

Plastia inguinal libre de tensión / Tension free inguinal plasty

La plastia inguinal es una de las intervenciones quirúrgicas más frecuentes en México, por lo que su conocimiento, evaluación y tratamiento adecuados son necesarios para obtener los resultados mas óptimos. En el Hospital General de Zona Núm. 1 "Grabriel Mancera", se efectuó la técnica de plastia inguinal con la colocación de una prótesis de malla en 250 pacientes con excelentes resultados, sin recidivas a 22 meses en promedio de seguimiento, a excepción de cuatro infecciones superficiales. Se sugiere el empleo de esta técnica, la cual debe ser difundida y utilizada con más frecuencia, ya que su realización es fácil, segura, disminuye el tiempo quirúrgico, la incidencia de complicaciones y el periodo de incapacidad en 50 por ciento. Por supuesto será la técnica de elección en la plastia inguinal una vez que sea bien conocida por todos los cirujanos.

Hernia ciática: reporte de un caso y revisión de la literatura / Sciatic hernia: case report and review of the literature

Presentamos a un paciente masculino con una masa en la región glútea izquierda con dolor en ésta zona e irradiando a la cara posterior del muslo que se agravaba con la dorsiflexión y extensión de la cadera. Se pensó que se trataba de un tumor de partes blandas, por lo que se intervino mediante un abordaje transglúteo, encontrando una hernia ciática (tipo suprapiriforme); el saco herniario contenía intestino delgado. Se cerró el defecto mediante la ligadura del saco y la aproximación del músculo piriforme al glúteo menor. La evolución postoperatoria fué satisfactoria y después de un año de seguimiento, no se ha observado recurrencia. Informamos de este caso por su rareza y por la presentación de un hombre sin factores predisponentes para desarrollarla. Se discute la etiología, diagnóstico y tratamiento.

Absceso esplénico: una complicación poco frecuente en el paciente diabético / Splenic abscess: an infrequent complication in the diabetic patient

Objetivo: Informar un caso de absceso explénico tratado con drenaje externo y antimicrobianos adecuados con buen resultado. Sede: Hospital General de Zona No. 1 "Gabriel Mancera" IMSS, México, D.F. Diseño: Estudio Informativo. Paciente: Presentamos el caso de una paciente diabética de 45 años de edad, que preentó un absceso esplénico. Fue tratada con drenaje externo mediante laparotomía exploradora, metronidazol y gentamicina, con resultados satisfactorios. Revisamos las manifestaciones clínicas, los métodos diagnósticos y el tratamiento de esta entidad

La colecistitis alitiásica aguda (CAA) en pacientes no hospitalizados / Acute laithiasic cholecystitis (AAC) in non hospitalized patients

El incremento de la colecistitis alitiásica aguda (CCA) en pacientes no hospitalizados generó la revisión de los expedientes clínicos de 810 casos de colecistectomía por colecistitis aguda; 27 fueron acalculosas (3.3 por ciento). La CCA predominó en mujeres (20/27) cuya edad promedio fue de 37 años. En doce pacientes (44 por ciento) la colecistitis se asoció con diabetes mellitus e hipertensión. El cuadro clínico fue similar al de los pacientes con colecistitis litiásica y el diagnóstico preoperatorio sólo se realizó en 33 por ciento mediante ultrasonografía. Los hallazgos operatorios fueron: vesícula edematosa sin cálculos, pared engrosada y necrosada, así como adherencias perivesiculares. A todos los pacientes se les ralizó colecistectomía inmediata, con una morbilidad de 14.4 por ciento y sin mortalidad. La CAA no solamente ocurre en pacientes en estado crítico, se presenta también en pacientes no hsopitalizados y la colecistectomía inmediata es el tratamiento de elección

Comparación entre la anestesia local y el bloqueo peridural en plastia inguinal / Comparison between local anesthesia and peridural block used in inguinoplasty

En este estudio se recomienda la anestesia local como procedimiento de elección en la reparación de la hernia inguinal unilateral y no complicada. Se presenta un estudio prospectivo, comparativo y aleatorio en 165 pacientes con hernia inguinal, dividiéndolos en dos grupos: grupo I, 80 pacientes operados con anestesia local; grupo II, 85 pacientes operados bajo bloqueo peridural. Se excluyeron los pacientes con hernia recidivante o complicada. El tiempo anestésico-quirúrgico empleado fue menor en el grupo I, con promedio de 71.5 minutos en comparación al II, que empleó 121.3 minutos en promedio. Las complicaciones fueron menores en el grupo I y la estancia hospitalaria fue significativamente menor en comparación al grupo II. Se considera que la anestesia local en la plastia inguinal unilateral y no complicada debe ser el procedimiento de elección por su buena tolerancia y efectividad, únicamente se requiere experiencia en su uso por parte del cirujano