Progresses in clinical treatment of multiple rib fractures and flail chest / 中国胸心血管外科临床杂志

@#The incidence of rib fracture in patients with chest trauma is about 70%. Simple rib fractures do not need special treatment. Multiple rib fractures and flail chest are critical cases of blunt trauma, which often cause serious clinical consequences and need to be treated cautiously. Nowadays, there is a controversy about the diagnosis and treatment of multiple rib fractures and flail chest. In the past, most of the patients were treated by non-operative treatment, and only less than 1% of the patients with flail chest underwent surgery. In recent years, studies have confirmed that surgical reduction and internal fixation can shorten the hospital stay, and reduce pain and cost for patients with flail chest, but there is still a lack of relevant clinical consensus and guidelines for diagnosis and treatment, which leads to great differences in clinical diagnosis and treatment plans. This article reviewed the treatment, surgical indications and surgical timing of multiple rib fractures and flail chest.

Evaluation of barbed suture for celiorrhaphy and subcutaneous closure in bitches with pyometra submitted to ovariohysterectomy

ABSTRACT Purpose To evaluate the use of barbed sutures over the surgical time, the leukogram, the tissue thickness in which the sutures were employed (ultrasonography), the costs, and the possible complications in bitches with pyometra submitted to ovariohysterectomy (OH). Methods Convectional 2.0 polyglyconate suture was used in the control group (CG n = 10) and 2.0 barbed polyglyconate suture in the barbed group (BG n = 10) to perform celiorrhaphy (simple continuous pattern) and subcutaneous closure (continuous intradermal pattern). Data were assessed using paired (leukogram between 24 and 48 h within the same group) and unpaired (leukogram, surgical time, tissue thickness, and costs) Student's t-test. The Fisher exact test was used to assess the occurrence of seroma between groups (p < 0.05). Results are shown as mean ± standard error of mean. Results The time spent to perform the celiorrhaphy (195.30 ± 17.37 s vs. 204 ± 16.00 s), subcutaneous closure (174.0 ± 15.86 s vs. 198.0 ± 15.62 s), and the total surgical time (24.30 ± 1.44 min vs. 23.00 ± 1.30 min) did not differ between BG and CG, respectively (p > 0.05). Leukogram at 48 h post-surgery did not differ between groups (p = 0.20). No differences were observed in the subcutaneous and the abdominal wall thickness (cm) assessed by ultrasonography at 48 h in BG (0.31 ± 0.04, 0.80 ± 0.05) and CG (0.34 ± 0.03, 0.72 ± 0.06), respectively. Similarly, 15 days post-surgery the same structures did not differ between BG (0.26 ± 0.02, 0.74 ± 0.08) and CG (0.26 ± 0.03, 0.64 ± 0.05) (p > 0.05). In one bitch from each group, a mild seroma was observed on one side of the surgical wound 48 h after surgery (p = 1.00). The procedures in which barbed sutures were used had an average additional cost of R$ 200.00 ± 11.66 (p < 0.0001). Conclusions Barbed suture has proven to be efficient and safe for abdominal and subcutaneous closure. However, considering its current high cost in addition thatthe surgical time of bitches with pyometra undergone OH was not reduced, no advantages were observed with theuse of barbed sutures for this type of surgery.

Caracterización de los pacientes con hernia inguinal operados por la técnica de Lichtenstein / Characterization of Patients with Inguinal Hernia Operated on Using the Lichtenstein Technique

RESUMEN Introducción: En la provincia de Mayabeque se emplea la técnica de Lichtenstein en la reparación de la hernia inguinal, con una recidiva inferior al 3 por ciento. Objetivo: Caracterizar a los pacientes con diagnóstico de hernia inguinal operados por la técnica de hernioplastia de Lichtenstein. Métodos: Se realizó un estudio longitudinal y retrospectivo en pacientes operados de hernia inguinal en el Hospital "Leopoldito Martínez" de enero-2013 a diciembre-2017. El universo estuvo constituido por 218 y una muestra probabilística sistemática de 128 casos. Los datos se obtuvieron de las historias clínicas. Las variables cuantitativas se resumieron mediante media aritmética y desviación estándar y las variables cualitativas mediante los por cientos. La comparación de proporciones se realizó a través del chi-cuadrado y la dócima de Duncan, considerándose un nivel de significación para p < 0,05. Resultados: Predominó el sexo masculino (94,54 por ciento), la edad entre 41 - 60 años (42,96 por ciento), tipo de hernia III A (60,15 por ciento) y evolución media de la misma 42,3 meses; el tiempo quirúrgico fue de 1-2 horas (65,62 por ciento) con media de 1 h, 26 minutos. Prevalecieron las complicaciones dolor agudo (13,28 por ciento) e infección del sitio quirúrgico (3,12 por ciento) y estadía hospitalaria < 24 horas (79,68 por ciento) con una recidiva de 2,34 por ciento. Conclusiones: La técnica de Lichtenstein es efectiva en la reparación de la hernia inguinal en la provincia de Mayabeque. La media del tiempo quirúrgico se estima en 1 hora y 26 minutos como máximo y la estadía hospitalaria a expensas de las complicaciones de 24-72 horas. El por ciento de recidivas es alto y debe mejorar depurando la técnica(AU)

