Endoscopic Mini-or Less-Open Sublay Operation (E/MILOS) in ventral hernia repair: a minimally invasive alternative technique / Endoscopic Mini or Less Open Sublay Repair (E/MILOS) na correção das hérnias ventrais: uma alternativa técnica minimamente invasiva

ABSTRACT The ideal ventral hernia surgical repair is still in discussion1. The defect closure with a mesh-based repair is the base of surgical repair, in open or minimally invasive techniques2. The open methods lead to a higher surgical site infections incidence, meanwhile, the laparoscopic IPOM (intraperitoneal onlay mesh) increases the risk of intestinal lesions, adhesions, and bowel obstruction, in addition to requiring double mesh and fixation products which increase its costs and could worsen the post-operative pain3-5. The eTEP (extended/enhanced view totally intraperitoneal) technique has also arisen as a good option for this hernia repair. To avoid the disadvantages found in classic open and laparoscopic techniques, the MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair) concept, created by W. Reinpold et al. in 2009, 3 years after eTEP conceptualization, allows the usage of bigger meshes through a small skin incision and laparoscopic retro-rectus space dissection, as the 2016 modification, avoiding an intraperitoneal mesh placement6,7. This new technique has been called E-MILOS (Endoscopic Mini or Less Open Sublay Repair)8. The aim of this paper is to report the E-MILOS techniques primary experience Brazil, in Santa Casa de Misericórdia de São Paulo.

RESUMO O tratamento cirúrgico ideal para correção das hérnias ventrais ainda é motivo de grande discussão1. O fechamento do defeito associado a utilização de telas para reforço da parede abdominal são passos fundamentais da terapia cirúrgica, podendo ser realizados tanto pela via aberta quanto pelas técnicas minimamente invasivas2. A via aberta apresenta maiores taxas de infecção de sítio cirúrgico, enquanto o reparo laparoscópico IPOM (intraperitoneal onlay mesh) acarreta um risco aumentado de lesões intestinais, aderências e obstruções intestinais, além de requerer uso de telas de dupla face e dispositivos de fixação que encarecem o procedimento e não raro aumentam a dor no pós-operatório3-5. A técnica eTEP (extended/enhanced view totally extraperitoneal), tem ganhado importância, mostrando-se uma boa opção para a correção das hérnias ventrais também2. A fim de se evitar as desvantagens das técnicas abertas e laparoscópicas "clássicas" o conceito MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair), desenvolvido por W. Reinpold et al. em 2009, 3 anos antes do advento do eTEP, possibilita ao cirurgião o uso de telas de grandes dimensões no plano retromuscular através de uma pequena incisão na pele e dissecção laparoscópica deste espaço, conforme modificação realizada em 2016, evitando a colocação de uma tela no espaço intraperitoneal6-7. Esta nova técnica passou a se chamar EMILOS (Endoscopic Mini or Less Open Sublay Repair)8 Este artigo tem como objetivo relatar nossa experiência inicial no emprego da técnica E-MILOS no Brasil, na Santa Casa de Misericórdia de São Paulo.

Subxiphoid and subcostal arch thoracoscopic versus median sternotomy enlarged thymectomy for the treatment of myasthenia gravis complicated with thymoma: A propensity score matching study / 中国胸心血管外科临床杂志

@#Objective    To compare clinical effects of enlarged thymectomy for the treatment of myasthenia gravis (MG) complicated with thymoma via subxiphoid and subcostal arch thoracoscopic resection versus median sternotomy resection. Methods    We retrospectively analyzed the clinical data of patients with MG complicated with thymoma admitted in Tangdu Hospital of the Air Force Military Medical University between December 2011 and December 2021. Patients who underwent subxiphoid and subcostal arch thoracoscopic enlarged thymectomy were allocated to a SR group, and patients who underwent median sternotomy enlarged thymectomy were allocated to a MR group. Perioperative outcomes were compared between the two groups. Results    A total of 456 patients were collected. There were 51 patients in the MR group, including 30 males and 21 females aged 23-66 (49.5±11.8) years. There were 405 patients in the SR group, among whom 51 patients were matched to the MR group by propensity score matching, including 28 males and 23 females aged 26-70 (47.2±12.2) years. The operations were accomplished successfully in all patients, and no conversion to thoracotomy occurred in the SR group. The SR group had advantages in the operation time, intraoperative blood loss,  chest drainage duration, hospital stay time, patients’ satisfaction level, pain score and complications (all P<0.05). No statistical difference was found in the number of intraoperative lymph node dissection stations, number of intraoperative lymph nodes dissected or remission of MG between the two groups (P>0.05). Conclusion    Subxiphoid and subcostal arch thoracoscopic enlarged thymectomy and lymphadenectomy is a safe, effective and feasible minimally invasive procedure for the treatment of MG complicated with thymoma.

Cirugía fetoscópica en síndrome de banda amniótica: comunicación del primer caso exitoso en el Perú con correlación posnatal a los 6 y 12 meses de vida

El síndrome de banda amniótica (SBA) o complejo de disrupción de banda amniótica es aquella malformación congénita que ocurre como consecuencia de bridas amnióticas de etiología heterogénea, patogénesis que involucra una serie de manifestaciones clínicas fetales, tales como constricción, amputación y múltiples defectos craneofaciales, viscerales y de la pared del cuerpo. La prevalencia estimada de SBA oscila entre 1:15,000 y 1:1,200 nacidos vivos. Afecta a ambos sexos por igual. El diagnóstico prenatal puede sospecharse tan pronto como el primer trimestre tardío, cuando las imágenes por ultrasonido detectan anillos de constricción, amputaciones de extremidades y/o defectos craneofaciales. La terapia prenatal puede ofrecer una alternativa de tratamiento con la liberación de anillos de constricción bajo fetoscopia en aquellos fetos que se verían beneficiados con el procedimiento.

