Apendectomía Convencional vs. Laparoscópica en pasantes de cirugía general / Conventional Vs Laparoscopic Appendectomy in General Surgery Interns

La apendicitis aguda (AA) es una de las afecciones más frecuentes para la consulta por el servicio de guardia que requiere tratamiento quirúrgico, con una incidencia estimada de entre 6 y 8%. Métodos: Se crearon dos grupos compuestos por 25 pacientes seleccionados al azar: G1. Apendectomía laparoscópica (AL). G2. Apendectomía convencional (CA). Analizamos variables como sexo, edad, tiempo de operación, dolor postoperatorio, estadía en el hospital y complicaciones postoperatorias. Resultados: el 53.2% de los pacientes eran hombres y el 46.8% restante eran mujeres, con una edad media de 31 años. La serie arrojó una tasa de complicación general del 28% para G1 y 68% para G2. Conclusión: lo que marca la evolución no es solo la capacidad del residente interino, sino también la condición del órgano y los propios factores del paciente

Acute appendicitis (AA) is one of the most frequent conditions for consultation by the on-call service that requires surgical treatment, with an estimated incidence of between 6 and 8%. Methods: Two groups made up of 25 randomly selected patients were created: G1. Laparoscopic appendectomy (AL). G2. Conventional appendectomy (CA). We analyzed variables such as sex, age, operating time, postoperative pain, hospital stay, and postoperative complications. Results: 53.2% of the patients were male and the remaining 46.8% were female, with a mean age of 31 years. The series yielded a general complication rate of 28% for G1 and 68% for G2. Conclusión: What marks the evolution is not only the capacity of the acting resident, but also the condition of the organ and the patient's own factors

Estrategia de superación para el desarrollo de habilidades del cirujano general en el preoperatorio mediato / An upgrading strategy for the development of skills in the general surgeon in the mediated preoperative period

Introducción: La superación profesional en cirujanos generales, particularizada en la atención preoperatoria, es una vía para acrecentar la educación permanente o continua, que contribuye a formar hombres de ciencias con determinados valores y actitudes. Objetivo: Diseñar una estrategia de superación para el desarrollo de las habilidades profesionales en la atención preoperatoria mediata que contribuya al mejoramiento del desempeño profesional de los médicos cirujanos generales. Métodos: Se utilizaron como métodos teóricos: análisis-síntesis, histórico-lógico, sistematización, inducción-deducción, modelación, análisis documental, sistémico estructural funcional; y como empírico, la observación científica. Resultados: El diseño de la estrategia respondió al desarrollo de las habilidades profesionales en la atención preoperatoria mediata y se fundamentó desde los referentes filosóficos, sociológicos, psicológicos, epistemológicos, pedagógicos y la educación médica. Se concibió en cuatro etapas y se utilizó el ciclo Deming, que establece relaciones esenciales con coherencia lógica interna a la educación médica, en particular en el área de la formación permanente y continuada de los profesionales de la salud. Conclusiones: El diseño de la estrategia profesional permite el enriquecimiento de las ciencias de la educación médica desde el posgrado como ciencia en construcción, específicamente en el área de la formación permanente y continua de médicos cirujanos generales. Al profundizar desde el plano interno, externo y contextual para el desarrollo de las habilidades profesionales en el preoperatorio mediato, la estrategia propuesta resulta dinámica, lo que permite el mejoramiento del desempeño profesional a partir de la superación(AU)

Introduction: Professional improvement in general surgeons, particularly in preoperative care, is a way to increase permanent or continuous education, which contributes to the creation of men of science with certain values and attitudes. Objective: To design an upgrading strategy for the development of professional skills in preoperative care that contributes to the improvement of professional performance in general surgeons. Methods: As theoretical methods, analysis-synthesis was used, together with the historical-logical method, systematization, induction-deduction, modeling, documentary analysis, and the structural-functional-systemic method; while, at the empirical level, scientific observation was used. Results: The design of the strategy responded to the development of professional skills in preoperative mediated care and was based on philosophical, sociological, psychological, epistemological, pedagogical and medical education referents. It was conceived in four stages and used the Deming cycle, which establishes essential relationships with internal logical coherence to medical education, particularly in the area of permanent and continuous education for health professionals. Conclusions: The design of the professional strategy allows the enrichment of medical education sciences from the postgraduate level as a science under construction, specifically in the area of permanent and continuous training of general surgeons. Insofar it deepens from the internal, external and contextual levels for the development of professional skills in the mediate preoperative period, the proposed strategy is dynamic, allowing for the improvement of professional performance from the point of view of self-upgrading(AU)

Simulador de fosa ilíaca derecha para la adquisición de habilidades básicas en apendicectomía convencional / RIGHT ILIAC FOSSA SIMULATOR FOR THE ACQUISITION OF BASIC SKILLS IN CONVENTIONAL APPENDICECTOMY

Introducción: La simulación quirúrgica es un método de enseñanza que cada día va abarcando más terreno, dejando de lado al modelo tradicional de aprendizaje en los servicios de cirugía. El proceso inflamatorio del apéndice cecal es todavía una de las patologías más prevalentes en el área del cirujano general, quien debe tener varias estrategias para poder resolver la misma. Aquí presentamos un simulador de fosa iliaca derecha para la adquisición de habilidades básicas en apendicetomía convencional. Material y Métodos: se desarrolló un simulador de fosa iliaca derecha de la siguiente manera: se recorta el centro la tapa de una caja de aglomerado, y tanto los foamy como el papel crepé en rectángulos del tamaño de la tapa de la caja; se crea un preparado cadavérico utilizando el intestino vacuno; se coloca el preparado y por encima una compresa teñida en la bolsa de polietileno, dentro de la caja; se cierra la caja y se colocan las láminas de foamy y el papel crepé encima de la tapa, fijadas con los tornillos y tuercas, representando la pared abdominal. Resultado: Simulador reproducible, económico y de fácil elaboración. Tiempo total de armado: 1 hora. Conclusiones: Se puede utilizar para simular la técnica quirúrgica de apendicectomía convencional y sus variantes