ABSTRACT Introduction: In Mayabeque Province, the Lichtenstein technique is used to repair inguinal hernia, with a recurrence below 3 percent. Objective: To characterize patients with a diagnosis of inguinal hernia operated on by the Lichtenstein hernioplasty technique. Methods: A longitudinal and retrospective study was carried out in patients operated on for inguinal hernia at Leopoldito Martínez Hospital, from January-2013 to December-2017. The universe consisted of 218, with a systematic probabilistic sample of 128 cases. The data were obtained from medical records. Quantitative variables were summarized by arithmetic mean and standard deviation, while qualitative variables were summarized by percentages. The comparison of proportions was carried out through the chi-square and Duncan's test, considering a level of significance of P< 0.05. Results: There was a predominance of the male sex predominated (94.54 percent), the age between 41 and 60 years (42.96 percent), and the hernia type III A (60.15 percent), with mean evolution of 42.3 month. Surgical time was 1-2 hours (65.62 percent), with a mean of one hour and 26 minutes. There was predominance of acute pain complications (13.28 percent), surgical-site infection (3.12 percent) and hospital stay below 24 hours (79.68 percent), with a recurrence of 2.34 percent. Conclusions: The Lichtenstein technique is effective for inguinal hernia repair in the Mayabeque Province. Mean surgical time is estimated to be a maximum of one hour and 26 minutes, while hospital stay, at the expense of complications, was 24-72 hours. The percentage of recurrences is high and should improve by refining the technique(AU)

Experiencia del equipo quirúrgico y grado de dificultad de la intervención. ¿Variables significativas en la incidencia de complicaciones durante la cirugía laparoscópica ginecológica? / Experience of the surgical team and level of difficulty of the intervention. Significant variables in the incidence of complications during laparoscopic gynecological surgery?

Resumen OBJETIVO: Primario: observar si el grado de dificultad de la intervención y la experiencia del equipo quirúrgico influyen en la incidencia de complicaciones y consecuencias adversas de la cirugía laparoscópica ginecológica. Secundario: valorar cuál de las dos variables influye de forma más negativa y, además, estudiar los mecanismos que pueden implementarse en la práctica diaria, clínica y formativa para reducir las consecuencias quirúrgicas adversas. MATERIALES Y MÉTODOS: Estudio descriptivo, observacional y retrospectivo efectuado en el Hospital Universitario Virgen Macarena de Sevilla entre enero de 2015 y febrero de 2016. Se incluyeron todas las cirugías laparoscópicas indicadas por diagnóstico de patología benigna. La muestra se dividió en 3 grupos en función de la distribución de los cirujanos y su experiencia quirúrgica. Las intervenciones se categorizaron conforme a la dificultad en tres grados (el 3 correspondió al de mayor dificultad). RESULTADOS: Se incluyeron 195 cirugías laparoscópicas. La experiencia del equipo quirúrgico fue un factor determinante en los desenlaces heterogéneos, por lo que el grado de dificultad de la intervención tuvo una relación más estrecha con las consecuencias quirúrgicas adversas. Por lo que se refiere al grado de dificultad previo a la cirugía, solo fueron estadísticamente significativos el tiempo quirúrgico y la pérdida hemática, que fue mayor en las intervenciones grado 3. La estancia hospitalaria media, las reintervenciones, reingreso, conversión a laparotomía o complicaciones también fueron mayores en el grupo con grado 3 de dificultad y menor en el 1, pero sin significación estadística. CONCLUSIÓN: Con base en lo reportado se desprende que el grado de dificultad de la intervención tiene más influencia en las complicaciones quirúrgicas que la experiencia del cirujano y el ayudante.

