Interpretation of consensus on the surgical management of benign gallbladder diseases (2021 edition) / 中华外科杂志

Benign gallbladder diseases are common diseases in surgery,which are closely related to the occurrence of gallbladder cancer.Currently,nonstandard treatment exited in the surgical management of benign gallbladder diseases in China. Based on relevant domestic and foreign literature,guidelines,and expert consensus,consensus on the surgical management of benign gallbladder diseases(2021 edition) has been formulated. Further,recommendations related to diagnosis and treatment were presented to improve the standardization of surgical diagnosis and treatment of benign gallbladder diseases in China,so as to eliminate the clinical harm of gallbladder diseases and reduce the incidence rate of gallbladder cancer and prevent the occurrence. After the publication of the consensus,it has aroused heated discussion. This paper will interpret the hot issues.

Consensus on the surgical management of benign gallbladder diseases(2021 edition) / 中华外科杂志

Benign gallbladder diseases are common in surgery department,and the incidence rate is increasing in recent years.Currently,nonstandard treatment existed in the surgical management of benign gallbladder diseases in China.Based on relevant domestic and foreign literature,guidelines,and expert consensus,this consensus expounds on the diagnosis and surgical treatment of common benign gallbladder diseases such as gallstone,cholecystitis,gallbladder polypoid,gallbladder adenomyosis,gallbladder variation and deformity,complications after cholecystectomy.Further,recommendations related to diagnosis and treatment were presented to improve the standardization of surgical diagnosis and treatment of benign gallbladder diseases in China,so as to eliminate the clinical harm of gallbladder diseases and reduce the incidence rate of gallbladder cancer and prevent the occurrence.

¿Está exenta de consecuencias adversas la perforación iatrogénica de la vesícula biliar durante la colecistectomía laparoscópica electiva? / Iatrogenic gallbladder perforation during elective laparoscopic cholecystectomy, is it exempt from adverse consequences?

Resumen Objetivo: Este estudio se llevó a cabo para valorar las consecuencias de la perforación iatrogénica de la vesícula biliar (PIVB), investigando su asociación con complicaciones posoperatorias, uso de antibióticos y drenajes, duración de la cirugía y estancia posoperatoria. Materiales y Método: Se incluyeron 1.703 pacientes con colecistectomía laparoscópica electiva, divididos en dos grupos: con PIVB (Grupo 1; n = 321) y sin PIVB (Grupo 2; n = 1.382). Se compararon los resultados entre ambos grupos. Resultados: El porcentaje de PIVB fue de 18,85%. El vertido aislado de bilis ocurrió en 241 pacientes (14,15%) y el de bilis y cálculos en 80 pacientes (4,64%). La incidencia de infección del sitio quirúrgico no fue diferente entre ambos grupos. La incidencia de PIVB fue mayor en varones (43,3% vs 31,3%), pacientes con adherencias perivesiculares (17,75% vs. 10,5%) y pacientes con diagnóstico histológico de colecistitis aguda (11,52% vs. 4,92%). La PIVB se asoció significativamente con mayor duración de la cirugía (77,3 vs. 65,4 minutos), mayor uso de drenajes y antibióticos y mayor estancia posoperatoria. No hubo complicaciones tardías. Discusión y Conclusión: La PIVB no aumenta la incidencia de infección, pero se asocia con un mayor uso de drenajes y antibióticos, mayor duración de la cirugía y mayor estancia posoperatoria.

Aim: This study was conducted to evaluate the outcomes in patients with iatrogenic gallbladder perforation (IGP), investigating its association with postoperative complications, use of antibiotics and drains, operative time and postoperative stay. Materials and Method: 1703 patients who underwent elective laparoscopic cholecystectomy were included and divided in two groups: with IGP (Group 1, n = 321) and without IGP (Group 2, n = 1382). We compared the outcomes between both groups. Results: The IGP rate was 18.85%. Isolated bile spillage occurred in 241 patients (14.15%), and stone spillage in 80 patients (4.64%). The incidence of surgical site infections was not different between both groups. The IGP rate was significantly higher in male (43.3% vs 31.3%), in patients with perivesicular adhesions (17.75% vs 10.5%) and in patients with histologic diagnosis of acute cholecystitis (11.52% vs 4.92%). Operative time was significantly longer in patients with IGP (77.3 vs 65.4 minutes). Intraoperative drain and antibiotic use, as well as postoperative stay were, also, significantly higher in patients with IGP. There was not any late complication. Conclusión: Bile and gallstones spillage do not lead to an increase in surgical site infections, but is associated with an increased use of antibiotics and drains, longer operative time and longer postoperative stay.