Amniotic band syndrome (ABS) or amniotic band disruption complex is a congenital malformation that occurs because of amniotic flanges of heterogeneous etiology, a pathogenesis that involves a series of fetal clinical manifestations, such as constriction, amputation, and multiple craniofacial, visceral and wall defects. The estimated prevalence of ABS ranges from 1:15.000 to 1:1.200 liveborn. It affects both sexes equally. Prenatal diagnosis may be suspected as early as the late first trimester when ultrasound imaging detects constriction rings, limb amputations and/or craniofacial defects. Prenatal therapy may offer an alternative treatment with release of constriction rings through fetoscopy in those fetuses that would benefit from the procedure.

Cirugía torácica por puerto único. Experiencia inicial / Uniportal thoracic surgery. Initial Experience / Cirurgia torácica de portal único. Experiência inicial

Resumen: Introducción: La cirugía torácica videoasistida es hoy un procedimiento aceptado por ser seguro, factible y efectivo para el tratamiento de casi todas las enfermedades del tórax. En el 2010 se comienzan a publicar procedimientos complejos por un solo puerto, con una gran expansión a nivel mundial. Esta vía de abordaje es al menos equiparable a la multiportal en lo que concierne a resultados en el postoperatorio, o incluso mejor en lo referente a dolor, neuralgia intercostal y estadía hospitalaria. Realizamos un análisis retrospectivo de los procedimientos uniportales entre septiembre de 2018 y agosto de 2020. Resultados: 40 pacientes fueron sometidos a procedimientos por vía uniportal torácica. De estos, 18 pacientes fueron sometidos a resecciones anatómicas (45%), 19 a resecciones atípicas (no anatómicas), una timectomía y dos biopsias pleurales. Se realizaron 12 lobectomías (30%), 3 neumonectomías (7,5%) y 3 segmentectomías (7,5%). Se convirtieron a cirugía abierta 6 pacientes (15%) y falleció un paciente por sepsis respiratoria. En cuanto a las complicaciones tuvimos en las resecciones anatómicas ocho complicaciones (cinco mayores), en las no anatómicas 4 complicaciones (2 mayores). Del postoperatorio un paciente con dolor de más de un mes de evolución, uno con parestesias en el territorio intercostal y dos con disnea. Las resecciones anatómicas tuvieron una media de internación de 8 días y 5.8 días de drenaje pleural, mientras que las no anatómicas 5,5 días de internación y 3.3 días de drenaje pleural. Conclusión: la cirugía uniportal es segura y practicable en centro de bajo volumen.

Abstract: Introduction: video assisted thoracic surgery is widely accepted today as a safe, feasible and effective procedure to treat almost all thoracic conditions. In 2010, uniportal complex procedures begin to appear in scientific publications around the world, evidencing major expansion. This surgical approach is at least comparable to the multiportal approach in terms of postoperative results or even in regards to pain, intercostal neuralgia and length of hospital stay. We performed a retrospective study of uniportal procedures between September 2018 and August 2020. Results: 40 patients underwent uniportal thoracic surgeries. 18 of these were subject to anatomic resections (45%), 19 to atypical resection (non-anatomic), one thymectomy and two pleural biopsies, 12 lobectomies (30%), 3 neumomectomies (7,5%) and 3 segmentomectomies (7,5%). In 6 patients the procedure was converted to an open surgery (15%) and one patient died for respiratory sepsis. As to the occurrence of complications, 8 complications were seen in anatomic resections (5 major complications) and 4 complications in non-anatomic resections (2 major complications). One patient reported pain that lasted over one week in the postoperative stage, another one referred paresthesia and two reported dyspnea. Length of stay in the hospital was 8 days in anatomic resections and 5.8 days of pleural drainage, whereas in non-anatomic resections it was 5.5 and 3.3 respectively. Conclusion: uniportal surgery is safe and feasible in a relatively small health center.

Resumo: Introdução: a cirurgia torácica videoassistida é hoje um procedimento aceito por ser seguro, viável e eficaz para o tratamento de quase todas as doenças torácicas. Em 2010, começaram a ser publicados procedimentos complexos por porta única com grande expansão mundial. Essa abordagem é pelo menos comparável à abordagem multiporta em termos de resultados pós-operatórios ou ainda melhor em termos de dor, neuralgia intercostal e internação hospitalar. Realizamos uma análise retrospectiva dos procedimentos uniportais entre setembro de 2018 e agosto de 2020. Resultados: 40 pacientes foram submetidos a procedimentos por via torácica uniportal. Destes, 18 pacientes foram submetidos a ressecções anatômicas (45%), 19 foram submetidos a ressecções atípicas (não anatômicas), uma timectomia e duas biópsias pleurais. Foram realizadas 12 lobectomias (30%), 3 pneumectomias (7,5%) e 3 segmentectomias (7,5%). Seis pacientes (15%) foram convertidos para cirurgia aberta e um paciente morreu de sepse respiratória. Em relação às complicações, tivemos 8 complicações (5 maiores) nas ressecções anatômicas, 4 complicações (2 maiores) nas ressecções não anatômicas. No pós-operatório, um paciente com dor há mais de um mês de evolução, um com parestesia em território intercostal e dois com dispneia. As ressecções anatômicas tiveram internação média de 8 dias e 5,8 dias de drenagem pleural, enquanto as não anatômicas tiveram 5,5 dias de internação e 3,3 dias de drenagem pleural. Conclusão: a cirurgia uniportal é segura e praticável em um centro de baixo volume.