Abstract OBJECTIVE: Primary: to observe whether the degree of difficulty of the intervention and the experience of the surgical team influence the incidence of complications and adverse consequences of laparoscopic gynecological surgery. Secondary: to assess which of the two variables influences more negatively and, in addition, to study the mechanisms that can be implemented in daily, clinical and educational practice to reduce the adverse surgical consequences. MATERIALS AND METHODS: Retrospective, observational and descriptive study carried out in the Virgen Macarena University Hospital of Seville, between January 2015 and February 2016. Including all laparoscopic surgeries performed for benign pathology in that period. The sample has been divided into 3 groups according to the distribution of the surgeons, taking into account their surgical experience. On the other hand, the interventions have been categorized according to the difficulty in three levels (with 3 being the most difficult). RESULTS: 195 laparoscopic surgeries have been collected. The experience of the surgical team has been a factor that has shown heterogeneous results, so the level of difficulty of the intervention seems more related to the surgical adverse effects. Regarding the level of difficulty prior to surgery, only surgical time and blood loss were statistically significant, which was greater in level 3 interventions. Variables such as average hospital stay, reoperations, readmission, conversion to laparotomy or complications were also higher in the group of level 3 of difficulty and lower in group 1, but without statistical significance. CONCLUSION: The results raise the theory of which the level of difficulty of the intervention influences of more direct form in the surgical complications that the surgical experience of the surgeon and the assistant.

Curva de aprendizaje en histerectomía laparoscópica. ¿Cuántas intervenciones se necesitan para dominar la técnica con estándares de seguridad? / Learning curve of laparoscopic hysterectomy. How many interventions are required to consider the technique dominated with safety standards?

Resumen OBJETIVO: Demostrar si se cumple lo publicado en referencia a las curvas de aprendizaje en histerectomía laparoscópica, para un mismo equipo quirúrgico, en variables como el porcentaje de complicaciones, conversiones a laparotomía, tiempo quirúrgico, pérdida de hemoglobina, días de hospitalización, etcétera. MATERIALES Y MÉTODOS: Estudio analítico, observacional de cohortes, prospectivo y de intervención efectuado de julio de 2014 a octubre de 2017 en el Departamento de Ginecología del Hospital General Santa María del Puerto, Cádiz, España. Criterio de inclusión: pacientes con histerectomía total o supracervical laparoscópica. RESULTADOS: Se analizaron 45 procedimientos divididos en 3 cohortes de 15 pacientes cada una de acuerdo con el orden temporal de realización. Así, el grupo 1 fue el de las primeras 15 histerectomías efectuadas, el grupo 2 de la 16 a la 30, y el grupo 3 de la 31 a la 45; es decir, las últimas 15 llevadas a cabo. El porcentaje de complicaciones y conversión a laparotomía fue de 13.3% en el grupo 1, de 6.7% en el grupo 2 y de 0% en el 3 (p = 0.343). El tiempo quirúrgico medio en el grupo 1 fue de 164 minutos, en el 2 de 101 minutos y en el 3 de 90 minutos (p = 0.001). Entre los diferentes grupos se registraron mejoras progresivas estadísticamente significativas en la pérdida de hemoglobina o la estancia hospitalaria. CONCLUSIONES: Con base en nuestros resultados la curva de aprendizaje es de 45 intervenciones, suficientes para practicar con estándares de seguridad este tipo de cirugías.

Abstract OBJECTIVE: To observe the learning curve in a surgical team of laparoscopic hysterectomy. Determine the number of surgeries needed to achieve a surgical time 90 minutes average, a percentage of total complications less than 10% and a conversion to laparotomy rate to less than 5%. MATERIAL AND METHODS: For this we have analyzed data collected prospectively, in 45 patients undergoing total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy, carried out by the same surgical team, and divided into 3 cohorts of 15 patients by temporal order of preparation; made July 2014 to October 2017, in the Department of Gynecology of the Hospital General Santa Maria del Puerto. RESULTS: We analized 45 procedures divided into 3 cohorts of 15 patients each according to the temporal order of performance. Thus, group 1 was that of the first 15 hysterectomies performed, group 2 from 16 to 30, and group 3 from 31 to 45; that is, the last 15 carried out. The complications and conversion rate to laparotomy was 13.3% in group 1; 6.7% in group 2, and 0% in group 3 (p = 0.343). The mean surgical time in group 1 was 164 minutes, in 2 of 101 minutes and in 3 of 90 minutes (p = 0.001). Among the different groups there were statistically significant progressive improvements in the loss of hemoglobin or hospital stay. CONCLUSIONS: Our results indicate that a learning curve of 45 interventions is sufficient to deal with this type of surgery with safety standards.