Síndrome de Klipper-Trenaunay-Weber con compromiso vesical y uterino tratado por vía endoscópica y endovascular / Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Hallazgos y propuesta de sistematización de las variaciones quirúrgicamente importantes de la arteria cística en un estudio in vivo en 2000 colecistectomías laparoscópicas ambulatorias / Findings and proposal for systematization of surgically important variations of the cystic artery based on an in vivo study of 2000 outpatient laparoscopic cholecystectomies

Realizar un estudio anatómico in vivo con la especial y pequeña disección quirúrgica durante una colecistectomía laparoscópica sobre las variaciones de la arteria cística. Estudio prospectivo de 38 meses, en 2000 pacientes consecutivos sometidos a colecistectomía laparoscópica programada, sin signos de inflamación aguda, ni alteración que impida disección y correcta evaluación del triángulo hepatocístico. Se disecó quirúrgicamente identificándose la arteria cística y posible duplicación, eran clínicamente importantes aquellas con diámetro mayor a 1,5 mm, requerían maniobra hemostática. Se anotaron los hallazgos en planilla especial a los fines del presente estudio. En 1831 casos había arteria única en medio del triángulo hepatocístico. Hubo 169 variaciones (8,45 %). En 97 casos: doble vascularización, con una arteria en situación normal y otra ubicada lateralmente al triangulo hepatocístico. En 44 pacientes había una arteria única lateralmente al conducto cístico que no lo cruzaba nunca. En 22 casos existía una arteria cruzando el colédoco y el cístico entrando en el triángulo. En 6 oportunidades una doble arteria, una en el triángulo hepatocístico y otra lateralmente que no cruzaba el cístico ni colédoco. En una oportunidad se observó una sola arteria importante que salía directamente de la placa cística entre segmento 4 y 5, y en otro caso solo pequeñas arterias proveniente de la placa cística. Podemos dividirlas en arterias únicas o dobles, en base exclusiva a la necesidad de maniobra hemostática. Podemos decir que las variaciones estarán presentes en aproximadamente 1/12 casos y necesitará una maniobra hemostática especial en 1/20 casos.

This is an anatomical study with the special and small dissection of a laparoscopic cholecystectomy on the surgically important variations of the cystic artery. A prospective, 19-month study was conducted in 2000, including consecutive patients undergoing programmed laparoscopic cholecystectomy, without signs of acute inflammation, or alteration, that would prevent dissection and correct evaluation of the cystohepatic triangle. It was surgically dissected, identifying the main cystic artery and its possible collateral arteries. Those with a diameter greater than 1.5 mm being considered as clinically important, requiring haemostatic maneuver (clipping and / or electrocoagulation). The findings were recorded on a special form for the purposes of this study. The classic, single-artery arrangement in the middle of the cystohepatic triangle was found in 1831 cases. The variations found were 169 (8.45 %). In 97 cases there was double vascularization, with one artery in normal position and another outside the cystic duct. In 44 patients, a single artery that did not cross the cystic was observed. In 22 cases an artery outside the cystic but crossing it before the duct. In 6 cases a double artery, one in the cystohepatic triangle and another outside the triangle, did not cross the cystic or the bile duct. In one instance, a single major artery was seen emerging directly from the cystic plaque between segments four and five. These can be divided into single or double arteries, based exclusively on the need for hemostatic maneuver. Knowledge of anatomical variations of the cystic artery is important for the surgeon. The variation presents in 1 of 12 cases, and requires a special hemostatic maneuver in 1 of 20 cases.

