Abordaje abierto versus laparoscópico para la reconstitución del tránsito luego de la cirugía de Hartmann: resultados de una experiencia de 10 años / Open versus laparoscopic approach for Hartmann's reversal: results of a 10-year retrospective cohort study

Resumen Objetivo: El objetivo de este estudio es comparar los resultados perioperatorios del abordaje abierto (AA) con el abordaje laparoscópico (AL) para la reconstitución de tránsito (RT), y determinar factores de riesgo asociados a morbilidad posoperatoria. Material y Métodos: Se estudiaron pacientes consecutivos sometidos a RT entre enero de 2007 y diciembre de 2016 en nuestro centro. Se excluyeron aquellos con grandes hernias incisionales que requirieran reparación abierta simultánea. Se consignaron variables demográficas y perioperatorias, y se compararon ambos grupos. Además, se realizó una regresión logística para la identificación de factores de riesgo asociados a morbilidad posoperatoria en la serie. Resultados: Se realizaron 101 RT en el período. Se excluyeron 14 casos por hernia incisional, por lo que se analizaron 87 casos (46 AA y 41 AL). Diez pacientes en el grupo AL (24,4%) requirieron conversión, principalmente por adherencias. La morbilidad total de la serie fue de 36,8%, siendo mayor en el AA (50% vs 21,9%, p = 0,007). Hubo una filtración anastomótica en cada grupo. La estadía posoperatoria fue de 5 (3-52) días para el AL y 7 (4-36) días para el AA (p < 0,001). En la regresión logística, sólo el AA fue un factor de riesgo independientemente asociado a morbilidad posoperatoria (OR 2,89, IC 95% 1,11-7,49; p = 0,029). Conclusión: El abordaje laparoscópico se asocia a menor morbilidad y estadía posoperatoria que el abordaje abierto para la reconstitución del tránsito pos-Hartmann. En nuestra serie, el abordaje abierto fue el único factor independientemente asociado a morbilidad posoperatoria.

Introduction: Hartmann's reversal (HR) is considered a technically demanding procedure and is associated with high morbidity rates. Aim: The aim of this study is to compare the perioperative results of the open approach (OA) with the laparoscopic approach (LA) for HR, and to determine the risk factors associated with postoperative morbidity. Material and Methods: Consecutive patients undergoing HR between January 2007 and December 2016 at a university hospital were included. Patients with large incisional hernias that required an open approach a priori were excluded from the analysis. Demographic and perioperative variables were recorded. Analytical statistics were carried out to compare both groups, and a logistic regression was performed to identify risk factors associated with postoperative morbidity in the series. Results: A hundred and one HR were performed during the study period. Fourteen cases were excluded due to large incisional hernias, so 87 cases (46 OA and 41 LA) were analyzed. Ten patients in the LA group (24.4%) required conversion, mainly due to adhesions. The total morbidity of the series was 36.8%, being higher in the OA group (50% vs. 21.9%, p = 0.007). There was one case of anastomotic leakage in each group. The length of stay was 5 (3-52) days for LA and 7 (4-36) days for OA (p < 0.001). In the logistic regression, the OA was the only independent risk factor associated with postoperative morbidity in HR (OR 2.89, IC 95% 1.11-7.49; p = 0.029). Conclusion: A laparoscopic approach is associated with less morbidity and a shorter length of stay compared to the open approach for Hartmann's reversal. An open approach was the only factor independently associated with postoperative morbidity in our series.

Postoperative ileus after laparotomy for gastrointestinal cancer treated with electroacupuncture: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the effect of electroacupuncture (EA) on postoperative ileus after laparotomy for gastrointestinal cancer.@*METHODS@#A total of 90 patients with postoperative ileus after laparotomy for gastrointestinal cancer were randomized into an EA group and a conventional treatment group, 45 cases in each one. In the conventional treatment group, the postoperative fast track surgical regimen was accepted. In the EA group, on the base of the treatment as the conventional treatment group, acupuncture was applied to Zusanli (ST 36), Shangjuxu (ST 37), Yinlingquan (SP 9) and Taichong (LR 3) and electric stimulation was attached on Zusanli (ST 36) and Yinlingquan (SP 9), with continuous wave, 2 Hz in frequency and 3-5 mA in intensity. Acupuncture was provided once daily till the onset of postoperative exhaust and defecation. The first postoperative exhaust time, the first postoperative defecation time, the postoperative hospital stay and the wound pain under standing on the next morning after entering group were compared in the patients between the two groups. The impact of the EA expectation was analyzed on the first postoperative exhaust time, the first postoperative defecation time and the postoperative hospital stay separately.@*RESULTS@#The first postoperative exhaust time and the first postoperative defecation time in the EA group were earlier than the conventional treatment group (P<0.05), the postoperative hospital stay was shorter than the conventional treatment group (P<0.05), and the rate of wound pain in the postoperative standing was lower than the conventional treatment group (P<0.05). EA expectation had no obvious correlation with the clinical therapeutic effect (P>0.05).@*CONCLUSION@#EA can relieve postoperative ileus symptoms, alleviate pain and shorten hospital stay in the patients after laparotomy for gastrointestinal cancer.

Presencia de infección de sitio quirúrgico en procedimientos gineco-obstétricos en un hospital de II nivel de atención, Honduras 2017-2018 / Presence of surgical site infection in obstetric-gynecological procedures in a level II care hospital, Honduras 2017-2018

OBJETIVO: Identificar la presencia de infección de sitio quirúrgico y factores de riesgo en pacientes sometidas a cirugías Gineco-Obstétricas de forma programada o de urgencia en un hospital de II nivel de atención en Honduras. METODOLOGÍA: Estudio observacional, descriptivo, retrospectivo; recopilando 226 fichas del registro de infección de sitio quirúrgico recuperadas de los expedientes clínicos brindados por el servicio de estadística del Hospital Mario Catarino Rivas. Captando pacientes sometidas a cirugías Gineco-Obstétricas, durante el 2017 y 2018. RESULTADOS: 99 fichas cumplieron los criterios de inclusión, reportando una edad de 24 años [RIQ, 19,0 - 30,0], peso 82,0 kg [RIQ, 51,7 - 98,25], talla 154 cm [150,0 - 158,0] y el IMC de 25,8 ± 3,6 kg/m2. Un 9,1% presento antecedentes de inmunosupresión. 5,1% presento ISQ. El 55.6% de las cirugías se realizó el mismo día de ingreso del paciente. El tiempo entre la profilaxis antibiótica y el comienzo de la intervención quirúrgica es de 60 minutos [RIQ, 40,0 - 160,0]. La duración de los procedimientos quirúrgicos son de 45 minutos [RIQ, 35,0 - 55,0]. Los microrganismos aislados en los cultivos fueron Cocos gram positivos (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSIÓN: La presencia de ISQ en cirugías Gineco-Obstétricas del HMCR es del 5.1%, identificando los siguientes factores de riesgo: edad extrema, obesidad, diabetes mellitus, estado inmunitario (VIH), profilaxis antibiótica (temprana); por último, la técnica y el tiempo quirúrgico.