Acretismo placentario con abordaje predictivo y preventivo de hemorragia obstétrica / Placental accreta with predictive and preventive approach to obstetric hemorrhage

Resumen OBJETIVO Exponer el tratamiento médico y quirúrgico indicado en el Hospital Universitario de Saltillo a pacientes con acretismo placentario. MATERIALES Y MÉTODOS Estudio retrospectivo, transversal y analítico efectuado en pacientes tratadas con enfoque predictivo y preventivo de hemorragia obstétrica atendidas entre los años 2015-2017. Se incluyeron todas las pacientes operadas con la técnica descrita. Se analizan las variables maternas y fetales posquirúrgicas que aportan información para evaluar los resultados obstétricos mediante medias y porcentajes. RESULTADOS Se incluyeron 10 pacientes con media de edad de 31 años, 70% con antecedente de cesárea y 50% de legrado. El sangrado transquirúrgico tuvo una media de 1067 cc, con un tiempo quirúrgico promedio de 3.6 h, la media de transfusión de concentrados eritrocitarios fue de 2.3, el Apgar de los recién nacidos se reportó en ≥ 7, no se requirió reinternvención y no se encontraron casos de muerte materna. CONCLUSIONES Si bien el tamaño de la muestra es pequeño continuaremos recabando datos de lo sucedido con otras pacientes. Es indispensable estudiar más casos para tener evidencias de nuestra propuesta de tratamiento con pruebas aún más sólidas. También hace falta un seguimiento prolongado a las pacientes para conocer si hay o no complicaciones tardías.

Abstract OBJECTIVE Expose the medical and surgical treatment indicated in the University Hospital of Saltillo to patients with placental accreta. MATERIAL AND METHODS A retrospective, cross-sectional and analytical study, patients treated with a predictive and preventive approach of obstetric hemorrhage were studied in Hospital Universitario de Saltillo during 2015-2017. RESULTS 10 patients were included, with a mean age of 31 years, 70% had a history of cesarean section and 50% curettage. Transurgical bleeding averaged 1067 cc, an average surgical time of 3.6 hrs, average of transfusion of erythrocyte concentrates was 2.3, Apgar of newborns was reported ≥7, no surgical reoperation was required, no cases were found of maternal death. CONCLUSIONS Although the size of the sample is small, we will continue to collect data on what happened with other patients. It is essential to study more cases to have evidence of our treatment proposal with even more solid evidence. There is also a need for prolonged follow-up of patients to determine whether there are late complications or not.

Procedimientos diagnósticos y terapéuticos para pacientes con síndrome febril luego de histerectomía total abdominal / Diagnostic and therapeutic approach of febrile syndrome in patients after total abdominal hysterectomy

Resumen OBJETIVO: Describir las pruebas paraclínicas y los medicamentos indicados para revertir la fiebre en las pacientes que la tuvieron en las siguientes 48 horas posteriores a la histerectomía total abdominal. MATERIALES Y MÉTODOS: Estudio observacional, transversal, retrospectivo, descrip-tivo, abierto, no controlado consistente en la revisión de los expedientes de pacientes con histerectomía total abdominal. Se incluyeron pacientes programadas en la consulta externa sólo para histerectomía total abdominal con fiebre en las primeras 48 horas posintervención. De acuerdo con la distribución de cada variable se utilizaron estadís-tica paramétrica y no paramétrica, prueba de Wilcoxon y diferencia de proporciones. RESULTADOS: De 181 histerectomías practicadas, 34 pacientes tuvieron fiebre en las primeras 48 horas del posquirúrgico (19%). El tiempo quirúrgico fue de 116.7 ± 29.4 minutos y el sangrado de 498.5 ± 221.4 mL. Los leucocitos se incrementaron en 30% luego de la detección de fiebre con respecto a los valores prequirúrgicos; la hemoglobina disminuyó en 14%. El examen general de orina se reportó alterado en 29%. El primer pico febril alcanzó 38.6 ± 0.5 °C a las 32.8 ± 8.3 horas poscirugía con persistencia de 1.5 ± 0.9 días. El 44% de las pacientes recibió un antibiótico luego de la evidencia de fiebre de causa infecciosa; los más indicados fueron: nitrofurantoína y ciprofloxacina. CONCLUSIONES: Ante la evidencia del primer pico febril es importante efectuar dos pruebas de laboratorio: biometría hemática y examen general de orina y con base en los reportes decidir si es necesaria la prescripción o no de antibiótico.

Abstract OBJECTIVE: To describe the paraclinical tests and the medications indicated to revert the fever in the patients who had it in the following 48 hours after the total abdominal hysterectomy. MATERIALS AND METHODS: Observational, cross-sectional, retrospective, descriptive, open, uncontrolled study consisting of the review of the records of patients with total abdominal hysterectomy. Patients scheduled in the outpatient clinic were included only for total abdominal hysterectomy with fever in the first 48 hours post-intervention. According to the distribution of each variable, parametric and non-parametric statistics, Wilcoxon test and proportional differences were used. RESULTS: Of 181 hysterectomies performed, 34 patients had fever in the first 48 hours after surgery (19%). The surgical time was 116.7 ± 29.4 minutes and the bleeding were 498.5 ± 221.4 mL. The leukocytes were increased by 30% after the detection of fever with respect to the presurgical values; hemoglobin decreased by 14%. The general urine test was reported altered in 29%. The first febrile peak reached 38.6 ± 0.5 °C at 32.8 ± 8.3 hours after surgery with a persistence of 1.5 ± 0.9 days. 44% of patients received an antibiotic after evidence of infectious cause fever; the most indicated were: nitrofurantoin and ciprofloxacin. CONCLUSIONS: Given the evidence of the first febrile peak, it is important to perform two laboratory tests: blood count and urinalysis, and based on the reports, decide whether the prescription of antibiotics is necessary.