Complete gallbladder duplication: seventh report in world literature

Gallbladder duplication results from a rare abnormality of embriogenesis and is twice as common in women as in men. The signs and symptoms of double gallbladder cholecystitis are the same as those of single gallbladder cholecystitis: strong pain in the epigastric region and right hypochondrium, which may irradiate to the back and be accompanied by nausea and/or vomiting, Murphy positive sign, and pain on palpation of these regions; plastron may also be present. For this reason, many cases are still diagnosed intraoperatively, making surgery difficult and increasing the possibility of biliary tract injury. We report the case of a female patient with epigastric and dorsal pain for 4 days, which worsened with the ingestion of salty and fatty foods and was accompanied by nausea and vomiting. Physical examination showed a positive Murphy sign. A complete abdominal ultrasound examination showed gallbladder duplication, both lithiasic. Magnetic resonance cholangiography confirmed the duplication of the gallbladder and cystic ducts, with a single main biliary tract and acute lithiasic cholecystitis in both gallbladders. A laparoscopic cholecystectomy of both vesicles was performed without complications, and the patient was discharged 3 days after the procedure. (AU)

Casuística. Vesícula biliar siniestra (sinistraposición): Caso clínico / Left-sided Gallbladder (Sinistraposition of the gallbladder)

A rare case of left-sided gallbladder (sinistraposition) is reported with review of the literature. Left-sided gallbladder is very unusual, with a frequency of 0.3% of the cases, being generally associated to situs inversus. The aim of this invesigation was to establish the association between left-sided gallbladder and right-sided round ligaments. Left-sided gallbladder is a rare anomaly and has been classified into two situations: 1) gallbladder migration to the left side, and 2) development of a second gallbladder with atrophy of the original one. Left-sided gallbladder were reported to be associated with right-sided round ligaments.

Vólvulo de la vesícula biliar como causa de abdomen agudo: reporte de caso y revisión de la literatura / Gallbladder volvulus as a cause of acute abdomen: case report and literature review

Resumen Antecedentes: El vólvulo de la vesícula biliar se produce por el giro de la vesícula sobre su mesenterio a lo largo del eje del conducto y arteria císticos, con afectación de la irrigación vascular de forma completa o incompleta, pudiendo existir ciertas características anatómicas predisponentes. Caso clínico: Masculino de 87 años quien cursó con abdomen agudo; sospechando cuadro de piocolecisto, se realizó exploración quirúrgica encontrando como hallazgos triple torsión vesicular y múltiples litos color oscuro; se realizó colecistectomia abierta, cursando con una evolución satisfactoria. Discusión: Se trata de una entidad infrecuente que puede simular una colecistitis aguda; generalmente tiene buen pronóstico cuando el diagnóstico se realiza a tiempo. El tratamiento de elección es la colecistectomía laparoscópica.

Abstract Background: The gallbladder volvulus is produced by the rotation of the gallbladder over its mesentery along the axis of the cystic duct and artery, with involvement of vascular irrigation in a complete or incomplete way, and there may be certain predisposing anatomical characteristics. Clinical case: Male patient of 87 years who attended with acute abdomen, suspecting pyogenic cholecystitis, performs surgical exploration finding as vesicular triple twist, multiple stones dark. Open cholecystectomy is performed, following a satisfactory evolution. Discussion: It is an uncommon entity that can simulate acute cholecystitis, usually has a good prognosis, when the diagnosis is made on time. The treatment of choice is laparoscopic cholecystectomy.

Hallazgos clínicos e histopatológicos en pacientes con adenomiomatosis vesicular / Clinical and histopathological findings in patients with gallblader adenomyomatosis

Objetivo: El objetivo del estudio es describir la presentación clínica e histopatológica de la adenomiomatosis vesicular en una serie de pacientes colecistectomizados. Material y método: Entre el 1 de enero del 2010 y el 30 abril del 2015 se realizaron 6.957 colecistectomías, diagnosticándose adenomiomatosis en 95 de las vesículas extirpadas (1,4%). Se describen los hallazgos clínicos e histopatológicos en estos pacientes. Resultados: En 53 pacientes (55,8%) se presentó dolor abdominal. Alteraciones histológicas concomitantes se presentaron en la mucosa vesicular de 34 pacientes (35,8%), siendo la metaplasia pilórica la más frecuente (21%); y en 8 pacientes (8,4%) se presentó displasia de alto y bajo grado. Las patologías asociadas más frecuentes fueron colelitiasis 82,1% y colecistitis crónica 85,3%. Conclusiones: En la serie estudiada se observaron diversas alteraciones histológicas, incluyendo la displasia de alto grado. La colelitiasis se presentó con una frecuencia elevada.