Introduction: Surgical simulation is a teaching method that covers more ground every day, leaving aside the traditional apprenticeship model in surgery services. The inflammatory process of the cecal appendix is still one of the most prevalent pathologies in the area of the general surgeon, who must have several strategies to solve it. Here we present a right iliac fossa simulator for the acquisition of basic skills in conventional appendectomy. Material and Methods: We cut the center of the lid of the chipboard box, then cut the foamy and the crepe paper into rectangles the size of the lid of the box. We create a cadaveric preparation using the bovine intestine. Then put the preparation with a dyed compress above it in the polyethylene bag, inside the box. We close the box and place on the lid the foamy and crepe paper, fixed with bolts and nuts. Result: Cheap and easy-made simulator. We can armed de simulator in one hour. Conclusions: It can be used to simulate the conventional appendectomy surgical technique and its different variants.

Colecistectomía videolaparoscópica en el Hospital Militar Docente Dr. Mario Muñoz Monroy, Matanzas, 2014-2017 / Video laparoscopic cholecistectomy in the Military Hospital of Matanzas. 2014-2017

RESUMEN Introducción: en enero de 2000, comenzó la cirugía videolaparoscópica en el Hospital Militar Docente Dr. Mario Muñoz Monroy, de la ciudad de Matanzas. El equipo quirúrgico, en esa época, lo constituían cirujanos con varios años de experiencia y con una sólida formación en cirugía convencional. También poseían habilidades demostradas en la realización de colecistectomía a cielo abierto. A partir de 2011, una nueva generación de cirujanos desarrolló la cirugía mínimamente invasiva, con poca experiencia en cirugía a cielo abierto. Por lo tanto, se presentó la contradicción de que cada vez menos cirujanos tenían la experiencia técnica que requieren los casos más difíciles. Objetivo: determinar la seguridad en la realización de la colecistectomía laparoscópica. Materiales y métodos: Investigación observacional, descriptiva y retrospectiva de los pacientes intervenidos de afecciones biliares benignas, por la técnica de colecistectomía laparoscópica, entre enero de 2014 y diciembre de 2017. Resultados: fueron colecistectomizados 2 016 pacientes. De ellos, 1 759 (87 %) correspondieron al sexo femenino, y 257 (13 %) al masculino. Comorbilidades presentes en el 46,3 %. Cirugías: electivas, 1 801; urgentes, 215. Eventos adversos, 38 (1,88 %). Conversiones, 28 (1,3 %). Mortalidad operatoria, 5 (0,24 %). Conclusiones: resultan seguras las colecistectomías laparoscópicas por el bajo índice de eventos adversos, conversiones y mortalidad operatoria (AU).

ABSTRACT Introduction: video laparoscopic surgery began in January 2000, at the Dr. Mario Muñoz Monroy Military Hospital. The surgical team, at that time, were surgeons with years of experience and a solid training in conventional surgery. They also had demonstrated skills in performing open cholecystectomy. Starting in 2011, a new generation of surgeons developed minimally invasive surgery, with little experience in open surgery. Therefore, it arose the paradox that fewer and fewer surgeons had the technical experience required in the most difficult cases. Objective: to determine the safety in performing laparoscopic cholecystectomy. Materials and methods: retrospective, descriptive and observational research of the patients who underwent surgeries of benign biliary conditions, by the technique of laparoscopic cholecystectomy in the period January 2014- December 2017. Results: 1759 patients were cholecystectomized. 87.25% were female ones and 257 (13%) were male: Comorbidities were present in 46.3%. 1 801 were elective surgeries; emergency surgeries were 215. There were 38 (1.88%) adverse events and 28 (1.3%) conversions. The operatory mortality was 5 (0.24%). Conclusions: laparoscopic cholecystectomy are safe because of the low index of adverse events, conversion and operatory mortality (AU).

Mortalidad operatoria en cirugía mayor. Análisis retrospectivo en un Servicio de Cirugía / Operative mortality in major surgery. Retrospective analysis in a Surgery Service

RESUMEN Introducción: la propia asistencia médica provoca, en determinadas situaciones, problemas de salud que pueden llegar a ser importantes para el enfermo. El análisis de la mortalidad es uno de los parámetros utilizados para investigar la seguridad en la realización de procederes de cirugía mayor. Objetivo: determinar los factores asociados a la mortalidad operatoria en cirugías mayores. Materiales y métodos: se realizó un estudio observacional, descriptivo y retrospectivo, de los pacientes que fallecieron tras la realización de una cirugía mayor, en el Hospital Militar Docente Dr. Mario Muñoz Monroy, de Matanzas, en el período comprendido de enero de 2011 a diciembre de 2019. Resultados: la tercera edad aportó 77,3 % de los fallecidos. La hipertensión arterial, diabetes mellitus y cardiopatía isquémica fueron las principales comorbilidades. El abdomen agudo fue el diagnóstico operatorio más frecuente con 98 (58,3 %). Las complicaciones aportaron el 11,9 % de los fallecidos; los eventos adversos, 29,7 %, y por el curso natural de la enfermedad, murió un 58,3 %. El síndrome de disfunción múltiple de órganos y el shock séptico resultaron las principales causas de muerte (62 %). Conclusiones: la mortalidad operatoria estuvo asociada a factores de riesgo como edad avanzada, enfermedades crónicas y cirugía de urgencia. Los eventos adversos elevan la incidencia de mortalidad en cirugía mayor. Las infecciones son la principal causa de mortalidad operatoria (AU).