Prognostic Factors Associated with Surgical Time of Endonasal Dacryocystorhinostomy

PURPOSE: To determine the prognostic factors associated with surgical time of endonasal dacryocystorhinostomy (DCR). METHODS: From April 2009 to June 2014, 66 eyes of 66 patients who underwent endonasal DCR for 5-year periods were retrospectively evaluated with regard to surgical time and several other factors. The factors were patient factors (age, sex), category of diagnosis (inflammation and non-inflammation), and systemic factors (diabetes mellitus [DM], hypertension [HTN], anticoagulant agents, sinusitis history). We divided the study period into three subperiods and compared their surgical time. The anatomical factor of thickness of the maxillary frontal process was evaluated by computed tomography (CT), as was the existence of symptom recurrence after surgery and reoperation according to surgical time. A total of 66 cases (right: 31, left: 35) were included. Any case with concurrent surgery, abnormal structure of the nasal cavity, or bilateral DCR was excluded. RESULTS: Average surgical time was 49.95 minutes. Surgical time of endonasal DCR was short in inflammatory cases (p = 0.047), in the third surgical period (p = 0.001), and was correlated with thickness of the maxillary frontal process (p = 0.001). In addition, surgical time correlated with the existence of symptom recurrence after surgery and reoperation (p = 0.012). CONCLUSIONS: It is considered that surgeon skill affects surgical time, and the thickness of the maxillary frontal process by CT will aid in the prediction of surgical time and success rate of endonasal DCR.

EBM methodology-based analysis of surgical time influencing factors / 中华医学图书情报杂志

Objective To improve the utilization ratio of operating room in Affiliated Hospital of Central South Uni-versity Xiangya Medical School by providing more comprehensive reference data for the design of surgical time pre-diction and dispatch system. Methods A questionnaire was designed according to the review of literature and consul-tation of experts for investigating the surgical time influencing factors. The surgical time influencing factors were ana-lyzed by stratified sampling. Results The surgeons-related factor was the highest influencing factor while the pa-tients themselves-related factor was the lowest influencing factor in the 2-dimensional factors. The selected 38 1-dimensional factors could affect the operating time with their mean influencing value>2 . 45 . The recognition of sur-gical time influencing factors was different in different operating rooms. Conclusion There are a variety of surgical time influencing factors. However, the surgeons-related factor is the highest influencing factor. The cognition of anesthesia-related factors and surgeons-related factors differs in different operating rooms.

Comparação entre as abordagens lateral direita e mediana ventral em cadelas submetidas à ovariossalpingo-histerectomia / Comparison between the right lateral and ventral median approach in a bitch undergoing ovariosalpinghysterectomy

A fim de comparar as abordagens abdominais, pela linha mediana ventral e lateral direita em cadelas pré-púberes e adultas submetidas a ovariossalpingo-histerectomia, utilizaram-se 28 cadelas hígidas, distribuídas em dois grupos experimentais de igual número: grupo abordagem mediana ventral (AMV) e grupo abordagem lateral direita (ALD), com sete animais adultos e sete animais pré-púberes em cada grupo. O procedimento cirúrgico foi dividido em nove manobras cirúrgicas distintas, e o tempo para conclusão de cada uma delas, suas facilidades e dificuldades, assim como o tempo cirúrgico total, foram determinados. O tempo médio desde o início da incisão da pele até a entrada na cavidade peritoneal foi menor nas cadelas adultas (P≤0,001) e pré-púberes (P≤0,001) do grupo AMV, mas o tempo médio para identificação uterina foi menor nas cadelas pré-púberes (P≤0,001) do grupo ALD. O tempo cirúrgico total foi menor utilizando-se a abordagem lateral direita (grupo ALD) nas cadelas adultas (P≤0,001) e pré-púberes (P≤0,001). Seu uso não se relacionou com complicações cirúrgicas e facilitou a identificação uterina, possibilitando redução no tempo cirúrgico total. Assim, a abordagem lateral direita demonstrou ser uma alternativa segura em cadelas adultas e pré-púberes submetidas à OSH eletiva.