Aim: The aim of the study was to describe the clinical and histopathologic presentation of adenomyomatosis (ADM) of the gallbladder in a series of patients. Material and method: Between January 1, 2010 to April 30, 2015, 6957 patients underwent cholecystectomy. Among them, ADM was diagnosed in 95 of cholecystectomy specimens (1.4%). Clinical and pathological findings in these patients are described. Results: In 53 patients (55.8%) presented abdominal pain. Concomitant histological changes occurred in the gallbladder mucosa of 34 patients (35.8%), being the most frequent pyloric metaplasia (21%); and in 8 patients (8.4%) high-grade dysplasia and low-grade dysplasia was presented. The most frequent associated pathologies were cholelithiasis in 82.1%, and chronic cholecystitis in 85.3%. Conclusions: In this serie, various histological changes were observed, including high-grade dysplasia. Cholelithiasis was presented with high frequency.

Frequency of cholecystectomy and associated sociodemographic and clinical risk factors in the ELSA-Brasil study / Frequência de colecistectomia e fatores de risco sociodemográficos e clínicos associados no estudo ELSA-Brasil

ABSTRACT: CONTEXT AND OBJECTIVE: There are few data in the literature on the frequency of cholecystectomy in Brazil. The frequency of cholecystectomy and associated risk factors were evaluated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). DESIGN AND SETTING: Cross-sectional study using baseline data on 5061 participants in São Paulo. METHODS: The frequency of cholecystectomy and associated risk factors were evaluated over the first two years of follow-up of the study and over the course of life. A multivariate regression analysis was presented: odds ratio (OR) and 95% confidence interval (95% CI). RESULTS: A total of 4716 individuals (93.2%) with information about cholecystectomy were included. After two years of follow-up, 56 had undergone surgery (1.2%: 1.7% of the women; 0.6% of the men). A total of 188 participants underwent cholecystectomy during their lifetime. The risk factors associated with surgery after the two-year follow-up period were female sex (OR, 2.85; 95% CI, 1.53-5.32), indigenous ethnicity (OR, 2.1; 95% CI, 2.28-15.85) and body mass index (BMI) (OR, 1.10; 95% CI, 1.01-1.19 per 1 kg/m2 increase). The risk factors associated over the lifetime were age (OR, 1.03; 95% CI, 1.02-1.05 per one year increase), diabetes (OR, 1.92; 95% CI, 1.34-2.76) and previous bariatric surgery (OR, 5.37; 95% CI, 1.53-18.82). No association was found with parity or fertile age. CONCLUSION: Female sex and high BMI remained as associated risk factors while parity and fertile age lost significance. New factors such as bariatric surgery and indigenous ethnicity have gained importance in this country.

RESUMO CONTEXTO E OBJETIVO: Há escassez de dados na literatura sobre a frequência de colecistectomia no Brasil. Avaliou-se a frequência de colecistectomia e os fatores de risco associados no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). DESENHO E LOCAL: Estudo transversal com dados da linha de base de 5061 participantes em São Paulo. MÉTODOS: Avaliou-se a frequência de colecistectomia e fatores de risco associados nos dois primeiros anos de seguimento do estudo e ao longo da vida. Apresentou-se regressão logística [razão de chances (RC); intervalo de confiança de 95% (IC 95%)] multivariada. RESULTADOS: Um total de 4716 (93,2%) indivíduos com informação sobre colecistectomia foi incluído. Após 2 anos de seguimento, 56 participantes tinham sido operados (1,2%: 1,7% nas mulheres; 0,6% nos homens), totalizando 188 participantes com colecistectomia durante a vida. Os fatores de risco associados à cirurgia após dois dois anos de seguimento foram sexo feminino (RC, 2,85; IC 95%, 1,53-5,32), etnia indígena (RC, 2,1; IC 95%, 2,28-15,85) e índice de massa corpórea, IMC (RC, 1,10; IC 95%, 1,01-1,19 por aumento de 1 kg/m2); e, ao longo da vida: idade (RC, 1,03; IC 95%, 1,02-1,05 por um ano de aumento), diabetes (RC, 2,10; IC 95%, 1,34-2,76) e cirurgia bariátrica prévia (RC, 5.37; IC 95%, 1,53-18,82). Não se observou associação com paridade ou idade fértil. CONCLUSÃO: Sexo feminino e IMC elevado permanecem sendo fatores de risco associados à colecistectomia, mas paridade e idade fértil perderam significância. Novos fatores de risco, como cirurgia bariátrica prévia e etnia indígena, ganharam relevância no país.