ABSTRACT Introduction: medical care itself causes, in certain situations, health problems that could be very important for the patient. The mortality analysis is one of the parameters used to study safety performing procedures of major surgery. Objective: to determine the factors associated to operatory mortality in major surgeries. Materials and methods: a retrospective, descriptive and observational study was carried out of the patients who passed away after undergoing a major surgery in the Military Hospital Dr. Mario Munoz Monroy in the period between January 2011 and December 2019. Results: 77.3 % of the deceased were elder people. The main co-morbidities were arterial hypertension, diabetes mellitus and ischemic heart disease. The most frequent surgery diagnosis was acute abdomen with 98 patients (58.3 %). Complications yielded 11.9 % of the deceases, adverse events 29.7 % and 58.3 % died due to the natural course of the disease. The organs multiple dysfunction syndrome and septic shock were the main causes of dead (62 %). Conclusions: operatory mortality was associated to risk factors like advanced age, chronic diseases and emergency surgery. The adverse events increase mortality incidence in major surgery. Infections are the main causes of operatory mortality (AU).

Experiencia inicial en Buenos Aires con la cirugía transoral robótica (TORS) / Initial experience with transoral robotic surgery (TORS) in Buenos Aires

Antecedentes: la cirugía robótica es una alternativa a la cirugía abierta, microcirugía láser CO2, o quimiorradioterapia en vía aerodigestiva superior. El robot permite trasladar la técnica quirúrgica abierta a un abordaje mínimamente invasivo, con acceso por boca, para patología benigna y maligna. Actualmente se emplean diferentes terapéuticas con similares resultados oncológicos. Objetivo: introducir una herramienta quirúrgica para abordaje bucal. Comunicar la experiencia inicial con el uso del robot. Evaluar la preservación de respiración y deglución. Analizar variables que determinaron una disminución en la hospitalización. Material y métodos: 13 mujeres y 11 hombres. Edad entre 16 y 82 años, media de 55,08. Total 24 pacientes con enfermedad inflamatoria crónica (8), tumores benignos (4) y malignos (12). Variables consideradas en cirugía robótica: tiempo y lugar de internación, complicaciones, estado respiratorio y deglutorio, uso de técnicas reconstructivas. Se realizó videoendoscopia de deglución para objetivar la seguridad del método. Resultados: tiempo medio de internación: 1,92 días. El 83,3% internado 1 día. El 79,9% en internación general. Unidad cerrada: 20,1%. Ninguna traqueostomía. Cicatrización del lecho por segunda. Sin complicaciones. Edema de lengua: 2 pacientes. Conclusiones: la cirugía robótica favorece la exéresis con baja morbilidady máxima preservación de tejidos sanos. Disminuye: edema posoperatorio, uso colgajos para reparar el lecho, traqueotomía temporaria, tiempo de internación. La videoendoscopia de deglución demuestra utilidad para determinar la deglución segura. Limitante del presente trabajo es el tamaño de la muestra. Es importante incrementar el número de pacientes para valorizar supervivencia y calidad de vida.

Background: robotic surgery is an alternative to open surgery, CO2 laser microsurgery, or chemoradiation for the upper aero-digestive tract. This system allows surgeons to use the open surgical technique in a minimally invasive approach through the mouth to treat benign and malignant disorders. Different treatments are currently used with similar oncologic outcomes. Objective: the aim of this study was to introduce a surgical tool through transoral approach, report the initial experience with the use of the robotic system, evaluate respiratory and digestive functional preservation and analyze the variables associated with shorter hospital length of stay. Material and methods: A total of 24 patients (13 women and 11 men, mean age 55.08 years [16-82]) were included. Eight patients had chronic inflammatory disease, four had benign tumors and 12 had cancer. The variables considered in robotic surgery were hospital length of stay, place of postoperative care, complications, respiratory and swallowing function and use of reconstructive techniques. Flexible endoscopic evaluation of swallowing was performed to document safe function. Results: mean length of stay was 1.92 days; 83.3% stayed for one day; 79.9% were admitted to the general ward and 20.1% stayed in intensive or intermediate care units. None of the patients required tracheostomy. Healing of the surgical bed occurred by secondary intention. There were no complications. Tongue edema occurred in two patients. Conclusions: robotic surgery favors tumor removal with low morbidity and maximum preservation of healthy tissues while reducing postoperative edema, use of flaps for reconstruction, temporary tracheostomy and hospital length of stay. Flexible endoscopic evaluation of swallowing is useful to determine safe swallowing function. The main limitation of our study is the sample size. It is important to increase the number of patients to evaluate survival and quality of life.