OBJECTIVE: To identify the presence of surgical site infection and risk factors in patients undergoing Gynecological-Obstetric surgeries on a scheduled or emergency basis in a 2nd level of care hospital in Honduras. METHODOLOGY: Observational, descriptive, retrospective study, compiling 226 data sheets of the surgical site infection record recovered from the clinical records provided by the statistics service of the "Hospital Mario Catarino Rivas". Recruiting patients undergoing Gynecological-Obstetric surgeries, during 2017 and 2018. RESULTS: 99 tabs met the inclusion criteria, reporting an age of 24 [RIQ, 19.0 - 30.0], weight 82.0 kg [RIQ, 51.7 - 98.25], size 154 cm [150.0 - 158.0] and BMI of 25.8 ± 3.6 kg/m2. 9.1% have a history of immunosuppression. 5.1% present ISQ. 55.6% of surgeries were performed on the same day as the patient's admission. The time between antibiotic prophylaxis and the onset of surgery 60 minutes [RIQ, 40.0 - 160.0]. Duration of surgical procedures 45 minutes [RIQ, 35.0 - 55.0]. Isolated micro-morphisms in crops were Cocos gram positives (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSION: The presence of ISQ in HMCR Gynecological-Obstetric surgeries is 5.1%, identifying the following risk factors: extreme age, obesity, diabetes mellitus, immune status (HIV), early antibiotic prophylaxis; finally, technique and surgical time.

An alternative approach to treatment of inferior vena cava filter perforation / Tratamento alternativo para perfuração de veia cava inferior por filtro

Abstract We report a case of inferior vena cava filter perforation immediately after filter implantation, recognized intraoperatively in a patient undergoing laparotomy for resection of locally advanced ovarian cancer. We describe an alternative approach with strut resection, less invasive than filter removal, enabling the device to be maintained and bleeding to be controlled.

Resumo Relatamos um caso de perfuração de veia cava inferior imediatamente após o implante de um filtro. A complicação foi reconhecida no intraoperatório de uma laparotomia para ressecção de um câncer de ovário localmente avançado. Descrevemos uma abordagem alternativa, menos invasiva do que a remoção do filtro, consistindo na ressecção das hastes do dispositivo. Essa abordagem permitiu a manutenção do filtro e o controle efetivo do sangramento.

Evisceración abdominal postraumática en un niño / Post-traumatic abdominal evisceration in a child

Introducción: Se considera un paciente politraumatizado aquel que presenta dos o más lesiones, de las que al menos una puede comprometer su vida o vaya a originar secuelas invalidantes. Una conducta inicial adecuada puede reducir la mortalidad de pacientes como el que se presenta, pues la atención inicial debe ser ordenada y sistemática; siempre se deben identificar y tratar con prioridad, las lesiones que comprometen la vida del paciente. Objetivo: Presentar un caso, que por su interés y singularidad en el mecanismo de acción, expone la secuencia de actuación que se llevó a cabo por cirujanos generales, fuera de un servicio de cirugía pediátrica. Caso clínico: Se reporta el caso de un paciente masculino de 6 años de edad, que acude al cuerpo de guardia politraumatizado y presenta una avulsión músculo cutánea abdominal con evisceración intestinal, al sufrir caída en movimiento con traumatismo abdominal penetrante con biela de pedal de una bicicleta. A pesar de no contar en la institución de atención, con servicio de cirugía pediátrica, se impuso la cirugía de emergencia por las condiciones del paciente. Conclusiones: Luego de laparotomía inicial con reconstrucción de la pared abdominal y cierre primario con puntos de seguridad, el paciente evolucionó de forma estable. Fue remitido para un servicio de terapia intensiva pediátrica, donde y evolucionó sin complicaciones, hasta su egreso(AU)

Introduction: A polytraumatized patient is considered to be one who presents two or more injuries, of which at least one may compromise his life or cause disabling sequelae. An adequate initial behavior can reduce the mortality of patients such as the one that occurs, because the initial attention must be orderly and systematic, the lesions that compromise the patient's life must always be identified and treated with priority. Objective: To present a case, which due to its interest and uniqueness in the mechanism of action, exposes the sequence of action that was carried out by general surgeons, outside of a pediatric surgery service. Clinical case: We report the case of a 6-year-old male patient who came to emergency, polytraumatized and presenting an abdominal skin muscle avulsion with intestinal evisceration, he suffered a fall during movement with penetrating abdominal trauma with a bike pedal crank. Despite not having a pediatric surgery service in the attending institution, emergency surgery was imposed due to the patient's conditions. Conclusions: After the initial laparotomy with reconstruction of the abdominal wall and primary closure with security points, the patients evolves in a stable way, he was referred to a pediatric intensive care service, where he evolved without complications until discharge(AU)

Abscesos residuales en apendicitis aguda: comparación entre abordaje laparotómico vs. laparoscópico / Residual abscesses in acute appendicitis: comparison between laparotomy vs. laparoscopic / Abcessos residuais na apendicite aguda: comparação entre laparotômico vs. laparoscópico