Total cost of hospitalization of patients undergoing elective laparoscopic cholecystectomy related to nutritional status / Custo total de internação de pacientes submetidos à colecistectomia videolaparoscópica eletiva relacionado ao estado nutricional

ABSTRACT Background: In the Western world, the population developed an overweight profile. The morbidly obese generate higher cost to the health system. However, there is a gap in this approach with regard to individuals above the eutrofic pattern, who are not considered as morbidly obese. Aim: To correlate nutritional status according to BMI with the costs of laparoscopic cholecystectomy in a public hospital. Method: Data were collected from medical records about: nutritional risk assessment, nutricional state and hospital cost in patients undergoing elective laparoscopic cholecystectomy. Results: Were enrolled 814 procedures. Average age was 39.15 (±12.16) years; 47 subjects (78.3%) were women. The cost was on average R$ 6,167.32 (±1830.85) to 4.06 (±2.76) days of hospitalization; 41 (68.4%) presented some degree of overweight; mean BMI was 28.07 (±5.41) kg/m²; six (10%) individuals presented nutritional risk ≥3. There was a weak correlation (r=0.2) and not significant (p <0.08) between the cost of hospitalization of the sample and length of stay; however, in individuals with normal BMI, the correlation was strong (r=0,57) and significant (p<0.01). Conclusion: Overweight showed no correlation between cost and length of stay. However, overweight individuals had higher cost of hospitalization than those who had no complications, but with no correlation with nutritional status. Compared to those with normal BMI, there was a strong and statistically significant correlation with the cost of hospital stay, stressing that there is normal distribution involving adequate nutritional status and success of the surgical procedure with the consequent impact on the cost of hospitalization.

RESUMO Racional: No mundo ocidental, a população desenvolveu um perfil de excesso de peso corporal. Os obesos mórbidos geram custo mais alto para o sistema de saúde. Entretanto, observa-se um hiato no tocante aos indivíduos acima do eutrofismo, mas não considerados obesos mórbidos. Objetivo: Correlacionar estado nutricional, segundo o IMC, com custo de internação de colecistectomias videolaparoscópicas. Método: Coleta de dados dos prontuários sobre: avaliação de risco nutricional, estado nutricional e custo de internação de pacientes submetidos à colecistectomia videolaparoscópica eletiva no período de janeiro de 2012 a dezembro de 2014. Resultados: Foram analisados 814 procedimentos. A idade média foi de 39,15 (±12,16) anos; 47 (78,3%) eram mulheres. O custo de internação foi, em média, de R$ 6.167,32 (±1.830,85) para 4,06 (±2,76) dias de internação. Quarenta e um (68,4%) pacientes apresentavam algum grau de sobrepeso; o IMC médio foi 28,07 (±5,41) kg/m²; seis (10%) indivíduos apresentavam risco nutricional ≥3. Houve correlação fraca (r=0,2) e não significativa (p<0,08) entre o custo de hospitalização e o tempo de permanência. No entanto, em indivíduos com IMC normal, a correlação foi forte (r=0,57) e significante (p<0,01). Conclusão: Sobrepeso não demonstrou correlação entre custo e tempo de internação. Entretanto, os indivíduos com sobrepeso apresentaram custo maior de internação em relação aos que não tiveram intercorrência, mas sem correlação com o estado nutricional. Em relação aos com IMC normal, houve correlação forte e estatisticamente significante com o custo para tempo de internação, reforçando que há provável distribuição normal envolvendo estado nutricional adequado e sucesso do procedimento cirúrgico com consequente impacto no custo de internação.

Íleo biliar: um relato de caso / Gallstone ileus: a case report

O presente trabalho relata o caso de uma paciente feminina, de 75 anos, que internou por um quadro de dor em hipocôndrio direito, vômitos e distensão abdominal com 5 dias de evolução. Secundariamente, apresentou rebaixamento do sensório, acidose metabólica, oligoanúria e hipotensão, necessitando de cuidados em unidade de terapia intensiva, com intubação orotraqueal (IOT), vasopressor e hemodiálise. A tomografia de abdome evidenciou presença de aerobilia e um cálculo misto na topografia do segmento ileal do intestino (AU)

This paper reports the case of a 75 y.o. female patient who was admitted for a painful condition in the right hypochondrium, vomiting and abdominal distension with 5 days of evolution. Secondly she presented sensorial loss, metabolic acidosis, oliguria and hypotension, requiring care in intensive care unit, with tracheal intubation (TI), vasopressor and hemodialysis. Abdominal CT scan revealed the presence of aerobilia and a mixed gallstone in the topography of the ileal segment of the intestine (AU)

The First Experiences of Robotic Single-Site Cholecystectomy in Asia: A Potential Way to Expand Minimally-Invasive Single-Site Surgery?