Papel de la proteína C reactiva y la velocidad de sedimentación globular en la predicción de colecistectomía laparoscópica dificultosa: su aplicación en un programa de residencia universitario / Role of C-reactive protein and erythrocyte sedimentation rate to predict difficult laproscopic cholecystectomy in a university residency program

Antecedentes: la colecistectomía laparoscópica es uno de los procedimientos quirúrgicos más frecuentemente realizados. Las diferencias en la anatomía y en el grado de inflamación vesicular suelen causar dificultades técnicas intraoperatorias. Objetivo: determinar el valor de la proteína C reactiva (PCR) y la velocidad de sedimentación globular (VSG) como predictores de colecistectomía dificultosa y evaluar su aplicación en la planificación prequirúrgica de un programa de residencia universitario. Material y métodos: se confeccionó un estudio retrospectivo, analítico, en un hospital universitario de tercer nivel. Se incluyeron 104 pacientes adultos operados de colecistectomía laparoscópica por litiasis vesicular sintomática entre enero y julio de 2019. Se categorizó a los pacientes en un grupo de colecistectomías dificultosas y otro de colecistectomías no dificultosas. Resultados: se obtuvieron diferencias estadísticamente significativas al comparar los valores de VSG y PCR de ambos grupos (p < 0,001). La sensibilidad de la VSG fue del 100%, la especificidad del 45%, el VPP del 40% y el VPN de 100%. La sensibilidad de la PCR fue del 87,5%, la especificidad del 86,3%, el VPP del 70% y el VPN de 95%. Ambos parámetros se vieron elevados en 14 de 16 colecistectomías dificultosas y en 2 de 44 colecistectomías no dificultosas. La sensibilidad para ambos parámetros elevados fue del 87,5%, la especificidad del 95%, el VPP del 87,5% y el VPN de 95%. Conclusión: la VSG y la PCR han demostrado ser un método fiable en la predicción de colecistectomías dificultosas por litiasis vesicular sintomática. Esto podría ser aplicado en la programación de cirugías dentro de un programa de residencia universitario.

Background: laparoscopic cholecystectomy is one of the most common procedures performed in general surgery. The anatomical differences of the gallbladder and the presence of factors related to inflammation can cause technical issues during surgery. Objective: the aim of the present study was to determine the value of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as predictors of difficult cholecystectomy and to evaluate their application during presurgical planning within a university residency program. Material and methods: we conducted a retrospective and analytical study in a tertiary university hospital. A total of 104 adult patients undergoing laparoscopic cholecystectomy due to symptomatic cholelithiasis between January and July 2019 were included. The patients were categorized into two groups: difficult cholecystectomy and non-difficult cholecystectomy. Results: there were statistically significant differences in ESR and CRP values between both groups (p < 0.001). Sensitivity of ESR was 100%, specificity was 45%, with a PPV of 40% and NPV of 100%. Sensitivity of CRP was 87.5%, specificity was 86.3%, with a PPV of 70% and NPV of 95%. Both parameters were elevated in 14 of 16 difficult cholecystectomies and in 2 of 44 non-difficult cholecystectomies. Sensitivity of CRP was 87.5%, specificity was 86.3%, with a PPV of 70% and NPV of 95%. Conclusion: measuring ESR and CRP has proved to be a reliable method to predict difficult cholecystectomies due to symptomatic cholelithiasis. This could be applied for surgical planning within a university residency program.

Application of the "five-line division method" in selecting surgical approach for spaceoccupying lesions in the saddle area and the adjacent areas / 南方医科大学学报

OBJECTIVE@#To explore the application of the"five-line division method "in selecting the surgical approach for occupying lesions in the saddle area and its adjacent areas.@*METHODS@#Based on the natural anatomic structures, 5 lines (alpha, beta, theta line and lambda, epsilon line) were drawn on the images of the craniocerebral axial plane crossing the middle of the saddle area and the craniocerebral median sagittal plane, thus dividing the saddle area and its adjacent areas into 6 regions in the axial plane (1, 2, 3, 1', 2', and 3' regions) and into 4 regions in the sagittal plane (I, II, III, and IV regions). Based on these divisions, the large space-occupying lesions in the saddle area and adjacent areas were classified and their respective surgical approaches were determined after reviewing the commonly used approaches in the saddle area and clinical experiences. We collected the data of 116 patients undergoing surgeries for space-occupying lesions involving the saddle and the adjacent areas in our hospital between September, 2014 and August, 2017, and analyzed their classifications and the corresponding surgical approaches based on the "five- line division method " to compare the consistency between the hypothetic approaches and the approaches adopted in the actual surgeries.@*RESULTS@#The actual surgical approaches adopted in the 116 cases were all selected under the guidance of experts in our hospital. The hypothetic surgical approaches selected based on the"five- line division method "showed a good consistency with the actually adopted approaches.@*CONCLUSIONS@#The"five-line division method "can spatially classify the commonly seen space-occupying lesions involving the saddle area and its adjacent area to provide assistance in the selection of surgical approaches for such lesions.

Factores asociados a las complicaciones de la cirugía electiva de las hernias inguinales / Factors associated with the complications of elective surgery of inguinal hernias

Introducción: La hernia inguinal es una de las enfermedades que más comúnmente requiere tratamiento operatorio y representa entre el 10- 15 por ciento de todas las intervenciones programadas. El porcentaje de complicaciones posoperatorias es de 5- 10 por ciento y aunque no son totalmente evitables, deben conocerse sus posibles causas para lograr reducir su incidencia. Objetivo: Identificar los factores asociados a las complicaciones de la cirugía electiva de las hernias inguinales. Métodos: Se realizó un estudio observacional y descriptivo, de una serie de 246 pacientes operados de hernias inguinales mediante cirugía electiva en el servicio de Cirugía General del Hospital Provincial Docente "Saturnino Lora" de Santiago de Cuba durante el bienio 2016-2017. Resultados: Se constataron 18 complicaciones (7,3 por ciento). Predominó el grupo etario de 51 a 70 años (47,8 por ciento) y el sexo masculino sobre las féminas con razón de 15,4:1. El estado físico preoperatorio fue clasificado ASA 1 en 183 pacientes (74,4 por ciento) y ASA 2 en 62 (25,2 por ciento). El 72,2 por ciento de los complicados tenían al menos una enfermedad asociada. El tipo 2 según clasificación de Nyhus prevaleció con 73 (29,7 por ciento) y 8 (44,4 por ciento) de los complicados. Conclusiones: Los factores referentes a la edad mayor de 50 años, sexo masculino, antecedentes de hipertensión arterial y diabetes mellitus, y hernias tipo II según la clasificación de Nyhus se asocian a la presentación de complicaciones agudas (edema del cordón espermático e infección del sitio operatorio) y crónicas (recidiva y granuloma) de la cirugía electiva de las hernias inguinales(AU)