La apendicitis aguda es la urgencia quirúrgica más frecuente con una incidencia de 1.17 pacientes/1,000 habitantes. Con el advenimiento de la laparoscopía, un nuevo enfoque mini invasivo surgió para el tratamiento de la apendicitis aguda. Se han demostrado algunas ventajas de este abordaje como menor dolor posoperatorio, incisiones más pequeñas, estadías hospitalarias más cortas y un rápido reintegro a las actividades diarias y laborales, con menor frecuencia de infecciones a nivel de la herida operatoria. Sin embargo, se ha asociado también con un aumento en la frecuencia de abscesos residuales intra-abdominales. En este trabajo analizamos de manera retrospectiva a todos los pacientes operados en el Hospital Maciel de Montevideo, a los que se les realizó una apendicectomía entre el 1° de Junio de 2013 y el 30 de junio de 2016, tanto por vía laparoscópica como laparotómica. Esto correspondió a un total de 426 pacientes. 235 (55%) eran hombres y 191 (45%) mujeres. La media de edad fue de 32,6 en un rango desde los 15 años hasta los 96 años de edad. 128 pacientes presentaban apendicitis edematosas (30%), 157 apendicitis flemonosa (36,9%) 76 pacientes apendicitis gangrenosas (17,8%) 37 pacientes absceso o plastrón (8,7%) y peritonitis en 28 pacientes (6,6%). Con respecto al abordaje, 287 se realizaron por vía laparoscópica (67,4%) y 139 se abordaron por vía laparotómica (32,6%). Los abscesos residuales representan el 3,28% del total, no habiendo diferencias significativas entre los diferentes abordajes. La gran mayoría de estos abscesos residuales pueden tratarse con antibioticoterapia exclusivamente. La tasa de conversión fue del 8,7%. No se observaron lesiones de víscera hueca con el abordaje laparoscópico en esta serie.

Acute appendicitis is the most frequent surgical emergency with an incidence of 17 patients/1,000 inhabitants. With the advent of laparoscopy, a new mini-invasive approach emerged for the treatment of acute appendicitis. Some advantages of this approach have been demonstrated, such as less postoperative pain, smaller incisions, shorter hospital stays and a rapid reintegration to daily and work activities, with a lower frequency of infections at the level of the operative wound. However, it has also been associated with an increase in the frequency of intra-abdominal residual abscesses. In this paper, we retrospectively analyzed all patients operated on at the Maciel Hospital in Montevideo, who underwent an appendectomy between June 1, 2013 and June 30, 2016, both laparoscopically and laparotomically. Of these 235 (55%) were men and 191 (45%) women. The average age was 32.6 in a range from 15 years to 96 years of age. 128 patients presented edematous appendicitis (30%), 157 phlegmonous appendicitis (36.9%), 76 patients gangrenous appendicitis (17.8%), 37 patients presented abscess or plastron (8.7%), and peritonitis had developed in 28 patients (6.6%). Regarding the approach, 287 were performed laparoscopically (67.4%) and 139 were approached via laparotomy (32.6%). The residual abscesses rate represents 3.28% of the series, with no significant differences in incidence between the two different approaches. The vast majority of these residual abscesses can be treated with antibiotic therapy alone. The conversion rate was 8.7%. No intestinal lesions were observed with the laparoscopic approach in this series.

A apendicite aguda é a emergência cirúrgica mais freqüente, com uma incidência de 17 pacientes/1.000 habitantes. Com o advento da laparoscopia, uma nova abordagem mini-invasiva surgiu para o tratamento da apendicite aguda. Isto têm demonstrado algumas vantagens, como menor dor pós-operatória, incisões menores, menor hospitalização e restabelecimento mais rápido as atividades diárias e ao trabalho, assim como infecções menos freqüentes ao nível da ferida cirúrgica. No entanto, também foi associado a um aumento na freqüência de abscessos residuais intra-abdominais. Foram analisados retrospectivamente todos os pacientes operados no Hospital Maciel de Montevidéu, submetidos a uma apendicectomia desde o dia 01 de Junho de 2013 a 30 de Junho de 2016, tanto por abordagem laparoscópica como laparotomica. Destes, 235 (55%) eram homens e 191 (45%) mulheres. A idade média foi de 32,6 com intervalo de 15 anos a 96 anos de idade. 128 pacientes apresentaram apendicite edematosa (30%), 157 apendicite flemonosa (36,9%) 76 pacientes apendicite gangrenosa (17,8%) 37 pacientes abscesso ou plastrão (8,7%) e peritonite em 28 pacientes (6,6% ) Quanto à abordagem, foram realizadas 287 apendicectomias por via laparoscópica (67,4%) e 139 foram abordadas por laparotomia (32,6%). Os abscessos residuais representam 3,28% do total, não havendo diferenças significativas entre as diferentes abordagens. A grande maioria desses abscessos residuais pode ser tratada apenas com antibioticoterapia. A taxa de conversão foi de 8,7% Nenhuma lesão visceral foi observada com a abordagem laparoscópica nesta série.

Pediatric abdominal non-Hodgkin's lymphoma: diagnosis through surgical and non-surgical procedures / Linfoma não Hodgkin abdominal pediátrico: diagnóstico por meio de procedimentos cirúrgicos e não cirúrgicos

Abstract Objective: To describe the success rate and the complications after procedures to diagnose abdominal non-Hodgkin's lymphoma in children and adolescents. Methods: A retrospective cross-sectional study was conducted with a population consisting of children and adolescents with abdominal non-Hodgkin's lymphoma diagnosed between September 1994 and December 2012. The sample comprised of 100 patients who underwent 113 diagnostic procedures, including urgent surgery (n = 21), elective surgery (n = 36), and non-surgical diagnosis (n = 56). Results: The most frequent procedures were laparotomy (46.9%) and ultrasound-guided core biopsy (25.6%). The rate of diagnostic success was 95.2% for urgent surgeries; 100% for elective surgeries and 82.1% for non-surgical procedures (p < 0.05). The rates of complication during the three diagnosis procedures considered were significant (p < 0.001; 95.2% of the urgent surgeries, 83.8% of the elective surgeries, and 10.7% of the non-surgical procedures). The length of time before resuming a full diet and starting chemotherapy was significantly reduced for patients who underwent non-surgical procedures when compared with the other procedures (p < 0.001). Conclusion: Non-surgical procedures for the diagnosis of pediatric abdominal non-Hodgkin's lymphoma are an effective option with low morbidity rate, allowing an earlier resumption of a full diet and chemotherapy initiation. Furthermore, non-surgical procedures should also be considered for obtaining tumor samples from patients with extensive disease.