Resultados de la cirugía endoscópica de la glándula tiroides por vía transaxilar en Perú / Results of transaxillary endoscopic surgery of the thyroid gland in Peru

RESUMEN Objetivo: Describir los resultados de la tiroidectomía endoscópica transaxilar sin insuflación de CO2 en Perú. Material y métodos: Estudio descriptivo, retrospectivo de una serie de casos basado en la revisión de las historias clínicas de los pacientes con tumor tiroideo sometidos a tiroidectomía endoscópica transaxilar sin insuflación de CO entre noviembre 2014 y marzo 2017, en instituciones públicas y privadas del sistema nacional de salud de la ciudad de Lima. Resultados: Se realizaron 24 tiroidectomías endoscópicas, de las cuales 15 fueron hemitiroidectomia, 8 tiroidectomía total y una tiroidectomía subtotal. El tiempo operatorio promedio fue de 193,8 minutos. Las complicaciones más frecuentes fueron el hematoma postoperatorio (12,5%) seguido de la hipocalcemia transitoria (8,3%); ningún caso presentó lesión del plexo braquial. Conclusiones: La tiroidectomía endoscópica por vía transaxilar es un procedimiento seguro, factible de realizar en instituciones de salud que cuenten con el equipamiento de cirugía video endoscópica, que podría indicarse en determinados pacientes.

SUMMARY Objective: To describe the results of transaxillary endoscopic surgery of the thyroid gland without insufflating CO2 in Peru. Methods: A retrospective case series based of chart review of patients with thyroid cancer undergoing transaxillary endoscopic surgery of the thyroid gland without insufflating CO2 from November 2014 to March 2017 in public and private institutions in Lima. Results: 24 transaxillary endoscopic procedures were performed, 15 of which were hemithyroidectomies, 8 were total thyroidectomies and one subtotal thyroidectomy. Mean operating time was 193.8 minutes. The most common complication was post operatory hematoma (12.5%) followed by transient hypocalcemia (8.3%), no lesions of the brachial plexus were observed. Conclusions: Transaxillary endoscopic surgery of the thyroid gland is a safe and feasible procedure to be performed in equipped centers.

Valor de la colangiografía transcística videolaparoscópica en pacientes con sospecha de coledocolitiasis / Value of the intraoperatory cholangiography videolaparoscopic in patient with choledocholithiasis suspicion

RESUMEN Fundamento: la colangiografía videolaparoscópica se ha convertido en un método diagnóstico y terapéutico en la coledocolitiasis. Objetivos: evaluar el valor de la colangiografía transcística en pacientes con sospecha de coledocolitiasis. Métodos: se realizó un estudio de tipo analítico para interpretar y verificar resultado con el objetivo de analizar la correspondencia entre sospecha de coledocolitiasis y resultado de la colangiografía transcística videolaparoscópica, en el Hospital Militar Clínico Quirúrgico Docente Octavio de la Concepción de la Pedraja, desde abril de 2012 hasta diciembre de 2018. La muestra estuvo compuesta por 62 pacientes con sospecha de coledocolitiasis. Resultados: en el estudio, predominó la sospecha moderada de coledocolitiasis en el sexo femenino a expensas de los estudios ecográficos y de laboratorio, específicamente el aumento en el valor de la fosfatasa alcalina y la dilatación del conducto biliar común entre 8 y 10 mm. Los resultados más frecuentes del proceder fueron; el conducto biliar principal sin alteraciones y adherencias vesiculares. El proceder se extendió por más de 60 minutos en más de la mitad de los casos. La estadía en el hospital después del procedimiento fue menos de tres días y prevaleció un excelente resultado. Conclusiones: las mujeres poseen un índice mayor de sospecha de coledocolitiasis y en un rango moderado. Los criterios de laboratorios y ecográficos prevalecen en estos pacientes, sin embargo, no son específicos de coledocolitiasis. La vía biliar principal sin alteraciones y las adherencias vesiculares son los resultados más frecuentes durante el proceder. El tiempo quirúrgico promedio en este proceder es mayor a 60 minutos. La estadía hospitalaria después del proceder es por lo general menor de tres días. El resultado final con este proceder fue excelente.

ABSTRACT Background: videolaparoscopic cholangiography has become a diagnostic and therapeutic method in choledocholithiasis. Objective: to evaluate the value of transcystic cholangiography in patients with suspected choledocholithiasis. Methods: an analytical study was carried out to interpret and verify the result with the objective of analyzing the correspondence between suspected choledocolithiasis and the result of translastic videolaparoscopic cholangiography, at the Octavio Teaching Surgical Clinical Military Hospital of La Concepción de la Pedraja, since April, 2012 to December, 2018. The sample consisted of 62 patients with suspected choledocolithiasis. Results: in the study, moderate suspicion of choledocholithiasis prevailed in the female sex at the expense of ultrasound and laboratory studies, specifically the increase in the value of alkaline phosphatase and dilation of the common bile duct between 8 and 10 millimeters. The most frequent results of the procedure were; the main bile duct without alterations and vesicular adhesions. The procedure extended for more than 60 minutes in more than half of the cases. The hospital stay after the procedure was less than three days and an excellent result prevailed. Conclusions: women have a higher index of suspicion of choledocholithiasis and in a moderate range. Laboratory and ultrasound criteria prevail in these patients, however, they are not specific to choledocholithiasis. The main bile duct without alterations and vesicular adhesions are the most frequent results during the procedure. The average surgical time in this procedure is more than 60 minutes. The hospital stay after proceeding is usually less than three days. The final result with this procedure is excellent.