Introduction: Inguinal hernia is a common surgical treatment illness and represents 10-15 percent of the programmed surgery. The postoperative complications records are 5-10 percent, although they are not avoidable, it is mandatory to know the possible causes to decrease the incidence rate. Objective: To identify the associated factors on the complications of elective inguinal hernia surgery. Methods: An observational and descriptive study of a series of 246 patients operated on elective inguinal hernia surgery in the General Surgery Service of "Saturnino Lora" Hospital of Santiago de Cuba during the years 2016-2017. Results: There were 18 complications (7,3 percent) of the sample. The age group of 51 to 70 years (47,8 percent) predominated and the male sex over females with a ratio of 15,4:1. Preoperative physical state was classified ASA 1 in 183 patients (74,4 percent) and ASA 2 in 62 (25,2 percent). 72,2 percent of the complicated patients had at least one associated disease. Type 2 according to Nyhus classification prevailed with 73 (29,7 percent) patients of the sample, and eight (44,4 percent) of complicated patients. Conclusions: Associated factors on acute and chronic complications of elective inguinal hernia surgery related to age, sex, associated illness, preoperative physical state and type of hernia according to Nyhus classification do not differ from that reported by the national and foreign literature(AU)

Particularities of upper lobe lung resection in case of tumors with bronchial and arterial plasty

In the case of lung cancer, surgery is the only method of therapy that gives the patient a chance to recover. However, even after radical surgery, up to 50 ­ 60 % of patients die in the subsequent five years from the disease progression. This study was aimed at identifying the technical particularities of surgery, depending on the side of the lung affected by a tumor and the possibility of applying the methods that improve the results of surgical therapy. The study was performed at the Thoracic Department of the Republican Clinical Oncology Dispensary in Ufa and the 1st Surgical Department of the Regional Oncology Center of the Regional Clinical Hospital in Khanty- Mansiysk. The study involved a total of 156 patients (including 148 male and eight female patients). The main result of the study has been the confirmation of the advantages of bronchoplastic surgery, which do not increase post-surgery mortality and improve the post-surgery period, and the relevant principles of preserving surgery.

Influence of diameter and geometry in the tapping of the pilot hole in pedicle screws / Influência do diâmetro e geometria no macheamento do orifício piloto nos parafusos pediculares / Influencia del diámetro y geometría en el taladramiento del agujero piloto en tornillos pediculares

ABSTRACT Objective: To evaluate the insertion torque and the pulling force of each screw with different diameters and tap. Methods: Polyurethane blocks with a pilot hole of 2.7 mm were used in the study. An experimental group with 5 blocks was formed, the insertion torque was evaluated with a torque meter, and the pullout strength of each Globus screw of 5.5 mm and 6.5 mm was assessed. Results: The comparison of the insertion torque on the 5.5 mm screws with pilot hole without tapping and with a smaller diameter than that of the screw (4.5 mm) and a different thread, and with the tapping with the same diameter as that of the screw (5.5 mm) and equal or different thread presented a statistical difference with a higher value of the insertion torque in the group in which the tapping was not performed. As for the pulling force of the 5.5 mm screw, the non-tapping of the pilot hole resulted in statistical difference with the same diameter of the screw (5.5 mm) and with a different thread of the screw. The pullout force on the 6.5 mm screw was higher in the group where the pilot hole was not tapped according to the non-parametric Kruskal-Wallis test, with significance level of p <0.05 in the comparison of the groups. Conclusions: Pilot hole tapping reduced insertion torque and pullout resistance of the pedicle screw influencing the fixation with tapping with the same screw diameter and different thread design.

RESUMO Objetivo: Avaliar o torque de inserção e a força de arrancamento de cada parafuso com diferentes diâmetros e machos. Métodos: Foram utilizados no estudo blocos de poliuterano com orifício piloto de 2,7mm, sendo feito um grupo experimentais com 5 blocos sendo avaliado o torque de inserção com torquímetro e avaliado o arrancamento de cada parafuso de parafusos Globus 5,5mm e 6,5mm. Resultados: A comparação do torque de inserção nos parafusos de 5,5mm entre a utilização de orifício piloto sem macheamento e o macheamento com diâmetro inferior ao diâmetro do parafuso (4,5mm) e rosca diferente, e com o macheamento com diâmetro igual do parafuso (5,5mm) e com rosca igual ou diferente apresentou diferença estatística com maior valor do torque de inserção no grupo em que o macheamento não foi realizado. Na força de arrancamento do parafuso 5.5mm o não macheamento do orifício piloto apresentou diferença estatística com o mesmo diâmetro do parafuso (5,5mm) e rosca diferente do parafuso. A força de arrancamento no parafuso 6,5mm foi maior no grupo em que o orifício piloto não foi macheado utilizando o teste não paramétrico de Kruskal Wallis com nível de significância adotado (p < 0,05) na comparação dos grupos. Conclusões: O macheamento do orifício piloto diminuiu o torque de inserção e resistência ao arrancamento do parafuso pedicular influenciando a fixação com macheamento com o mesmo diâmetro do parafuso e desenho de rosca diferente.