Resumo Objetivo: Descrever a taxa de sucesso e as complicações dos procedimentos para o diagnóstico de linfoma não Hodgkin abdominal em crianças e adolescentes. Métodos: Estudo retrospectivo transversal em uma população de crianças e adolescentes com linfoma não Hodgkin abdominal diagnosticada entre setembro de 1994 e dezembro de 2012. A amostra foi composta por 100 pacientes submetidos a 113 procedimentos diagnósticos, inclusive cirurgia de urgência (n = 21), cirurgia eletiva (n = 36) e diagnóstico não cirúrgico (n = 56). Resultados: Os procedimentos mais frequentes foram laparotomia (46,9%) e biópsia guiada por ultrassonografia (25,6%). A taxa de sucesso diagnóstico foi de 95,2% para cirurgias de urgência; 100% para cirurgias eletivas e 82,1% para procedimentos não cirúrgicos (p < 0,05). Houve diferença significativa entre as taxas de complicação associadas aos três grupos (p < 0,001; 95,2% das cirurgias urgentes, 83,8% das cirurgias eletivas e 10,7% dos procedimentos não cirúrgicos). O tempo decorrido até o reinício da dieta plena e o início a quimioterapia foi significativamente reduzido para os pacientes submetidos a procedimentos não cirúrgicos quando comparados com os outros procedimentos (p < 0,001). Conclusão: Os procedimentos não cirúrgicos para o diagnóstico do linfoma não Hodgkin abdominal pediátrico são uma opção efetiva com baixa taxa de morbidade, permitem uma retomada mais precoce de uma dieta plena e início de quimioterapia. Em pacientes com doença extensa, os procedimentos não cirúrgicos também devem ser considerados para a obtenção de amostras tumorais.

Consideraciones vigentes en torno al diagnóstico de la apendicitis aguda / Current considerations on the diagnosis of acute appendicitis

Introducción: La apendicitis aguda es la causa más común de abdomen agudo y de intervención quirúrgica efectuada en los servicios de urgencias y a pesar de ser conocida desde tiempos remotos, su diagnóstico todavía adolece de imprecisiones que preocupan a la comunidad científica. Objetivo: Realizar una revisión sobre los criterios vigentes en torno al diagnóstico de la apendicitis aguda a fin de profundizar en sus aspectos cognoscitivos. Métodos: Búsqueda digital en bases de datos Web of Science, Lilacs, Scielo, Latindex, Elsevier, PubMed, Medline y Google de publicaciones actualizadas en inglés y español. Resultados: En los últimos años ha descendido la mortalidad asociada a la apendicitis aguda, lo cual se atribuye a los avances tecnológicos de la cirugía y de la anestesiología y reanimación, la existencia de salas de cuidados intensivos para la atención de pacientes graves y de la utilización de antibióticos cada vez más potentes. No obstante, la morbilidad todavía refleja alta incidencia de perforaciones a pesar de la utilización de marcadores inflamatorios, los diagnósticos realizados mediante imágenes, y del desarrollo de técnicas videolaparoscópicas. Aun así, continúan realizándose apendicectomías en apéndices normales. Conclusiones: La clínica sigue siendo el método de elección para efectuar el diagnóstico, dado que los exámenes de laboratorio e imágenes no han logrado superarlo. Si bien constituyen una importante ayuda, toda vez que las escalas diagnósticas contribuyen a su precocidad en aras de disminuir la morbilidad y mortalidad, así como las apendicectomías innecesarias o en estadios avanzados de la enfermedad(AU)

Introduction: Acute appendicitis is the most common cause of acute abdomen and surgical treatment in the emergency services, and although this disease has been known since ancient times, its diagnosis still has inaccuracies that concern the scientific community. Objective: To make a review of the current criteria about the diagnosis of acute appendicitis in order to delve into its cognitive aspects. Methods: Search of updated publications in Spanish and English in Science, Lilacs, Latindex, Elsevier, PubMed, Medline and Google databases. Results: In the last few years, the acute appendicitis-associated mortality has decreased due to the technological advances in surgery, anesthesiology and resuscitation, the existence of intensive care units for critically-ill patients and the use of increasingly powerful antibiotics. However, morbidity rates still show high incidence of perforations despite the use of inflammatory markers, imaging-based diagnoses and the development of videolaparoscopic techniques. Despite all this, appendicectomies continue to be performed to treat normal appendices. Conclusions: The clinical method remains the method of choice to make a diagnosis, since the lab and imaging tests have not been better so far. Nevertheless, they are important support because the diagnostic scales contribute to their earliness with a view to reducing morbidity and mortality as well as unnecessary appendicectomies or appendicectomy in advanced disease stagings(AU)

Insuflación con aguja de Veress en punto de Palmer, hasta presión intraabdominal de 25 mmHg. Técnica para mejorar la seguridad del acceso laparoscópico ginecológico / Veress needle inflation at Palmer's point, up to intra-abdominal pressure of 25 mmHg. Technique to improve the safety of gynecological laparoscopic access

RESUMEN Objetivos: El objetivo del estudio es observar los beneficios de la entrada laparoscópica con trocar para la óptica, tras la insuflación previa con aguja de Veress en punto de Palmer, hasta conseguir una presión intraabdominal de 25 mmHg. Material y método: Estudio prospectivo de 115 cirugías laparoscópicas realizadas con la técnica anteriormente descrita, por el mismo equipo quirúrgico; de julio de 2014 a marzo de 2018, en el Departamento de Ginecología del Hospital General Santa María del Puerto. Resultados: El tiempo medio de las maniobras de acceso fue de 175 segundos. En el 84.3 % de las ocasiones, el acceso a la cavidad abdominal se consiguió en el primer intento. Sólo en dos ocasiones (1.7%), fue necesario cambiar la técnica de acceso. No se objetivó ninguna complicación o efecto adverso en el 96.5% de las cirugías. En dos pacientes (1.7%) se produjo un enfisema subcutáneo, en una ocasión un enfisema epiploico (0.9%) y en una paciente (0.9%), se objetivó una ligera intolerancia anestésica durante la realización del neumoperitoneo. No se registró durante el estudio ninguna complicación mayor asociada a las maniobras de acceso. Conclusiones: La entrada con presiones altas intraabdominales tras insuflación con aguja de Veress en punto de Palmer, es una técnica segura y reproducible para evitar complicaciones mayores, durante las maniobras de acceso a cavidad abdominal. Además, esta técnica no produce efectos adversos anestésicos relevantes secundarios a las altas presiones en pacientes sanas, debido al escaso tiempo durante el que se mantienen las mismas.