The Effect of the Increase in General Surgery Residency Openings in Brazil / O Reflexo do Aumento de Vagas da Residência de Cirurgia Geral no Brasil

Abstract: Introduction: In recent years, there has been an increase in the number of medical residency programs in all regions of Brazil, only in the last 4 years, from 2014 to 2018, there was an increase from 18,953 general spots offered for the first year of medical residency to 26,094, 37% more, this was also observed in General Surgery Residencies around Brazil. As a result, the number of general surgeons has increased substantially, from 12,430 in 2008 to 34,065 in 2018, an absolute percentage increase of 174%. These new surgeons are bringing with them their theoretical and practical knowledge already updated, regarding new techniques and surgical modalities. In this context, in the last 2 decades, video-assisted surgery has become the choice for numerous procedures in Brazil and in the World, considering its benefits for patients, such as less postoperative hospital stay and less metabolic response to surgical trauma, for example. The current study correlates the data between the increase in the number of spots in medical residency programs, related to the graduation of new surgeons in Brazil, to the increase of videolaparoscopic surgeries in the public health system. Methodology: Review and online analysis of the national electronic public health registry database - DATASUS. The most performed Surgeries in Brazil were chosen for our data analysis. Results: The results were divided into five geographically distributed areas in Brazil. At the end of the current study, the number of video-assisted surgeries increased by 233%, accompanied by a 63% increase in the number of medical residency openings and a 174% absolute increase in the number of new surgeons in Brazil at the same period. Conclusion: The current study showed that the increase in the number of video-assisted surgeries in the country is related to the exponential increase in the number of medical residency spots and, consequently, to the number of new graduated general surgeons. This increase occurs more and more in a context of videolaparoscopic techniques, revealing multiple benefits already recognized for patients. We could conclude, therefore, that the increase in the number of medical residencies in general surgery - which are increasingly teaching videolaparoscopic techniques - has contributed as a complementary factor to the increase in the number of video-assisted surgeries observed in all regions of Brazil.

Resumo: Introdução: Nos últimos anos, houve um aumento no número de vagas de residência médica em todas as regiões do Brasil. Apenas nos últimos quatro anos, de 2014 a 2018, houve um aumento de 18.953 vagas gerais ofertadas para o primeiro ano de residência médica para 26.094, 37% a mais, o que foi acompanhado também pela área de cirurgia geral. Em consequência, o número de cirurgiões gerais vem aumentando substancialmente, de 12.430 em 2008 para 34.065 em 2018, um aumento percentual absoluto de 174%. Esses novos cirurgiões vêm trazendo consigo seus conhecimentos teóricos e práticos já atualizados, em sua maioria, de novas técnicas e modalidades cirúrgicas. Nesse contexto, nas últimas duas décadas a cirurgia videoassistida vem se tornando a via de escolha para inúmeros procedimentos no Brasil e no mundo, tendo em vista seus benefícios para os pacientes, tais como menor permanência hospitalar no pós-operatório e menos resposta metabólica ao trauma cirúrgico. Este estudo correlaciona o aumento do número de vagas em residência médica e consequentemente de novos cirurgiões ao aumento de cirurgias videolaparoscópicas no sistema público de saúde. Metodologia: Os dados para revisão foram extraídos do Departamento de Informática do Sistema Único de Saúde (Datasus). Escolheram-se as cirurgias com maior frequência para análise dos dados. Resultados: Os resultados foram divididos nas cinco áreas geograficamente distribuídas pelo Brasil. Ao final do estudo atual, demonstrou-se que o número de cirurgias videoassistidas aumentou em 233%, acompanhado pela elevação de 63% no número de vagas de residência médica e acréscimo de 174% no número de novos cirurgiões no Brasil, no mesmo período. Conclusão: O atual estudo demonstrou que o aumento do número de cirurgias videoassistidas no país está relacionado diretamente com o aumento exponencial do número de vagas de residência médica e, por consequência, do número de novos cirurgiões gerais. A formação desses novos cirurgiões gerais ocorre, cada vez mais, num contexto de técnicas videolaparoscópicas que trazem consigo inúmeros benefícios já reconhecidos para os pacientes. Conclui-se, portanto, que o acréscimo no número de vagas de residências médicas em cirurgia geral - que cada vez mais empregam os ensinamentos em técnicas videolaparoscópicas - tem contribuído como fator complementar para o aumento do número de cirurgias videoassistidas observado em todas as regiões do Brasil.

Comparison of the effect of ultrasound-guided thoracic paravertebral nerve block and intercostal nerve block for video-assisted thoracic surgery under spontaneous-ventilating anesthesia

SUMMARY OBJECTIVE The aim of the current study was to compare the efficacy of two different techniques for blocking chest nerves during video-assisted thoracic surgery (VATS) under spontaneous-ventilating anesthesia. METHODS One hundred patients were recruited in this study and divided into two groups. The first, P group, underwent the TPVB approach; the second, I group, underwent the ICNB approach. Then, the rate of clinical efficacy, duration of the block procedure, and its complications were recorded for comparison of the effect of the two approaches. RESULTS No difference was found in the clinical effect of chest nerve blocks between the two groups. Two patients in the ICNB group were converted to general anesthesia due to severe mediastinal flutter (grade three). The number of patients who had grade one mediastinal flutter in the TPVB group was significantly higher than in the ICNB group. Vascular puncture was detected in four patients in the ICNB group and in one patient in the TPVB group. No other complications were observed. CONCLUSIONS No difference was found regarding the clinical efficacy in the two groups. However, ultrasound-guided TPVB was superior to ultrasound-guided ICBN during VATS for pulmonary lobectomy under spontaneous-ventilating anesthesia. Additionally, vascular puncture should receive more attention.