RESUMEN Objetivo: Evaluar el torque de inserción y la fuerza de extracción de cada tornillo con diferentes diámetros y machos. Métodos: Se utilizaron en el estudio bloques de poliuretano con agujero piloto de 2,7 mm. Se formó un grupo experimental con 5 bloques, y el torque de inserción se evaluó con llave de par y se analizó la fuerza de extracción de cada tornillo Globus de 5,5 mm e 6,5 mm. Resultados: La comparación del torque de inserción en los tornillos de 5,5 mm con agujero piloto sin taladramiento y con un diámetro más pequeño que el del tornillo (4,5 mm) y un roscado diferente, y con el taladramiento con el mismo diámetro que el del tornillo (5,5 mm) y con el roscado igual o diferente presentó una diferencia estadística con un valor más alto del torque de inserción en el grupo en el que no se realizó taladramiento. En cuanto a la fuerza de extracción del tornillo 5,5 mm el no taladramiento del agujero piloto resultó en una diferencia estadística solamente con el mismo diámetro del tornillo (5,5 mm) y con roscado diferente del tornillo. La fuerza de extracción en el tornillo de 6,5 mm fue mayor en el grupo que en el agujero piloto no tuvo taladramiento, de acuerdo con la prueba no paramétrica de Kruskal-Wallis, con nivel de significación de p < 0,05 en la comparación de los grupos. Conclusiones: El taladramiento del agujero piloto redujo el torque de inserción y la resistencia a la extracción del tornillo pedicular, lo que influye con la fijación con taladramiento con el mismo diámetro del tornillo e diferentes diseños de roscado.

A double row epiploicoplasty for primary closure of free perforated sigmoid diverticulitis / Epiploicoplastia de duas fileiras para fechamento primário de diverticulite perfurada livre de sigmoide

ABSTRACT Acute free perforation of the sigmoid diverticulitis is an emergency surgical intervention required condition. Although the sigmoid resection and temporary end colostomy or abdominal lavage and drainage are the most commonly used surgical methods for its treatment, the most effective surgical method has not been established yet. We applied a different surgical method for the surgical treatment of free perforation of acute sigmoid diverticulitis outside of these surgical procedures. A double row epiploicoplasty was performed for surgical treatment of free perforated sigmoid diverticulitis with surgical success in a patient who had concominant serious diseases.

RESUMO A perfuração livre aguda da diverticulite de sigmoide é um problema que exige intervenção cirúrgica de emergência. Embora a ressecção de sigmoide e a colostomia de extremidade temporária ou a lavagem e drenagem abdominal sejam os métodos cirúrgicos mais comumente utilizados para o seu tratamento, o método cirúrgico mais eficaz ainda não foi estabelecido. Aplicamos um método cirúrgico diferente para o tratamento cirúrgico de perfuração livre de diverticulite de sigmoide aguda fora desses procedimentos cirúrgicos. Uma epiploicoplastia de duas fileiras foi realizada para o tratamento cirúrgico de diverticulite perfurada livre de sigmoide com sucesso cirúrgico em um paciente com doenças graves concomitantes.

Linfoma difuso de celulas b grandes de origen yeyunal: reporte de caso y revisión de la literatura / Diffuse large b-cell lymphoma, jejunal origin: case report and literature review

El linfoma difuso de células B grandes, es una neoplasia maligna linfoproliferativa caracterizada por la reproducción monoclonal de linfocitos de la estirpe B en diferentes órganos y tejidos. Se describe el caso de un paciente femenino de 63 años de edad, quien ingresa al servicio de urgencias por cuadro de dolor abdominal, asociado a pérdida de peso y presencia de melenas. Durante la hospitalización presenta cuadro de obstrucción intestinal y agravamiento del cuadro clínico, por lo que se indica realizar laparotomía exploratoria en donde se encuentra una gran masa con múltiples ganglios en meso de yeyuno de aspecto tumoral. El estudio de patología con inmunohistoquímica de la muestra reporta reactividad difusa para CD20 y para vimentina, además de CD3 y BCL2, hallazgos compatibles con Linfoma de células B grandes, un linfoma no Hodgkin gastrointestinal de presentación infrecuente en yeyuno.

Diffuse large B-cell lymphoma is a malignancy lymphoproliferative characterized by monoclonal lymphocytes B strain reproduction in different organs and tissues. This article is a case report of a female 63-year-old, who admitted to the emergency room with abdominal pain associated with weight loss and presence of manes. During hospitalization, she presents intestinal obstruction associated with clinical worsening and indicating completion of Laparotomy Diagnostics where it's found a large malignant tumor mass with multiple nodes in meso aspect jejunal tumor. The study of pathology with immunohistochemistry of the sample reports diffuse reactivity for CD20 and for vimentin in addition to CD3 and BCL2, compatible findings with large B cell lymphoma, gastrointestinal Non-Hodgking lymphoma of jejunum uncommon presentation.