In order to compare the abdominal approaches, through the ventral midline and right lateral in pre-pubertal adult female dogs undergoing ovariohysterectory we used 28 otherwise healthy dogs, divided into two experimental groups of equal number: Ventral Median Approach Group (VMA) and Right Side Approach Group (RSA), with seven adult animals and seven pre-pubertal animals in each group. The surgical procedure was divided into nine different surgical maneuvers, and the time required for completion of each of them, their strengths and difficulties, as well as the total surgical time were determined. The time from the start of the skin incision to the entrance into the peritoneal cavity was lower in adult female dogs (P≤0.001) and pre-pubertal (P≤0.001) in the VAM group, but the time for uterine identification was lower in pre-pubertal female dogs (P≤ 0.001) in the RSA group. The total surgical time was shorter using the right lateral approach (RSA group) in adult (P≤ 0.001) and pre-pubertal (P≤0.001) female dogs. Thus, the right-side approach has proved to be a safe alternative in adult and pre-pubertal dogs undergoing elective OSH. Its use was not associated with surgical complications, and facilitated uterine identification, allowing a reduction in the total surgical time.

Moldes individualizados para alineación de la artroplastía primaria de rodilla / Individualized molds for alignment of primary knee arthroplasty

Introducción: Los sistemas de bloque de corte específicos (BCE) se han presentado como una interesante medida para obtener una correcta alineación en la artroplastía de rodilla, aunque se desconoce cuál de todos los métodos existentes para realizar la planificación es el adecuado. Material y métodos: Se ha diseñado un estudio prospectivo comparando dos sistemas de BCE con planificaciones diferentes (Signature con TAC + teleradiografia; Visionaire con RMN) con el sistema convencional de alineación. Se analizaron parámetros radiográficos, funcionales preoperatorios y postoperatorios, estancia hospitalaria, necesidad de transfusión, tiempo quirúrgico y complicaciones asociadas. Resultados: Un total de 10 pacientes fueron intervenidos por cada grupo. No se observaron diferencias estadísticamente significativas entre los dos sistemas de alineamiento específicos y el sistema convencional (p > 0.05), aunque se objetivó una mayor precisión con estos sistemas, siendo discretamente superior en el sistema Signature. También se observó un menor tiempo quirúrgico en los pacientes intervenidos con los BCE, ligeramente inferior en los intervenidos con el sistema Visionaire (p > 0.05). Conclusiones: Los nuevos sistemas BCE pueden ser útiles para mejorar la alineación en la artroplastía de rodilla así como disminuir el tiempo quirúrgico. A la espera de series mayores que corroboren estos datos, los autores recomiendan estos sistemas en aquellos casos en los que los sistemas convencionales no sean adecuados.

Introduction: Patient-specific cutting blocks (PSCB) have been proposed as an interesting option to achieve appropriate alignment in knee arthroplasty. However, there is no information as to which of the available planning methods is the right one. Material and methods: A prospective study was designed to compare two PSCB systems using different planning methods (Signature with CAT scan + teleradiography; Visionaire with MRI) with the standard alignment method. Radiographic and functional pre- and postoperative parameters were analyzed, together with hospital stay, blood transfusion needs, operative time and associated complications. Results: A total of 10 patients per group were operated on. No statistically significant differences were observed between both of the patient-specific alignment systems and the standard system (p > 0.05). However, greater precision was achieved with the former systems and the Signature system was slightly more accurate. Operative time was shorter in patients in whom PSCBs were used, and it was still slightly shorter in those in whom the Visionaire system was used (p > 0.05). Conclusions: The new PSCB systems may be useful to improve alignment in knee arthroplasty and reduce the operative time. While larger case series confirming these data become available, the authors recommend using these systems in cases in which the standard systems do not work properly.

A multicentre retrospective analysis of surgical effects of the 1310 Hypertensive intracerebral hemorrhage / 中华急诊医学杂志

Objective To explore the relationship between different hemorrhage position,hemorrhage volume,surgical time and outcome of treatment with surgical methods of HICH.Methods A total of 1310 patients were admitted from six hospitals from January 2004 to January 2008,the 1310 patients were divided into six groups according to different operation:craniotomy through bone flap (group A),craniotomy through small bone window (group B),stereotactic drilling drainage (group C1 and group C2),neuron-endoscopy operation (group D) and external ventricular drainage (group E),considering hemorrhage position,hemorrhage volume,surgical time and result of surgical methods were reviewed and analyzed.Results ①Craniotomy through bone flap should be selected with the case of superficial or deep hematoma volume (＞ 80 mL),median line structure distinct motion,metaphase or advanced stage of hernia of brain.②Craniotomy through small bone window and neuron-endoscopy should be selected with the case of moderate hematoma volume (50-80 mL) ③Drilling drainage should be selected with the case of small hematoma volume in superficial or deep hematoma volume (20-50 mL) ④Extemal drainage should be selected in dealing with ventricular hemorrhage.Small bone window or neuron-endoscopy should be selected in ventricular casting mould.⑤The appropriate operation time for patients with hematoma volume less than 80 mL should be 6-12 hours and large hematoma should be immediately operated to save lives.The operation time should depend on patients detail condition.Conclusions Craniotomy through bone flap was suitable for large hematoma and hernia of brain; Stereotactic drilling drainage should be selected in patients with hematoma volume less than 80mL; and the operation results in dealing with HICH would be improved via suitable operation time and surgical methods and adividual according to Hemorrhage position and Hemorrhage volume.