RESUMO OBJETIVO O objetivo do presente estudo é comparar a eficácia de duas técnicas diferentes para o bloqueio nervoso torácico durante cirurgia torácica vídeo-assistida (CTVA) e anestesia com ventilação espontânea. METODOLOGIA Cem pacientes foram incluídos no estudo e divididos em dois grupos. Em um (grupo P), foi utilizada a abordagem de BPVT e no outro (grupo I), a abordagem de BIC. Então, a taxa de eficácia clínica, duração do procedimento de bloqueio e suas complicações foram registradas para a comparação do efeito das duas abordagens. RESULTADOS Nenhuma diferença foi observada no efeito clínico do bloqueio nervoso torácico entre os dois grupos. Dois pacientes no grupo de BIC foram convertidos para anestesia geral devido a fibrilação mediastinal grave (grau três). O número de pacientes com fibrilação mediastinal de grau um no grupo de BPVT foi significativamente maior do que no grupo de BIC. Perfuração vascular foi detectada em quatro pacientes do grupo de BIC e em um do grupo de BPVT. Não foram observadas outras complicações. CONCLUSÃO Não houve diferença de eficácia clínica entre os dois grupos. No entanto, BPVT guiado por ultrassom foi superior ao BIC guiado por ultrassom durante CTVA para lobectomia pulmonar com anestesia em ventilação espontânea. Além disso, deve-se prestar mais atenção quanto à perfuração vascular.

Use of simulators in video laparoscopic surgery in medical training: a prospective court study with medicine academic at a university in Southern Brazil / Uso de simuladores em cirurgia videolaparoscópica na formação médica: estudo prospectivo de coorte com acadêmicos de medicina de uma universidade no Sul do Brasil

ABSTRACT Introduction: the onset of minimally invasive surgery, such as laparoscopic surgery, was accompanied by an increased frequency of complications, many of which were life-threatening. With the objective of minimizing morbidity and mortality and accelerating the learning curve, video laparoscopic surgery simulators were developed to improve the psychomotor skills required for these procedures. Objective: to compare the performance of second year medical students of the Lutheran University of Brazil, in simulated videolaparoscopic surgeries performed at the Realistic Simulation Center of the Faculty of Health Sciences of Porto Alegre. Method: prospective cohort study with 16 medical students with no prior experience in video-surgery simulation. The students performed simulated exercises and were evaluated regarding Coordination, Navigation by Instrument and Time in the accomplishment of the procedures. Results: the sample consisted of 69% women and 31% men with a mean age of 23.2 years. The students obtained better results in the second simulation application. The skill in Navigation by Instrument task was the one that showed the best evolution in the studied group. The Total Time in the accomplishment of the procedures was the parameter with greater difference between the successive simulations. Conclusion: medical students presented a significant improvement in their performance with the repetition of the simulation exercises, demonstrating that the Laparoscopic Surgery Simulators are a promising tool in medical training and development of surgical skills.

RESUMO Introdução: o início da cirurgia minimamente invasiva, como a cirurgia laparoscópica, foi acompanhado por frequência aumentada de complicações, muitas com risco de morte. Com o objetivo de minimizar a morbidade e mortalidade e acelerar a curva de aprendizado, foram desenvolvidos simuladores de cirurgia videolaparoscópica para aprimoramento de habilidades psicomotoras necessárias nestes procedimentos. Objetivo: comparar o desempenho de acadêmicos do segundo ano de medicina da Universidade Luterana do Brasil, na realização de cirurgias videolaparoscópicas simuladas, feitas no Centro de Simulação Realística da Faculdade de Ciências da Saúde de Porto Alegre. Método: estudo prospectivo de coorte com 16 alunos de Medicina sem experiência prévia em simulação de vídeocirurgia. Os alunos realizaram exercícios simulados e foram avaliados quanto a Coordenação, Navegação por Instrumento e Tempo na Realização dos Procedimentos. Resultados: a amostra foi composta por 69% de mulheres e 31% de homens com média de idade de 23,2 anos. Os acadêmicos obtiveram melhora dos resultados na segunda aplicação da simulação. A habilidade na tarefa Navegação por Instrumento foi a que teve melhor evolução no grupo de alunos avaliados. O Tempo Total na realização dos procedimentos foi o parâmetro com maior diferença entre as simulações sucessivas. Conclusão: os acadêmicos de Medicina apresentaram expressiva melhora de desempenhos com a repetição dos exercícios de simulação, demonstrando que os Simuladores de Cirurgia Videolaparoscópica são ferramentas promissoras no treinamento de habilidades cirúrgicas na formação médica.

Treatment of Blowout fracture with video-assisted surgery / Tratamento de fratura Blowout com auxílio de vídeo-cirurgia

ABSTRACT Posterior fractures of the orbital floor are challenging, since an incomplete visualization of the defect through conventional surgical accesses may compromise the surgical outcome. The use of the endoscope as an auxiliary method during orbital reconstructions may be considered as a tool of considerable importance, mainly due to the visualization of the whole extension of fracture and adaptation of meshes or bone grafts. This study aims to report a clinical case of a patient diagnosed with extensive blowout fracture showing diplopy, enophthalmos, and ophthalmoplegia in supraversion, who underwent a subciliary approach combined with transantral video assisted surgery. There were no intercurrences on the procedure. Currently, patient has 1 year of follow up, with reestablished orbital function and architecture.