ABSTRACT Objectives: The aim of the study is to observe the benefits of laparoscopic trocar entry for optics, after previous insufflation with Veress needle at Palmer's point, until an intra-abdominal pressure of 25 mmHg is achieved. Material and method: Prospective study of 115 laparoscopic surgeries performed with the previously described technique, by the same surgical team; from July 2014 to March 2018, in the Department of Gynecology of the Hospital General Santa María del Puerto. Results: The average time of access maneuvers was 175 seconds. In 84.3% of the cases, access to the abdominal cavity was achieved on the first attempt. Only on two occasions (1.7%), it was necessary to change the access technique. No complication or adverse effect was found in 96.5% of the surgeries. Subcutaneous emphysema (1.7%) occurred in two patients, epiploic emphysema (0.9%) and in one patient (0.9%), a slight anesthetic intolerance was observed during the pneumoperitoneum. No major complications associated with the access maneuvers were recorded during the study. Conclusions: The entry with high intra-abdominal pressures after insufflation with Veress needle at Palmer's point, is a safe and reproducible technique to avoid major complications, during maneuvers of access to the abdominal cavity. In addition, this technique does not produce relevant adverse anesthetic effects secondary to high pressures in healthy patients, due to the short time during which they remain.

Incidência de hérnias incisionais em pacientes submetidos a laparotomias medianas em um hospital de ensino no interior do estado do Rio Grande do Sul / Incidence of incisional hernias in patients submitted to midline laparotomy in a teaching hospital in the interior of Rio Grande do Sul

Introdução: Avaliar o comportamento da parede abdominal dos pacientes submetidos à laparotomia mediana em um programa de residência médica em cirurgia geral no interior do estado do Rio Grande do Sul. Métodos: Trata-se de um estudo longitudinal de cará- ter descritivo que avalia o comportamento da parede abdominal após laparotomia mediana, no período de 2011 a 2014, em pacientes com idade superior a 13 anos. Resultados: Dos 30 pacientes avaliados, 12 apresentaram hérnia incisional (40%); destes, 25% eram obesos e 25% diabéticos. Em 17% dos casos com hérnia incisional, houve infecção de ferida operatória. No grupo que apresentou hérnia, a maioria dos pacientes teve o fechamento de sua parede realizado por residentes do primeiro ano (R1). Em 42% dos casos com hérnia, foi utilizado poliglactina 910 para fechamento da parede abdominal. Os pacientes que foram diagnosticados com hérnia incisional permaneceram internados uma média de 4 dias a menos que os pacientes que não apresentaram hérnia. Todos os pacientes foram submetidos à laparotomia mediana e 29 deles foram submetidos à cirurgia de urgência, não sendo possível realizar uma comparação entre estas variáveis. Conclusão: De todos os parâmetros analisados, o tipo de fio de sutura utilizado para fechamento da parede, bem como por quem este fechamento foi realizado e o tempo que estes pacientes permaneceram internados foram os mais expressivos quanto ao desenvolvimento de hérnia incisional(AU)

Background: To evaluate the behavior of the abdominal wall in patients undergoing laparotomy in a medical residency program in general surgery in the interior of Rio Grande do Sul. Methods: This is a descriptive longitudinal study that evaluates the behavior of the abdominal wall after laparotomy, in the period from 2011 to 2014 in patients aged over 13 years. Results: Of the 30 patients evaluated, 12 had incisional hernia (40%), and of these, 25% were obese and 25% were diabetic. In 17% of the cases with incisional hernia, there was wound infection. In the group with hernia, most patients had the closing of their wall performed by a first year resident (R1). In 42% of the cases with hernia, polyglactin 910 was used for closure of the abdominal wall. The patients diagnosed with incisional hernia remained hospitalized an average of four days less than did those without hernia. All patients underwent midline incision and 29 of them underwent emergency surgery, but it was not possible to make a comparison between these variables. Conclusion: Of all the analyzed parameters, the type of suture used to lock the wall, who performed this closure and the length of time these patients remained hospitalized were the most significant ones regarding the development of incisional hernia(AU)

Evaluación de criterios para laparotomía en lesiones abdominales por arma blanca / Laparotomy criteria assessment in abdominal stab wounds

Introducción: las lesiones traumáticas penetrantes del abdomen involucran usualmente la violación de la cavidad abdominal por una herida realizada con arma blanca u otro tipo de objeto cortopunzante. Esto constituye un problema de salud y uno de los motivos de urgencia, más comunes en la consulta de cirugía. En Cuba, los accidentes donde se incluyen este tipo de lesiones constituyeron la quinta causa de defunciones, en ambos sexos, en el año 2014. Objetivo: evaluar los criterios indicativos de laparotomía en pacientes con heridas abdominales por arma blanca. Método: se realizó un estudio de evaluación de medios diagnósticos en pacientes sometidos a una laparotomía exploratoria por herida abdominal con arma blanca. La población estuvo constituida por todos los pacientes con este tipo de lesión y la muestra por los intervenidos quirúrgicamente. Se evaluaron diversos elementos clínicos y complementarios indicativos de laparotomía ante la posibilidad de lesión orgánica significativa. Resultados: la edad promedio fue de 32 años; predominó el sexo masculino (91,3 por ciento). De los pacientes, 41,3 por ciento se presentaron signos de intoxicación exógena, y 51,25 por ciento de las laparotomías fueron terapéuticas. Mostraron mejores resultados de sensibilidad, especificidad y valores predictivos positivos la presencia de choque hipovolémico (84,2 por ciento), signos clínicos de hemorragia continua (82,4 por ciento) y perforación obvia del tracto gastrointestinal (90,9 por ciento). Entre los complementarios la laparoscopia mostró valores de sensibilidad (89,5 por ciento) y especificidad (81,8 por ciento) superior al resto. Conclusiones: el choque hipovolémico, los signos de hemorragia continua, signos de perforación obvia del tracto gastrointestinal, y la laparoscopia revelaron los mejores resultados como criterios indicativos de laparotomía en heridas abdominales por arma blanca(AU)