Seguridad en cirugía mayor. Experiencia de cinco años / Safety in major surgery. Five-year experience

Introducción: los errores en cirugía existen desde que el hombre mismo se atrevió a violar la integridad del cuerpo humano buscando resolver un problema de salud. La Organización de la Salud, en el 2008 lanza el programa "Cirugías Seguras", pues ha calculado que se realizan 234 millones de cirugías mayores al año y se producen alrededor de un millón de muertes relacionadas con procedimientos quirúrgicos mayores. Objetivo: determinar la seguridad en las cirugías mayores. Material y Métodos: se realizó un estudio observacional descriptivo y retrospectivo analizando los resultados de las cirugías mayores en el servicio de cirugía general del Hospital Militar Docente "Dr. Mario Muñoz Monroy" de Matanzas, en el periodo comprendido de enero del 2011 a diciembre del 2015. Resultados: se realizó un total de 7366 cirugías mayores, electivas 5525(75%), urgentes 1841(25%). Fueron clasificadas como A1 7264 (98,6%), se efectuaron 127 reintervenciones (1,7%), se produjeron 107 eventos adversos (1,4%) y una mortalidad operatoria de 86 pacientes (1,16%). Conclusiones: son seguras las intervenciones de cirugías mayores. Los eventos adversos se presentaron por debajo de lo reportado en la literatura médica mundial. La mortalidad operatoria está dentro de parámetros aceptados en estándares internacionales (AU).

Introduction: mistakes in surgery are committed since the moment the man had the courage of violating the integrity of the human body looking for solving a health problem. The World Health Organization started the program Cirugías seguras (Safe Surgeries in English) in 2008, because they calculated that 234 millions of major surgeries are done and around a million of deaths are related with major surgical procedures every year. Aim: to determine the safety of the major surgeries. Materials and Methods: an observational, descriptive and retrospective study was carried out analyzing the results of the major surgeries in the Teaching Military Hospital "Dr. Mario Muñoz Monroy" of Matanzas in the period from January 2011 to December 2015. Results: a total of 7 366 major surgeries were done: 5 525 elective surgeries (75 %) and 1 841 emergency surgeries (25 %). 7 264 were classified as A1 (98,6); 127 surgical re-interventions were done (1,7 %); 107 adverse events took place (1,4 %) and the surgical mortality was 86 patients (1,16 %). Conclusions: major surgical interventions are safe. The adverse events were less than data reported in the international medical literature. Surgical mortality fulfills the parameters accepted in international standards (AU).

Síndrome de Bouveret: A propósito de un caso / BOUVERET´S SYNDROME: CASE REPORT

El íleo biliar es una causa poco frecuente de obstrucción intestinal. Puede manifestarse de formas variadas según el sitio de obstrucción y las características del paciente. Cuando la obstrucción se localiza a nivel duodenal, bloqueando el paso del contenido gástrico, se trata de una entidad denominada síndrome de Bouveret

Gallstone ileus is an uncommon cause of intestinal obstruction. It can manifest itself in various shapes according to the site of obstruction and the patient´s characteristics. When the obstruction is located at the duodenum, blocking the passage of gastric contents, it is an entity called Bouveret´s syndrome

Hernia de Amyand. Reporte de caso / Amyand's hernia. Case report

La incidencia de la hernia de Amyand es muy baja. Siempre es diagnosticada en el transoperatorio, resulta casi imposible de realizar durante el pre-operatorio. Paciente femenina de 75 años de edad, con antecedentes de hernia inguinal derecha recidivante. Comenzó con dolor en epigastrio y en región inguinal derecha, además de náuseas y vómitos. Se identificó cicatriz quirúrgica y aumento de volumen en región inguinal derecha. Se decidió intervenir quirúrgicamente con el diagnóstico clínico de hernia inguinal derecha recidivante encarcelada. Durante el acto operatorio se identificó apendicitis aguda supurada como contenido del saco herniario inguinal. Se procedió a la realización de la apendicetomía y reparación de la hernia, en el mismo tiempo quirúrgico, y colocó la malla de polipropilenoe. Se aplicó antibióticos de amplio espectro. La paciente evolucionó de forma favorable. La biopsia confirmó el diagnóstico. El siguiente caso se presentó, pues a pesar de ser conocido, su incidencia es muy baja, por lo que existen dificultades para su diagnóstico (AU).

The incidence of Amyand's hernia is very low. It is always diagnosed in the trans-operatory period, being almost impossible during the pre-operatory period. This is the case of a female patient, aged 75 years, with antecedents of recidivist right inguinal hernia. It began with pain in epigastrium and in the right inguinal region in addition to nausea and vomits. Surgical scar and volume increase in the right inguinal region were identified. It was decided to make a surgery with the clinical diagnosis of incarcerated recidivist right inguinal hernia. During the surgery an acute suppurated appendicitis was identified as the content of the inguinal hernial sac. The appendectomy was carried out and hernia was repaired in the same surgical time; a polypropylene mesh was placed. Broad spectrum antibiotics were applied. The evolution of the patient was satisfactory. The biopsy confirmed the diagnosis. The case was presented because despite of being known, its incidence is very low, so there are difficulties for diagnosing it (AU).

Anestesia para cirugía convencional en paciente con tetralogía de Fallot. Presentación de un caso / Anesthesia for conventional surgery in a patient with Tetralogy of Fallot. Case presentation

La tetralogía de Fallot es la forma más frecuente de cardiopatía congénita cianótica que se presenta en los neonatos. Los cuatro componentes de la enfermedad son: la alineación anormal de la comunicación interventricular, la obstrucción infundibular del ventrículo derecho, el cabalgamiento aórtico de la comunicación interventricular y la hipertrofia del ventrículo derecho. En este trabajo se trata un caso que se presentó para una cirugía convencional frecuente, la Histerectomía Abdominal Total debido a un mioma uterino, en una paciente que padecía de tetralogía de Fallot, con 43 años de edad, situación poco frecuente en la práctica diaria. El objetivo de este trabajo es exponer la experiencia del caso, que necesitó un manejo cuidadoso y que no aparece en la literatura básica. Habitualmente se aplica anestesia para niños con esta malformación para mejorar la calidad de vida o corregirla definitivamente, y porque precisamente solo el 2 % de los pacientes con esta enfermedad, que no han sido tratados quirúrgicamente, pueden arribar a la cuarta década de vida (AU).