RESUMO As fraturas posteriores do assoalho orbital são desafiadoras, visto que a incompleta visualização do defeito por meio dos acessos cirúrgicos convencionais poderá comprometer o resultado cirúrgico. O uso do endoscópio como método auxiliar durante as reconstruções orbitais pode ser considerado uma ferramenta de grande importância principalmente para visualização de toda a extensão da fratura e adaptação das malhas ou enxertos ósseos. Este trabalho tem como objetivo relatar um caso clínico de um paciente diagnosticado com uma extensa fratura blowout apresentando clinicamente diplopia, enoftalmo e oftalmoplegia em supraversão, o qual foi submetido a tratamento através da abordagem subciliar combinada com a cirurgia vídeo-assistida transantral. O procedimento foi realizado sem intercorrências, estando o paciente com 1 ano de acompanhamento, com função e arquitetura orbital restabelecidos.

Comparison of renal function after robot - assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy

ABSTRACT Purpose: To investigate the effect of robot assisted laparoscopic radical prostatectomy (RALP) and open retropubic radical prostatectomy (RRP) on early renal function in this study. Materials and Methods: Preoperative and postoperative urea, creatinine, Hb, eGFR values of patients who had undergone RALP and RRP with prostate cancer (PCa) diagnosis were recorded in our clinic. The percentages of change in these values are calculated. Preoperative and postoperative urea, creatinine, Hb and eGFR changes were compared with each other. Student-t test was used for intergroup comparison, and paired sample t test was used to compare changes between preoperative and postoperative values of the same group. Results: There were 160 and 93 patients in the RALP and RRP group, respectively. In the RALP group, postoperative urea and creatinine increased significantly compared to preoperative baseline values while eGFR was decreased (p = 0.0001, p = 0.001, p = 0.0001, respectively). Except for Hb in the RRP group, the changes in these values were statistically insignificant (p = 0.50, p = 0.75, p = 0.30, respectively). Conclusions: We should be more careful when we perform RALP in patients at risk of impaired renal function despite being a minimally invasive surgical method with superior visual characteristics.

Bronchus perforation by EZ-Blocker™ endobronchial blocker during esophageal resection after neoadjuvant chemoradiation: a case report / 대한마취과학회지

BACKGROUND: Double-lumen tubes (DLT) and endobronchial blockers (EB) are used for one-lung ventilation in thoracic surgery. More complications are seen when using DLT when compared to EB, while major complications are rarely seen. CASE: This case report describes a perforation of the right mainstem bronchus by an EZ-Blocker EB in a patient undergoing a minimally invasive esophagectomy after neoadjuvant chemoradiation. CONCLUSIONS: We advise to insert an EZ-Blocker™ EB with caution and only under direct bronchoscopic visualization, especially in previous irradiated patients.

Early efficacy of endoscopic laminectomy and traditional hemilaminectomy for lumbar spinal stenosis / 中华骨科杂志

Objective@#To compare the clinical effects of endoscopic laminectomy with traditional hemilaminectomy for lumbar spinal stenosis.@*Methods@#From January 2016 to April 2017, 61 patients with lumbar spinal stenosis were treated surgi-cally. Percutaneous endoscopic laminectomy was performed in 32 patients (minimally invasive group), including 13 males and 19 females, aged 38-76 years, with an average age of 58.47±7.51 years. Twenty-nine patients (open group) underwent hemilaminecto-my, including 11 males and 18 females, aged 38-75 years, with an average age of 57.17±9.99 years. The operation time, bleeding, incision length, bedridden time and hospitalization time were recorded. Visual analogue scale(VAS), Oswestry disability index (ODI), dural sac cross-sectional area (DSCA), ventral intervertebral space height (VH), dorsal intervertebral space height (DH) and lumbar mobility (range of motion, ROM) were compared between the two groups.@*Results@#All of 61 patients were followed up for 14 to 27 months, with an average of 19.2±2.95 months. The operation time was 60.88±6.49 min in the minimally invasive group, and 52.07±9.45 min in the open group (t=4.277, P=0.000). The blood loss of minimally invasive group was 55.63±10.14 ml, and that of open group was 78.79±12.58 ml (t=7.952, P=0.000). The incision length of minimally invasive group was 23.31±4.56 mm, and open group 82.59±7.66 mm (t=12.047, P=0.000). Bed rest time was 21.97±6.42 h in minimally invasive group and 78.79±12.58 h in open group (t=12.047, P=0.000). The hospitalization time of the minimally invasive group was 8.53±2.75 d and the open group 11.34±3.12 d (t=3.745, P=0.000). All these parameters had statistical significance (P<0.05). At the last follow-up, the VAS score of minimally invasive group was 1.06±0.56, and the open group was 1.14±0.74 (t=0.469, P=0.634). ROM of open group was 5.66±1.12 degree, and ROM of minimally invasive group was 5.56±1.13 degree (t=0.140, P=0.710), VH of minimally invasive group was 14.75±2.81 mm, and open group was 14.44±2.89 mm (t=0.181, P=0.672). There was no significant difference between the two groups for these parameters. At the last follow-up, ODI score was 13.25%±1.08% in the minimally invasive group and 14.28%±2.10% in open group (t=5.911, P=0.018). DSCA score was 108.56±8.69 mm2 in the minimally invasive group, and 117.28±11.09 mm2 in open group (t=11.774, P=0.001). There were significant differences between the two groups for ODI and DS-CA.@*Conclusion@#Both endoscopic and open laminectomy have excellent clinical effects on lumbar spinal stenosis. Endoscop-ic laminectomy has the advantages of less local trauma, less damage to the stability of the lumbar spine and faster recovery. However, there's a higher technical requirement for endoscopic spine surgery.