Introduction: penetrating traumatic lesions of the abdomen usually leads to damage in the abdominal cavity from a wound caused with a white weapon or other sharp-piercing object. This circumstance constitutes a health problem and one of the most common reasons for emergency consultation in surgery. This type of lesions was the fifth leading cause of death for both sexes in Cuba in 2014. Objective: to evaluate the criteria indicative of laparotomy in patients with abdominal wounds caused with a white weapon. Method: a diagnostic modalities assessment study was carried out in patients who underwent exploratory laparotomy for abdominal wound caused by a white weapon. The target group was made up by the patients with this type of lesions. The sample consisted of surgery patients (n= 80). Several clinical and complementary elements indicative of laparotomy were assessed before the possibility of significant organic lesions. Results: the average age was 32 years, with a predominance of males (91.3 percent). 41.3 percent of the patients showed exogenous intoxication signs, only 51.25 percent of laparotomies were therapeutic ones. The presence of hypovolemic shock (84.2 percent), clinical signs of ongoing bleeding (82.4 percent) and obvious gastrointestinal tract perforation (90.9 percent) showed better sensitivity, specificity and positive predictive values. Among the complementary tests, laparoscopy showed values of sensitivity (89.5 percent) and specificity (81.8 percent) higher than the others. Conclusions: hypovolemic shock, signs of ongoing bleeding and signs of obvious gastrointestinal tract perforation, and laparoscopy showed the best results as criteria indicative of laparotomy in abdominal stab wounds(AU)

Síndrome de VOMIT (Victim of Modern Imaging Technology) en pacientes con trauma de abdomen cerrado que consultaron en la Unidad de emergencia del Hospital General ISSS sometidos a LPE periodo enero 2012 a diciembre 2014 / VOMIT (Victim of Modern Imaging Technology) syndrome in patients with blunt abdominal trauma who consulted in the Emergency Unit of the General Hospital of the ISSS submitted to exploratory laparotomy from January 2012 to December 2014

La tecnología se ha extendido a todas las áreas de la medicina, incluida la imagenología El síndrome V.O.M.I.T "VICTIM OF MODERN IMAGING TECHNOLOGY", describe el conjunto de consecuencias adversas secundarias a la mala aplicación e interpretación imagenológica, vinculadas al diagnóstico, tratamiento ó pronóstico de los pacientes politraumatizados que ingresan al Servicio de Emergencia. Es una entidad clínica en si misma dentro del capítulo de errores médicos y los servicios de emergencia son áreas de riesgo para que suceda. Sin duda, es imprescindible conocerlo, medirlo y plantear medidas preventivas. En nuestro medio la real incidencia de este problema se desconoce. Es por eso que la pregunta de nuestra investigación es: ¿Con que frecuencia la decisión de realizar una laparotomía exploradora en trauma cerrado de abdomen, con claras indicaciones clínicas se ve retrasada en espera de estudios de imagenología? Nuestra hipótesis era que La toma de conducta quirúrgica en trauma cerrado de abdomen en la unidad de emergencia del Hospital General del Seguro Social está siendo retrasada por el Síndrome de V.O.M.I.T. la cual fue verdadera. Es por esto que el objetivo general de nuestro estudio fue demostrar la presencia y frecuencia de este síndrome. Para ello recolectaremos del libro de procedimientos de Sala de Operaciones de la Unidad de Emergencia del Hospital General (ISSS) los números de expedientes de los pacientes que fueron sometido a Laparotomía Exploradora con diagnostico trauma cerrado de abdomen, en el periodo de Enero 2012 a Diciembre 2014 posteriormente se revisaron dichos expedientes y analizaron los datos los cuales se presentan posteriormente

Intra-peritoneal administration of Ecballium elaterium diminishes postoperative adhesions

PURPOSE: To evaluate the effects of Ecballium elaterium (EE), Elaterium officinarum, in postoperative intraperitoneal adhesions in rats. METHODS: Thirty rats were divided into three groups and underwent midline laparotomy under 35 mg/kg ketamine and 5 mg/kg xylazine anaesthesia. In group 1 (n=10), the sham operation group, the abdominal walls were closed without any process. In group 2 (n=10), the control group, the antimesenteric border of the ceacum and the corresponding parietal peritoneum were abraded with dry sterile gauze. In group 3 (n=10), the EE group, 2.5 mg/kg dose of EE was administered as intraperitoneally to the rats after abrasion. All rats were sacrificed on postoperative day 15. Samples were obtained RESULTS: The adhesion score was significantly decreased in the EE group (p=0.001) in comparison with the control group. Microscopically, the EE and sham groups were significantly lower than that of the control group (p<0.001 and p=0.000, respectively). Furthermore, the measurement of tissue levels of hydroxyproline was significantly lower in the sham and EE groups compared to the control group (sham group: 47.6 ± 10.6, EE group: 62.9 ± 9.7, Control group: 84.2 ± 22.1 mg /L/g-tissue). CONCLUSION: The grade and severity of abdominal adhesion could be significantly reduced through administered Ecballium elaterium and therefore be a suitable anti-inflammatory agent for the prevention of postoperative peritoneal adhesion in the future. .

LAPAROSCOPY VERSUS LAPAROTOMY IN THE REPAIR OF VENTRAL HERNIAS: systematic review and meta-analysis / Laparoscopia versus laparotomia no reparo das hernias ventrais: revisão sistemática e meta-análise

Objective To compare the laparotomy and laparoscopy techniques for correction of ventral hernia when related to perioperative complications, length of hospitalization, surgical time, and recurrence of hernia. Methods This was a systematic review of randomized controlled trials, which included studies retrieved from four databases (MEDLINE, Embase, Cochrane and LILACS), using a combination of the terms (Hernia, Ventral) and (Laparoscopy) and (Laparotomy). Results Six randomized trials were included, totaling 566 patients, 283 in the Laparoscopy group and 283 in the Laparotomy group. Laparoscopy reduced the risk of infection of the surgical wound (NNT = 5) and seroma formation (NNT = 13) and less length hospitalization (P = 0.02) compared to laparotomy in the correction of ventral hernias. Furthermore, laparoscopy increased the incidence of enterotomy (NNH = 25) and post operative pain (NNH = 8) and longer surgical time (P = 0.0009) when compared with laparotomy. There was no difference related to abscess (P = 0.79), hematoma (P = 0.43) and recurrency of ventral hernias (P = 0.25). Conclusions In the correction of ventral hernias, the use of laparoscopic technique is effective to reduce infections of the surgical wound and seroma formation, as well as, decrease the length hospitalization. .