Asociación entre el índice de masa corporal y los resultados perioperatorios y posoperatorios en pacientes sometidas a histerectomía laparoscópica total: Medellín (Colombia) 2002-2008 / The association between body mass index and perioperative and postoperative outcomes in patients undergoing total laparoscopic hysterectomy: Medellin, Colombia 2002-2008

Objetivos: evaluar la posible asociación entre el mayor índice de masa corporal (IMC) y los resultados peri y posoperatorios en pacientes a las que se les realizó histerectomía laparoscópica total (HLT). Metodología: cohorte histórica de pacientes a quienes se les practicó HLT en un período de 5 años en un centro de referencia para endoscopia ginecológica. Fueron incluidas todas las pacientes con HLT y con la información completa. Las pacientes fueron divididas en tres grupos según su masa corporal: IMC menor de 24,9 kg/m2, normal (n = 339); IMC entre 25-29,9 kg/m2, sobrepeso (n = 243) e IMC mayor de 30 kg/m2, obesidad (n = 94). Se compararon el tiempo quirúrgico, las complicaciones, la pérdida sanguínea, la necesidad de transfusión, la tasa de laparoconversión y el tiempo de estancia hospitalaria. Los tres grupos se contrastaron por medio de la prueba ANOVA. Resultados: 676 pacientes cumplieron los requisitos para el estudio. No hubo diferencias significativas en cuanto a la pérdida sanguínea, el tiempo quirúrgico, la estancia hospitalaria, la tasa de complicaciones o de laparoconversión. Conclusión: no se encontró asociación entre el índice de masa corporal y malos resultados peri y posoperatorios.

Objectives: evaluating the possible association between body mass index (BMI) and peri-and post-operative results in patients undergoing total laparoscopic hysterectomy (TLH). Methodology: a historical cohort of patients was taken over a 5-year period; they had undergone TLH in a referral centre for gynaecological laparoscopy. All patients who had undergone TLH and about whom complete information was available were included. Patients were divided into three groups according to body mass as follows: BMI below 24.9 kg/m2: “normal” (n = 339), BMI 25 -29.9 kg/m2: “overweight” (n = 243) and BMI greater than 30 kg/m2: “obese” (n = 94). Surgical time, complications, blood loss, transfusion requirement, laparoconversion rate and length of hospital stay were compared. ANOVA was used for comparing the three groups. Results: 676 patients met the study requirements. No significant differences regarding blood loss, operating time, hospital stay, complication rate or laparoconversion were found. Conclusion: no association was found between BMI and poor results during peri-and postoperative periods.

Histerectomía laparoscópica total en la unidad de endoscopia ginecológica de la Clínica del Prado, Medellín (Colombia) 2002 - 2008 / Total laparoscopic hysterectomy at the Clínica del Prado’s Gynaecological Endoscopy Unit in Medellín, Colombia 2002 - 2008

Objetivo: describir la experiencia en la práctica de Histerectomía Laparoscópica Total (HLT) con énfasis en las complicaciones presentadas. Metodología: el presente es un estudio de cohorte histórica en el cual se incluyeron las pacientes que fueron intervenidas entre diciembre de 2002 y abril de 2008 y en quienes, además, se completó al menos 90% de la información requerida en un formulario prediseñado. Durante la investigación, se evaluaron las características sociodemográficas, las indicaciones de cirugía, el porcentaje de laparoconversión y las causas de la misma, el tiempo quirúrgico, la pérdida sanguínea estimada, el tiempo de hospitalización, el número de dosis de analgésicos requeridos, los días de incapacidad y las complicaciones intraoperatorias y postoperatorias. Resultados: en total se incluyeron 837 pacientes, cuya edad promedio fue 42,7 años. 83,8% de las mujeres eran ASA I (American Society of Anesthesiologists) y la principal enfermedad de base fue la hipertensión arterial (9,9%). En 822 de ellas, el procedimiento se llevó a cabo por laparoscopia mientras que 15 (1,7%) requirieron laparoconversión. Las indicaciones más frecuentes para la cirugía fueron miomatosis (43,8%) y hemorragia uterina anormal (36,1%). Adicional a esto, el tiempo quirúrgico promedio fue 85,9 minutos, la pérdida sanguínea media fue de 60,6 mL y la tasa total decomplicaciones llegó a ser 12,5%; de lacuales, 3,1% lo constituyeron complicaciones mayores. Conclusiones: la tasa de complicaciones de la histerectomía laparoscópica total es similar a la informada en la literatura y está acompañada de una estancia hospitalaria breve.