Early efficacy of endoscopic laminectomy and traditional hemilaminectomy for lumbar spinal stenosis / 中华骨科杂志

Objective To compare the clinical effects of endoscopic laminectomy with traditional hemilaminectomy for lumbar spinal stenosis. Methods From January 2016 to April 2017, 61 patients with lumbar spinal stenosis were treated surgi?cally. Percutaneous endoscopic laminectomy was performed in 32 patients (minimally invasive group), including 13 males and 19 females, aged 38-76 years, with an average age of 58.47±7.51 years. Twenty?nine patients (open group) underwent hemilaminecto?my, including 11 males and 18 females, aged 38-75 years, with an average age of 57.17±9.99 years. The operation time, bleeding, incision length, bedridden time and hospitalization time were recorded. Visual analogue scale(VAS), Oswestry disability index (ODI), dural sac cross?sectional area (DSCA), ventral intervertebral space height (VH), dorsal intervertebral space height (DH) and lumbar mobility (range of motion, ROM) were compared between the two groups. Results All of 61 patients were followed up for 14 to 27 months, with an average of 19.2±2.95 months. The operation time was 60.88±6.49 min in the minimally invasive group, and 52.07±9.45 min in the open group (t=4.277, P=0.000). The blood loss of minimally invasive group was 55.63±10.14 ml, and that of open group was 78.79±12.58 ml (t=7.952, P=0.000). The incision length of minimally invasive group was 23.31±4.56 mm, and open group 82.59±7.66 mm (t=12.047, P=0.000). Bed rest time was 21.97±6.42 h in minimally invasive group and 78.79± 12.58 h in open group (t=12.047, P=0.000). The hospitalization time of the minimally invasive group was 8.53±2.75 d and the open group 11.34±3.12 d (t=3.745, P=0.000). All these parameters had statistical significance (P<0.05). At the last follow?up, the VAS score of minimally invasive group was 1.06±0.56, and the open group was 1.14±0.74 (t=0.469,P=0.634). ROM of open group was 5.66±1.12 degree, and ROM of minimally invasive group was 5.56±1.13 degree (t=0.140, P=0.710), VH of minimally invasive group was 14.75±2.81 mm, and open group was 14.44±2.89 mm (t=0.181, P=0.672). There was no significant difference between the two groups for these parameters. At the last follow?up, ODI score was 13.25%±1.08% in the minimally invasive group and 14.28% ± 2.10% in open group (t=5.911, P=0.018). DSCA score was 108.56 ± 8.69 mm2 in the minimally invasive group, and 117.28±11.09 mm2 in open group (t=11.774, P=0.001). There were significant differences between the two groups for ODI and DS?CA. Conclusion Both endoscopic and open laminectomy have excellent clinical effects on lumbar spinal stenosis. Endoscop?ic laminectomy has the advantages of less local trauma, less damage to the stability of the lumbar spine and faster recovery. However, there's a higher technical requirement for endoscopic spine surgery.

New trends in translational microsurgery

Abstract Technological advances such as optical instruments and surgical tools have enabled the considerable contributions of microsurgery to surgical therapies. Accordingly, surgical therapeutics has provided the latest information across a wide range of medical specialties, including immunology and pharmacology, despite specialization according to organs and organ systems. The International Society for Experimental Microsurgery, an academic organization, has utilized experimental microsurgery technology in the identification of curative concepts for diseases that remain difficult to treat. For this publication to mark the 32nd anniversary of the Brazilian Surgical Society, I introduced the following types of technology related to the further development of microsurgical technological innovations in the future: high-resolution three-dimensional (3D) video and touch-sensitive microsurgery robots.

Tiroides ectópica dual hiperfuncionante: abordaje quirúrgico dual / Dual hyperfunctioning thyroid ectopia: dual surgical approach

RESUMEN Paciente de 36 años en tratamiento de leucemia mieloide crónica con nilotinib a quien se le diagnostica hipertiroidismo por síntomas clínicos y exámenes de laboratorio. Se inicia tratamiento con metimazol más propanolol. Los estudios imagenológicos muestran un tejido ectópico tiroideo cervical infrahiodeo lateralizado a la izquierda y un nódulo en la base de la lengua. Presentó toxicidad hepática atribuida al tratamiento por lo que se decide extirpación quirúrgica de tiroides ectópica dual. Por la edad de la paciente y preocupación acerca del resultado estético, se realiza una tiroidectomía videoasistida por via axilar de la tiroides ectópica cervical y una resección transoral de la tiroides ectópica lingual. La patología confirma tejido tiroideo en ambas localizaciones sin signos de malignidad. La paciente se recuperó sin complicaciones y sin cicatriz cervical.

ABSTRACT A 36-year-old female patient with chronic myeloid leukemia being treated with nilotinib who was diagnosed with hyperthyroidism both on clinical and laboratory examination is presented. Imaging studies found left lateralized ectopic thyroid tissue of infrahyoid localization and a nodule at the base of the tongue. Hepatic toxicity was attributed to medical treatment, surgical removal of the dual thyroid ectopia was proposed. Due to the patients age and cosmetical concerns, a minimally invasive surgery was undertaken thru a video assisted transaxillary thyroidectomy for the cervical thyroid ectopia and a video assisted trans oral approach for the lingual thyroid ectopia. Post op pathology confirmed thyroid tissue at both locations and also excluded malignancy. The patient fully recovered without any complicaction and witout a residual cervical scar.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

ABSTRACT Objectives The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). Materials and methods From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. Results All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). Conclusions The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions / Eficácia da terapia tópica de irrigação com seringa e a influência da concha média na penetração sinusal de soluções