Objetivo Comparar as técnicas de laparoscopia e laparotomia para a correção de hérnia ventral quando relacionadas com as complicações perioperatórias, tempo de hospitalização, tempo cirúrgico e recorrência de hérnia. Métodos Foi realizada uma revisão sistemática de ensaios clínicos randomizados, que incluiu estudos de quatro bases de dados (MEDLINE, Embase, Cochrane and LILACS) usando a combinação dos descritores (Hernia ventral) AND (Laparoscopia) AND (Laparotomia). Resultados Seis ensaios clínicos randomizados foram incluídos, totalizando 566 pacientes, sendo 283 no grupo da Laparoscopia e 283 no grupo da Laparotomia. A laparoscopia reduziu o risco de infecção da ferida operatória (NNT = 5) e a formação do seroma (NNH = 13) além do tempo de hospitalização (P = 0,02) quando comparado à laparotomia para a correção de hérnias ventrais. Além disso, a laparoscopia aumentou a incidência de enterotomia (NNH = 25), dor pós-operatória (NNH = 8) e o tempo cirúrgico(P = 0,0009) quando comparado à laparotomia. Não houve diferença significantiva em relação ao abscesso (P = 0,79), hematoma (P = 0,43) e recorrência de hérnias ventrais (P = 0,25). Conclusões Na correção de hérnias ventrais, o uso da técnica laparoscópica é efetiva para reduzir infecção de ferida operatória e a formação do seroma, assim como diminui o tempo de hospitalização. .

Reintervenciones quirúrgicas abdominales / Abdominal surgical reintervention

Introducción: las complicaciones intrabdominales después de una laparotomía agravan el estado del paciente y ensombrece su pronóstico. La relaparotomía es aquella que se lleva a cabo en un paciente previamente operado y que en los treinta días del postoperatorio haya presentado una complicación intrabdominal.Objetivo: describir los resultados de las reintervenciones quirúrgicas abdominales.Método: se realizó un estudio descriptivo, transversal y prospectivo en el servicio de cirugía del Hospital General Docente Aleida Fernández Chardiet del municipio Güines, provincia Mayabeque, desde enero de 2008 hasta enero de 2011. La muestra coincidió con el universo N=n de 46 pacientes que fueron reintervenidos por complicaciones quirúrgicas intrabdominales. Se analizaron las variables edad, sexo, número de reintervenciones, tiempo entre la operación inicial y la relaparotomía, valor de la presión intrabdominal, así como su relación con la mortalidad y causa directa de muerte.Resultados: predominaron los pacientes entre 40-49años, el sistema de órganos más afectado en la intervención inicial fue el gastrointestinal y asociado a peritonitis bacteriana secundaria, predominaron los pacientes que se intervinieron antes de las 48 horas y los que tuvieron dos reintervenciones, la mayoría presentaron presión intrabdominal grado III y la causa de muerte más frecuente fue la disfunción múltiple de órganos Conclusiones: el aumento del tiempo entre la intervención inicial y la primera reintervención, el número creciente de reintervenciones y el aumento descontrolado de la presión intrabdominal por encima de valores normales incrementa directamente la mortalidad por las consecuencias del Síndrome Compartimental Abdominal.

Introduction: intra-abdominal complications after laparotomy aggravate the patient's condition and worsens prognosis. Relaparotomy is the one that is carried out in a previously operated patient and who has presented postoperative intra-abdominal complication within thirty days.Objective: to describe the results of surgical reinterventions. Method: a descriptive, cross-sectional and prospective study was conducted at the Surgery Service of Aleida Fernández Chardiet General Teaching Hospital of Güines Municipality, Mayabeque Province from January 2008 to January 2011. The sample coincided with the universe N=n of 46 patients who were reintervened due to intra-abdominal surgical complications. It was analyzed the variables age, sex, number of reinterventions, time between the initial operation and relaparotomy, value of the intra-abdominal pressure as well as its relation to mortality and direct cause of death.Results: patients were predominantly between 40 49 y.o., the most affected organ system in the initial intervention was the gastrointestinal one associated with secondary bacterial peritonitis, There was predominance of patients operated on before 48 hours and those who had two reinterventions, the majority presented intra-abdominal pressure Grade III and the most frequent cause of death was Multiple Organ Dysfunction.Conclusions: the increase of the time between the initial intervention and the first reintervention, the increasing number of reinterventions and the uncontrolled increase in intra-abdominal pressure above normal values directly increases mortality for the consequences of Abdominal Compartment Syndrome

Reparación de la hernia poslaparotómica mediante un modelo de hernioplastia incisional / Repair of post-laparotomy hernia by means of an incisional hernioplasty model

Introducción: la hernia incisional se encuentra dentro de las complicaciones más temidas por los cirujanos tras la realización de una laparotomía. La aplicación de técnicas tisulares para su reparación se empleó tradicionalmente, pero estas no mostraron buenos resultados. El advenimiento de los materiales protésicos ha disminuido el índice de recidiva y el dolor posoperatorio en los pacientes con hernia incisional. Objetivo: conocer los resultados obtenidos en nuestro centro con la aplicación de un modelo de hernioplastia incisional para el tratamiento de la hernia poslaparotómica. Métodos: se realizó un estudio de carácter prospectivo longitudinal en el Hospital Dr Carlos J Finlay, con 143 pacientes que presentaban hernias incisionales. Resultados: el sexo femenino fue el más afectado. La obesidad, el hábito de fumar, las enfermedades pulmonares obstructivas crónicas, y la colagenosis, se distinguen entre los factores de riesgo más frecuentes. La mayoría de los pacientes presentaban hernias medianas con anillos entre 10 y 15 cm. El seroma fue la complicación principal. El índice de recidiva fue solo del 2,06 por ciento. Conclusiones: el modelo de hernioplastia incisional propuesto representa una alternativa segura, pues ofrece un índice de recidiva aceptable(AU)