PURPOSE: Herein, we firstly present the robotic single-site cholecystectomy (RSSC) as performed in Asia and evaluate whether it could overcome the limitations of conventional laparoscopic single-site cholecystectomy. MATERIALS AND METHODS: From October 2013 to November 2013, RSSC for benign gallbladder (GB) disease was firstly performed consecutively in five patients. We evaluated these early experiences of RSSC and compared factors including clinicopathologic factors and operative outcomes with our initial cases of single-fulcrum laparoscopic cholecystectomy (SFLC). RESULTS: Four female patients and one male patient underwent RSSC. Neither open conversion nor bile duct injury or bile spillage was noted during surgery. In comparisons with SFLC, patient-related factors in terms of age, sex, Body Mass Index, diagnosis, and American Society of Anesthesiologist score showed no significant differences between two groups. There were no significant differences in the operative outcomes regarding intraoperative blood loss, bile spillage during operation, postoperative pain scale values, postoperative complications, and hospital stay between the two groups (p<0.05). Actual dissection time (p=0.003) and total operation time (p=0.001) were significantly longer in RSSC than in SFLC. There were no drain insertion or open conversion cases in either group. CONCLUSION: RSSC provides a comfortable environment and improved ergonomics to laparoscopic single-site cholecystectomy; however, this technique needs to be modified to allow for more effective intracorporeal movement. As experience and technical innovations continue, RSSC will soon be alternative procedure for well-selected benign GB disease.

Laparoscopic management of cholecystocolic fistula / Abordagem laparoscópica da fístula colecistocólica

INTRODUCTION: Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy. AIM: To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments. TECHNIQUE: After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery. CONCLUSION: Laparoscopy for resolution of cholecystocolic fistula isn't only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy. .

INTRODUÇÃO: A fístula colecistocólica é rara complicação das doenças calculosas do trato biliar. Sua apresentação clínica é variável e inespecífica, sendo o diagnóstico realizado, na maioria das vezes, incidentalmente durante o intraoperatório de sua causa base. A colecistectomia com fechamento da fístula é considerada o tratamento de escolha para a condição, sendo a videolaparoscopia cada vez mais reprodutível. OBJETIVO: Descrever a abordagem laparoscópica da fístula colecistocólica e ratificar a sua factibilidade mesmo diante da indisponibilidade de instrumentos mais específicos. TÉCNICA: Após dissecção da comunicação e secção do polo vesicular, a fístula é exteriorizada por uma cânula adequada e rafiada manualmente. Reintroduzido o segmento colônico na cavidade, a colecistectomia é realizada evitando-se a conversão do procedimento para a operação aberta. CONCLUSÃO: A videolaparoscopia para resolução de fístula colecistocólica é viável, com menor tempo de internação hospitalar e melhor pós-operatório quando comparada à laparotomia. .

Gallbladder tubrculosis mimicking malignancy: A rare case report.

Summary: Gallbladder tuberculosis is an extremely rare disorder even in endemic region. It often mimics gallbladder malignancy as both of them share some common presentations. This entity is very rarely diagnosed pre-operatively as neither clinical features nor radiology are pathognomonic of gallbladder tuberculosis. The case reported here presented as chronic calculous cholecystitis with mass at gallbladder neck. Patient underwent laparotomy with suspicion of gallbladder carcinoma, which was eventually diagnosed as a case of gallbladder TB following histopathological examination of the resected specimen. He also had pulmonary TB in association and was completely cured with short course antitubercular chemotherapy.