Objective: describing accumulated experience gained from performing Total Laparoscopic Hysterectomy (TLH) at the Clínica del Prado. Methodology: this was a descriptive, retrospective study (evidence level III) which involved patients who underwent TLH in the Gynaecological Endoscopic Unit at Clínica del Prado, Medellín, Colombia. 1,150 medical records from patients operated on between December 2002 and April 2008 were reviewed; those in which at least 90% of the data required by a predesigned instrument could be recovered were included for analysis. Main outcomes measured: demographic data, surgical indication, laparoconversion rate and causes, surgical time, estimated blood loss, uterine weight and height, time of hospital stay and complications. Results: 837 patients were included; TLH was entirely performed on 822 of them by laparoscopy whilst 15 (1.7%) required laparoconversion. The most frequent indications for surgery were fibroids (43.8%) and abnormal uterine bleeding (36.1%). Mean age was 42.7. 83.8% of the patients were ASA I (American Society of Anesthesiologists); the main comorbidity found was hypertension (9.9%). Mean surgical time was 85.9 minutes; mean estimated blood loss was 60.6 mL. The commonest histological diagnosis was fibroids (57.1%). Mean uterine weight was 180 grams and mean uterine height 10.2 cm. Complications affected 12.5% of the 837 patients, 3.1% of them being major ones.

Entrenamiento en un biosimulador y su impacto sobre la destreza en colecistectomía laparoscópica / Biosimulator training and its impact on skill in laparoscopic cholecystectomy

Objetivo: determinar el impacto educacional del entrenamiento en un biosimulador inanimado en términos de efectividad, tiempo y complicaciones, respecto a la colecistectomía laparoscópica. Material y métodos: estudio comparativo, experimental de una cohorte, prospectivo y longitudinal. Tres médicos residentes de primer año de cirugía y un interno de pregrado, fueron entrenados y evaluados en habilidades laparoscópicas elementales mediante el empleo de un biosimulador (maniquí de fibra de vidrio en el que se introducen órganos de animales ex vivo). Los sujetos fueron su propio control: realizaron un procedimiento inicial en el que se determinó tiempo quirúrgico, complicaciones y efectividad. Posteriormente observaron un corto video que mostraba el desarrollo idóneo de la colecistectomía, y en el que se identificaban las desviaciones específicas del desempeño adecuado. Posteriormente cada sujeto realizó 10 procedimientos. Resultados: no existieron diferencias en la evaluación inicial de habilidades elementales. Los individuos completaron todos los procedimientos propuestos. Las disecciones de las estructuras císticas y de la vesícula biliar fueron 61 % más rápidas al finalizar el estudio (p < 0.001); la tasa de complicación fue de 0.67 % (p <0.009). Conclusión: el entrenamiento de habilidades en cirugía endoscópica por medio de un biosimulador inanimado es mejor que el entrenamiento tradicional, ya que disminuye el tiempo quirúrgico y las complicaciones en la sala de operaciones.

OBJECTIVE: We undertook this study to determinate the educational impact of training in an inanimate biosimulator in terms of effectiveness, time and complications in performing laparoscopic cholecystectomy. METHODS: We used a comparative, experimental cohort, prospective and longitudinal. Three first-postgraduate-year residents and one pre-grade internship physician were trained and assessed in basic laparoscopic skills using a biosimulator (fiberglass [quot ]dummy[quot ] where animal organs are introduced ex-vivo). The participants acted as their own control, performing a procedure to determine surgical time, complications and effectiveness. Later they observed a short video demonstrating the suitable development of laparoscopic cholecystectomy. The video defined the specific deviations from the ideal cholecystectomy, which were considered as errors. Every procedure was videotaped, beginning with the careful dissection of cystic structures and clipping them, continuing with the dissection of the gallbladder from the liver with the standardized method. Each participant performed ten procedures. RESULTS: There were no differences in baseline assessment of basic skills. All participants completed all proposed procedures. Surgical time was 61% faster at the end of the study (p<0.001), as well as demonstrating a lower rate of complications of 0.67% (p<0.009). CONCLUSIONS: Skills training in endoscopic surgery by means of an inanimate biosimulator is superior to traditional training because it decreases surgical time and surgical complications without ethical considerations and the effect of a learning curve in the operating room.