Introduction: incisional hernia is included in the more fearsome complications by surgeons after carrying out of a laparotomy. The application of tissular techniques for its repair was traditionally used but these ones have not good results. The advent of prosthetic materials has decreased the relapse rate and the postoperative pain in patients presenting with incisional hernia. Objective: to know the results obtained in our center with application of an incisional hernioplasty model for treatment of post-laparotomy hernia. Methods: a longitudinal and prospective study was conducted in the Dr Carlos J Finlay Hospital in 143 patients with incisional hernias. Results: the female sex was the more involved one. Obesity, smoking, chronic obstructive pulmonary diseases and the collagenosis are included in the more frequent risk factors. Most of patients had medium hernias with rings between 10 and 15 cm. Seroma was the major complication. The relapse rate was only of 2,06 percent. Conclusions: the proposed model of incisional hernioplasty is a safe alternative, thus it offers an acceptable relapse rate(AU)

Beneficio de la goma de mascar vs metoclopramida en la prevención del íleo postoperatorio de laparotomía / Benefit of chewing gum vs metoclopramide in the prevention of postoperative ileus ofter laparotomy

Analizar el beneficio de la goma de mascar y la metoclopramida en la prevención del íleo postoperatorio de laparotomía, Hospital Victorino Santaella Ruíz, octubre-noviembre 2009. Estudio prospectivo, cuasiexpemental. Un total de 60 pacientes post-operados de laparotomía fueron seleccionados y distribuidos equitativamente en 3 grupos: metoclopramida, goma de mascar y grupo control. Se registro el inicio de ruidos hidroaéreos, expulsión de flatos, evacuaciones y tolerancia completa a la vía oral en cada grupo. Los resultados fueron semetidos a un análisis de varianza de una sola vía y test de comparaciones múltiples. Con respecto al grupo control el grupo goma de mascar demostró ventaja al evaluar los factores ruidos hidroaéreos (p<0,05) y tolerancia completa a la vía oral (p<0.02). De la misma manera lo demostró el grupo metoclopramida (p<0,05) sobre el grupo control cuando se evaluó el factor flatos. Y en relación al factor evacuaciones ambos grupos terapéuticos demostraron igual superioridad sobre el grupo control (p<0.02). No se observaron diferencias significativas entre los grupos goma de mascar y metoclopramida. No se observaron diferencias significativas entre la administración de goma de mascar y metoclopramida, sin embargo al compararlos individualmente con el grupo control ambos mostraron beneficios estadísticamente significativos, que fueron mayores cuantitativamente en el grupo goma de mascar. En base a lo anterior y a otras ventajas como; la virtual ausencia de efectos secundarios, su bajo costo, su fácil y amplia disponibilidad, podemos recomendar el uso de goma de mascar para la prevención del íleo postoperatorio.

Analyze the benefit of chewing gum and metoclopramide in the prevention of postoperative ileus after laparotomy, Hospital Victorino Santaella Ruíz, octubre-november 2009. A prospective clinical trial carried out on 60 post-operatives of laparotomy patients. They were randomly assigned into three groups: metoclopramide, chewing gum and control group. The beginning of bowel sounds, flatus, bowel movements and complete food tolerance were recorded in each group. The data were analysed using the one-way variance method and the multiple comparison test. With respect to control group, the chewing gum group showed some statistical advantage when the factor, bowel sounds and complete food tolerance were compared (p<0,05) and (p<0.02) respectively. Metoclopramide showed advantage over the control group in regard to flatus factor (p<0,05). For the bowel movement factor, both therapeutic groups showed identical superiority compared to control group (p<0.02). There was no statistical diference between metoclopramide and chewing gum groups. There were not statistical difference between both therapeutic groups; nevertheless, when both of them were compared individually with the control group, the chewing gum group showed cuantitatively more advantages than metoclopramide group in the prevention of postoperative ileus. Based on the previously describe and other advantages as absence of side effects low cost and easy accessibility we can recommend the use of chewing gum in the prevention of postoperative ileus.

Abordaje laparoscópico en cáncer de endometrio / Laparoscopic approach for endometrial cancer

El cáncer de endometrio es una neoplasia ginecológica relevante en todo el mundo, con cambios acelerados en su manejo. La cirugía es el tratamiento de elección, pero puede llegar a tener una alta tasa de complicaciones y retraso en el inicio de terapias adyuvantes por el trauma quirúrgico que provoca. Este artículo revisa el rol de la laparoscopia en el manejo de las pacientes con cáncer endometrial, haciendo hincapié en su seguridad oncológica, beneficios y complicaciones. Al comparar la vía clásica por laparotomía, la laparoscopia, en manos experimentadas, tiene similares resultados respecto de sobrevida, recurrencia y etapificación completa, pero con una menor tasa de complicaciones. La vía endoscópica podría ser la herramienta del futuro en el manejo del cáncer de endometrio.

Endometrial cancer is a relevant gynecologic neoplasm, with accelerated changes in its management. Surgery is the treatment of choice, but it can have a high rate of complications and delay in adjuvant therapies due to the surgical trauma that it inflicts. This article reviews the role of laparoscopy in the management of women with endometrial cancer, highlighting the oncologic safety, benefits and complications. Comparing laparotomy with laparoscopy, in experienced hands, it has the same results concerning to survival, recurrence and complete staging, with a lower rate of complications. Celioscopy could be the tool of the future in the management of endometrial cancer.

Gastrointestinal fistula: audit of management in a remote hospital

The management of gastrointestinal fistula continues to present considerable challenge to the surgeon in general and gastrointestinal surgeon in particular. To audit the management and report the outcome of the gastrointestinal fistula in a remote hospital. Eldamazeen Hospital is a regional hospital in the Blue Nile state, south east of Sudan. Retrospective analysis of demographic and clinical data of patients with gastrointestinal fistula admitted to the surgical department in the period from Feb 2003 through Feb 2008. 10 [83.3%] patients had high out-put fistula. Two fistulas were complex and 10 were simple. The small intestine was the commonest site of fistula followed by the large bowel. The commonest causes of the gastrointestinal fistula are emergency operations for stab wounds, laparotomy and caesarean section. The overall mortality rate is 2 [16, 7%] patients mainly due to inter-abdominal abscesses. Conservative treatment with nutritional support is the corner stay for successful treatment. However, early surgical management of septic foci should be considered