Colecistectomía laparoscópica por puerto umbilical asistido / Transumbilical laparoscopic cholecystectomy assisted with a second port: experience in 60 patients

Background: Transumbilical laparoscopic surgery offers substantial esthetic benefits. The use of a second port to introduce a second trocar, reduces the need of special or articulated instruments. Aim: To report the experience with transumbilical cholecystectomy, assisted using a second port, to reduce technical complexity. Patients and Methods: The surgical technique was prospectively evaluated in 60 patients aged 18 to 77 years (39 women), that required a cholecystectomy. All had a surgical risk classified according to the American Society of Anesthesiologists (ASA) as I or II. Patients with gallbladder cancer, choledocholithiasis, were excluded. Two trocar (10 and 5 mm) were introduced by transumbilical incision and other one 5 mm trocar was introduced in the right iliac fossa for 0° frontal optics. Results: The mean operative time was 72 minutes (range 35-165). Fifty seven patients had a 24 h hospital stay. Two patients had to be converted to open surgery due to a complex pedicle dissection and one patient required an additional trocar. There were three complications. An umbilical seroma, a bile leakage through a Luschka duct, that was managed conservatively and one bile tract stenosis, that appeared four months after the operation and required surgical repair. Conclusions: Transumbilical cholecystectomy using a second additional port was a successful procedure, with similar esthetic results as single port surgery, but less costly.

Introducción: La cirugía laparoscópica evoluciona hacia técnicas menos invasivas, entre ellas la cirugía por puerto único umbilical, con mayor beneficio estético. El objetivo del presente trabajo es presentar los resultados de una técnica en colecistectomías laparoscópicas por puerto umbilical asistido por segundo puerto. La hipótesis planteada es que la técnica descrita es sencilla, segura y con beneficio estético similar al puerto único umbilical. Pacientes y Métodos: Técnica quirúrgica realizada prospectivamente en una serie de 60 pacientes ASA I y ASA II con consentimiento informado. Se incluye colecistolitiasis, pólipos, colecistitis aguda y crónica. Se excluye cáncer vesicular y coledocolitiasis. No se excluyeron casos por complejidad técnica o IMC. Se insertan 2 trocares de trabajo de 10 y 5 mm por incisión transumbilical y trocar de 5 mm en fosa iliaca derecha para óptica frontal de 0°. Resultados: Tiempo operatorio promedio de 72 minutos, mediana de 60 y extremos de 35 y 165. Tuvieron hospitalización de 24 horas 57 pacientes (95 por ciento). Hubo 2 conversiones a cirugía abierta por difícil disección del pedículo y un caso requirió trocar adicional. Hubo 3 complicaciones: un seroma de ombligo, una bilirragia por conducto de Luschka manejado conservadoramente y 1 estenosis de vía biliar postoperatoria a 4 meses, con reparación quirúrgica. Conclusiones: La colecistectomía lapa-roscópica por puerto umbilical asistida, logra resultados exitosos y con similares ventajas estéticas que el puerto único. El bajo costo de nuestra técnica permite realizarla en hospitales públicos y centros privados con menores recursos.

Tratamiento de la enfermedad litiásica biliar en el embarazo / Treatment of the biliaris lithiasis disease in the pregnancy

La mujer embarazada está sujeta a todas las enfermedades quirúrgicas de las mujeres no embarazadas y el abdomen agudo quirúrgico no es una excepción. Puede considerarse, dentro de la patología médica, como unas de las afecciones más graves y dramáticas; cobra mayor significación cuando se presenta en el curso de un embarazo y con frecuencia el diagnóstico y tratamiento de estas pacientes debe adecuarse para atender preocupaciones en relación con un segundo paciente: el feto. Se decide hacer una revisión actualizada con el objetivo de exponer las particularidades de la enfermedad litiásica biliar en el embarazo, ya que es difícil para quien lo estudia encontrar el tema desarrollado con todos sus problemas y peculiaridades; a su vez, poder brindar a todos los que se sientan atraídos por tan apasionante tema una guía que le permita hacer un diagnóstico precoz para evitar consecuencias trágicas para la madre y su futuro bebé. Se concluye que la técnica quirúrgica a emplear dependerá de la institución, la preparación y entrenamiento del cirujano, la gravedad de la paciente y el trimestre del embarazo

The pregnant woman is subject to all surgical diseases of non-pregnant women and the surgical acute abdomen isn't an exception. It may to be considered within the medical pathology like one of the more severe and dramatic affections achieving a great significance when is present during pregnancy and frequently diagnosis of these patients must to be adjusted to care for worries in relation to a second patient: the fetus. An update review was made to expose the peculiarities of the biliary lithiasis disease in pregnancy since it is difficult for whom to make its study to find the subject developed with other problems and peculiarities; in his turn, to offer to all attracted by so fascinating subject, a guideline allowing to make an early diagnosis to avoid tragic consequences for mother and its future baby. We conclude that surgical technique to be used will depend on institution, training and preparation of surgeon, the severity of patient and the pregnancy trimester

Coristoma pancreático en la vesícula biliar / Heterotopic pancreas found in the gallbladder: report of one case

We report a 54 years old woman presenting with pain in the right upper abdominal quadrant. An abdominal ultrasound showed multiple gallbladder stones. The patient was operated with the diagnosis of cholelithiasis. During the pathological study of the excised gallbladder a 0.9 cm diameter yellowish nodule was found, that corresponded to heterotopic pancreatic tissue.