The tetralogy of Fallot is the most frequent form of cyanotic congenital heart diseases presented in newborns. The disease’s four components are: abnormal alignment of intraventricular communication, right ventricle infundibular obstruction, aortic straddling of intraventricular communication, and right ventricle hypertrophy. The case presented is a case of a frequent conventional surgery, the total abdominal hysterectomy due to a uterine myoma, in a patient, aged 43 years, suffering for tetralogy of Fallot, a little frequent situation in the daily practice. The objective is exposing the experience of the case, demanding a careful management, which was not found in the main literature sources. Anesthesia is usually used in children with this malformation to improve their life quality or it is definitively corrected; only 2 % of the patients suffering this disease that have not been surgically treated are still alive in the fourth decade of life (AU).

Tumor del cuerpo carotídeo. A propósito de un caso / Tumor of the carotid body.Concerning a case

Los tumores del cuerpo carotídeo son relativamente infrecuentes y raramente se diagnostican antes de la exposición quirúrgica, su diagnóstico es benigno, pero suelen ser muy vasculares por lo que su extirpación quirúrgica muchas veces resulta difícil. Estos tumores son de crecimiento lento y pueden evolucionar durante años. El objetivo de este estudio es presentar un caso con un tumor del cuerpo carotídeo en región lateral derecha del cuello. Clínicamente se observó un aumento de volumen de aproximadamente 4 cm, no doloroso a la palpación, de tipo gomoso y adherido a planos profundos, asintomático, tratado en nuestra institución durante el año 2014. Se le realizó exéresis simple de la lesión, y el departamento de Anatomía Patológica reportó el diagnóstico de referencia. La evolución de la paciente después de 17 meses ha sido satisfactoria (AU).

The tumors of the carotid body are relatively uncommon and rarely diagnosed before the surgical exeresis, their diagnosis is benign, but they are usually very vascular and its extirpation is very difficult. These tumors have a slow growth and it can evolve during years. The aim of this study is to present a case with a tumor of the carotid body in the right lateral region of the neck. An increase of volume was observed of approximately 4 cm, not painful, of gummy type and stuck to deep, asymptomatic plans, treaty in our institution during the year 2014. It was carried out exeresis of the lesion, and the department of Pathological Anatomy reported the reference diagnosis. The patient's evolution after 17 months has been satisfactory (AU).

Estudo de revisão da cirurgia de hernioplastia inguinal: técnica de Lichtenstein versus laparoscópica / Revision study of inguinal hernia repair surgery: Lichtenstein technique versus laparoscopic

Introdução: As hérnias inguinais são das afecções mais comuns na cirurgia geral e fomentam uma rica discussão sobre qual o melhor método cirúrgico para sua correção. Objetivos: O objetivo deste artigo é fazer uma revisão de literatura não sistemática descrevendo e comparando a técnica de Lichtenstein e a técnica laparoscópica, ressaltando os prós e contras de cada abordagem. Métodos: Essa revisão foi realizada entre novembro de 2015 e fevereiro de 2016 nos bancos de dados: PubMed/Medline, Biblioteca Virtual de Saúde (BVS), Bireme, Scielo, Lilacs, além de livros. Todas as buscas basearam-se nos seguintes descritores: "Hernia inguinal, laparotomy, laparoscopic". Resultados: A laparoscopia possui melhores indicativos quanto à dor crônica pós-operatória. As taxas de recidiva em análise de curto prazo são semelhantes, entretanto, alguns estudos evidenciam divergências quanto aos resultados em longo prazo. O tempo de recuperação é menor na técnica por vídeo, porém o tempo de internação hospitalar pós-procedimento não apresentou variação significativa. A videolaparoscopia possui, entretanto, maiores custos e riscos quando comparada com a técnica aberta de Lichtenstein. Vários desses riscos são associados à necessidade de realização de anestesia geral e à maior curva de aprendizado no desenvolvimento da técnica, acarretando em complicações intraoperatórias mais evidentes que na técnica aberta. Conclusão: A escolha do método mais adequado para a hernioplastia deve ser feita levando-se em consideração os riscos de cada uma delas, bem como características particulares de cada caso, como experiência do cirurgião, preferência do paciente, estado de saúde, custo e benefícios de uma em relação à outra. (AU)

Introduction: Inguinal hernias are one of the most common conditions in general surgery services and promote a substantial discussion about the best surgical intervention method. Objective: The aim of this study was to perform a non-systematic review describing and comparing the Lichtenstein open technique and the laparoscopic technique, highlighting the pros and cons of each surgical approach. Methods: A review was performed between November 2015 and February 2016 in databases such as PubMed/Medline, Virtual Health Library (BVS), Bireme, Scielo, Lilacs and also some textbooks. All searches were based on the following descriptors: "Inguinal Hernia, laparotomy, laparoscopic". Results: Laparoscopic repair has better indicators concerning postoperative chronic pain. Short-term analysis of recurrence rates is similar, although some studies show divergence in long-term results. A shorter recovery time is seen in video technique, but the length of post-procedure hospital stay does not show significant change. However, laparoscopy has higher costs and more severe risks when compared to open Lichtenstein technique. Several of these risks are associated with general anesthesia and the largest learning curve in the development of the technique which leads to more statistically evident intraoperative complications than the open technique. Conclusion: The choice of the most suitable method for hernia repair should take into consideration the risks and particular characteristics of each case, as well as the experience of the surgeon, patient preference, health status and costs and benefits of each one of the techniques. (AU)