Abstract Introduction: Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used. Objective: To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process Methods: Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study. Results: Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p < 0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p = 0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p = 0.27). Conclusion: Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Resumo Introdução: Terapias tópicas são a melhor opção de tratamento pós-operatório da rinossinusite crônica, principalmente com alto volume e pressão, como os squeeze bottles. Porém, não são opções disponíveis na realidade brasileira, na qual frequentemente são usados seringas para a irrigação. Objetivo: Averiguar a eficácia da terapia tópica nasossinusal com seringa e a influência da concha média nesse processo. Método: Estudo de intervenção em modelos de treinamento (S.I.M.O.N.T.). Após dissecção padronizada, três intervenções foram feitas (spray nasal 4 puffs, seringa de 60 mL e squeeze bottle de 240 mL) com a concha média normal e suturada. Foram capturadas imagens de cada seio após as intervenções, totalizando 144 imagens. As imagens foram classificadas por 10 avaliadores de acordo com a quantidade de volume residual de zero a 3, sendo zero e 1 considerados penetração ruim e 2 e 3, penetração boa. As 1.440 avaliações foram utilizadas neste estudo. Resultados: Considerando todas as situações de concha média, a quantidade de penetrações boas foi de 8,1% para spray; 68,3% para seringa e 78,3% para squeeze (p < 0,0001). Considerando todos os tipos de intervenção, a concha média normal obteve 48,2% de penetrações boas e a concha média suturada, 55% (p = 0,01). Considerando apenas concha média suturada, não houve diferença entre as intervenções seringa e squeeze (76,3% vs. 80,4%; p = 0,27). Conclusão: A terapia tópica de irrigação com seringa de 60 mL foi mais eficaz do que com spray nasal. O status da concha média mostrou-se fundamental e influenciou a terapia tópica. A irrigação com seringa foi tão eficaz quanto a com squeeze bottle quando a concha média foi suturada ao septo nasal.

The role of pneumoperitoneum in the glomerular filtration in an experimental model with 2/3 reduction of the renal mass / O papel do pneumoperitônio na função renal em um modelo experimental de redução de 2/3 do parênquima renal

Objective: To evaluate the influence of the CO2 pneumoperitoneum in the glomerular filtration in a rat model with a 2/3 reduction of renal parenchyma. Methods: Adult Wistar male rats (n = 50) were subjected to right nephrectomy and a 2/3 ligature of the renal left vascular branch. Animals were randomly distributed as follows: GI (n = 10) - simulated, GII (n = 20) ­ 8 mm Hg pneumoperitoneum, and GIII (n = 20) ­ 15 mm Hg pneumoperitoneum. After two (GIIA and GIIIA) and three (GIIB and GIIIB) hours of insufflation, and one hour of disinsufflation, they were evaluated for the following aspects: mean blood pressure (MBP), microhematocrit, urinary volume and inulin clearance. Results: The microscopic aspects showed signs of glomerulosclerosis that caused proteinuria. Renal function with 8 mm Hg pneumoperitoneum after two hours of disinsufflation ( % = 202.68) was better than after three hours ( % = 10.89). With 15 mm Hg pneumoperitoneum, the renal function was damaged by both procedures, that is, two ( % = -3.57) and three hours ( % = -3.25). Conclusion: Inulin clearance evidenced renal insufficiency in the model with a 2/3 reduction of renal mass, and depending on both the increase of the exposure time and the pressure intensity, it can be more intensified.

Este estudo tem como objetivo avaliar a influência do pneumoperitônio induzido CO2 sobre a função renal em um modelo em ratos com redução de 2/3 de sua massa renal. Em relação à metodologia, ratos Wistar (n=50), machos, adultos, foram submetidos à nefrectomia direita e ligadura de 2/3 do pedículo vascular renal esquerdo. A seguir, foram aleatoriamente distribuídos em GI (n=10)­ Simulado, GII (n=20) com pneumoperitônio de 8 mmHg e GIII (n=20) compneumoperitônio de 15 mmHg, por uma hora. Após duas (GIIA e GIIIA) e três (GIIB e GIIIB) horas da desinsuflação, foram avaliadas a pressão arterial média (PAM), micro -hematócrito, volume urinário e clearance da inulina. Os resultados da microscopia mostraram que o rim remanescente apresentou sinais de glomeruloesclerose, caracterizada pela proteinúria. A função renal com pneumoperitônio de 8 mmHg após duas horas da insuflação ( %=202,68) foi melhor do que com três horas ( %= 10,89). Com o pneumoperitônio de 15 mmHg tanto com duas ( %=-3,57) quanto três horas ( %=-3,25), a função renal esteve prejudicada. Concluiu -se que oclearance da inulina mostrou haver um comprometimento da função renal no modelo de redução de 2/3 do parênquima e que, dependendo do volume e do tempo de pneumoperitônio, pode ser agravada.

A pediatric case of relapsed pulmonary alveolar proteinosis despite successful whole lung lavage / 소아과

Pulmonary alveolar proteinosis (PAP) is a rare disease in children characterized by intra-alveolar accumulation of surfactant proteins, which severely reduces gaseous exchange. Whole lung lavage (WLL) is the preferred technique for the treatment of severe PAP. Herein, we present a pediatric case of PAP treated with WLL. An 11-year-old boy was admitted with the chief complaint of a dry cough lasting 6 months. He developed symptoms of dyspnea on exertion and had difficulty in climbing stairs. He was ultimately diagnosed with PAP through video-assisted thoracoscopic lung biopsy. As first-line of treatment for PAP, he underwent therapeutic WLL for each of his lungs on separate days. After a brief recovery, his symptoms gradually worsened; therefore, he underwent a second WLL. This is the first pediatric case of PAP relapse despite successful WLL in Korea.