La heterotopía pancreática corresponde a la presencia de tejido pancreático fuera de su localización habitual, que carece de continuidad anatómica y vascular con el páncreas normal; el 85 por ciento a 90 por ciento de los casos reportados comprometen estómago, duodeno o yeyuno, mientras que la localización en vesícula biliar es infrecuente y corresponde tan sólo al 1 por ciento de ellas. Esta entidad es generalmente asintomática y en la mayoría de los casos su diagnóstico constituye un hallazgo incidental durante el examen anatomo-patológico de la pieza quirúrgica. Se presenta el caso de una mujer de 54 años sometida a colecistectomía abierta electiva con el diagnóstico de colecistolitiasis. El examen anatomo-patológico de la pieza operatoria, junto con diagnosticar la colecistitis crónica litiásica, describe la presencia de tejido pancreático heterotópico en el espesor de la pared y a nivel del cuello de la vesícula biliar compuesto por acinos y conductos pancreáticos.

Colecistectomía laparoscópica con trócar umbilical único de 12 mm y óptica con canal operatorio: asistido con agujas percutaneas y dispositivos magneticos: reporte de 80 casos / Laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working cannel: assisted with percutaneous needles and magnetic devices: report of 80 cases

Presentar nuestra experiencia en la técnica de colecistectomia laparoscópica con trócar umbilical único. Sede: Departamento de Cirugía General de dos hospitales privados. Diseño: estudio prospectivo, observacional. 80 pacientes intervenidos quirúrgicamente con la técnica de colecistectomía laparoscópica con trócar umbilical único de 12mm y óptica con canal operatorio, 74 asistidos con agujas, percutáneas y 6 añadiendo dispositivos magnéticos, desde octubre 2008 al 31 de agosto del 2010. Se excluyeron casos de coledocolitiasis, cáncer y pacientes con cirugías abdominales previas. Se analizó edad, sexo, índice de masa corporal (IMC), tiempo quirúrgico, estancia hospitalaria, complicaciones, índice de conversión y resultado estético. Predomino el sexo femenino (5 a 1). La edad promedio fue de 41 años. El tiempo quirúrgico promedio fue de 63 minutos. IMC promedio 29. Adición de trócar en 7 pacientes (9%), no hubo conversiones a técnicas abiertas. El tiempo de hospitalización fue de 24 horas. Sin cicatriz abdominal visible en 73 pacientes en los que se completó el procedimiento por un trócar (91%). Morbilidad=3,75%, mortalidad=0%. La colecistectomía con trócar umbilical único y óptica con canal de trabajo asistida con agujas percutaneas es aplicable en el 91% de los pacientes con enfermedad vasicular. Con los imanes se logró tracción satisfactoria de la vesícula, siendo de mucha utilidad al realizar la técnica "cirugía sin huella".

To present our experience in the technique of laparoscopic cholecystectomy with single umbilical trocar. Headquarters: Departament of General Surgery of two private hospitals Design: Prospective, observational study. 80 patients operated with the techniqué of laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working channel: 74 attended with percutaneous needles and 6 adding magnetic devices, from Octuber 2008 to August 31, 2010. Cases of choledocholithiasis, cancer and patients with previous abdominal surgery were excluded. Age, sex, body mass index (BMI), surgical time, hospital stay, complications, index of conversión and cosmetic result were analyzed. Feminine sex predominated (5 to 1). The average age was 41 years. The surgical time average was 70 minutes. IMC average 29. Addition of trocars was need in 7 patients (9%), there were no conversion to open surgery. The hospitalization time was 24 hours. Abdominal scar was not visible in 73 patients in whom the precedure with one trocar was completed (91%). Morbidity=3.75%, mortality=0%. The laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working cannel attended with percutaneous needles is applicable in 91% of patients with gallbladder disease. With magnets satisfactory traction of the gallbladder was obtained, being very useful to per-form the technique "surgery without trace".