Apendicectomía laparoscópica con una sola incisión umbilical (SILS): experiencia en una unidad de cirugía de urgencias / Appendectomy using single-incision laparoscopic surgery: experience in an emergency department

Introduccion: La apendicectomía laparoscópica es un procedimiento ampliamente utilizado en el tratamiento de la apendicitis aguda, que normalmente necesita tres o más trócares para poder llevarse a cabo. Presentamos nuestra experiencia inicial en la apendicectomía por laparoscopia con una sola incisión umbilical (SILS). Método: Estudio prospectivo realizado entre diciembre de 2008 y octubre 2009, en el que los pacientes que aceptaron participar. Fueron operados por cirujanos especialmente dedicados a la patología quirúrgica urgente. El ombligo fue el único punto de entrada en todos los casos y se utilizó la misma técnica quirúrgica en todos ellos. Resultados: Realizamos 52 apendicectomías mediante SILS. La intervención fue realizada con éxito en todos los pacientes: el tiempo operatorio medio fue de 41 min, no se produjo conversión a cirugía abierta ni se necesitó la colocación de otros trócares adicionales y no hubo complicaciones intra ni post operatorias. La estancia media hospitalaria fue de 2,7 días. Conclusión: La apendicectomía en pacientes adultos mediante SILS es una técnica segura, sencilla y fácilmente reproducible (AU)

Background and objective: Laparoscopic appendectomy for acute appendicitis is a widely used procedure. Three ormore trocars are normally required. We present our early experience performing appendectomy by means of singleincision laparoscopic surgery (SILS) for acute appendicitis. Methods: Prospective study from December 2008 to October 2009 in patients who gave their informed consent. Specialists in emergency surgery were responsible for carrying out the procedures. The navel was the point of entry in allcases. Results: We performed 52 emergency laparoscopic appendectomies using a single umbilical incision. The intervention was successful in all patients. The average operating time was 41 minutes. There were no conversions to open surgery or requirement for additional trocars. No complications were observed during or after the procedures. The mean hospital stay was 2.7 days. Conclusion: Adult appendectomy using SILS is a safe procedure that is reproducible and easy to perform (AU)

Etiopatogenia de la obesidad: actualidad y futuro / Aetiopathogeniy of obesity: current situation and prospects

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Retroperitoneal approach in laparoscopic adrenalectomy: is it advantageous?

Recently, the retroperitoneal laparoscopic approach has been described as advantageous in avoiding the respiratory and hemodynamic effects of CO2 pneumoperitoneum and giving direct access without the need to move abdominal organs. Forty-two laparoscopic adrenalectomies (LpA) were performed in 36 patients with a variety of adrenal disorders, including 9 patients with nonfunctioning tumors, 11 patients with aldosterone adenoma, 10 patients with Cushing's adenoma, and 6 patients with Cushing's disease. Twenty-two adrenalectomies were performed using the transperitoneal approach (TLpA), and 20 via the retroperitoneoscopic approach (RLpA). Arterial blood samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. At the end of the operation, the PaCO2, PetCO2, and base deficit all increased significantly in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values. Arterial pH decreased significantly in both TLpA and RLpA groups. All clinical parameters evaluated (operation time, analgesic dosing requirements, hospital stay, and the days until return to normal activity) were similar in the TLpA and RLpA approaches. Two patients in the TLpA (10.5%) group and two patients in the RLpA (10%) group needed conversion to open surgery. This study shows the safety and efficacy of laparoscopic adrenalectomy via the transperitoneal or retroperitoneal route in patients with a variety of adrenal disorders. The retroperitoneoscopic approach could be the primary choice in patients with previous abdominal surgery.

Laparoscopic surgery for treatment of splenic disorders: an update.

Laparoscopic splenectomy is a feasible and safe technique in the hands of skilled laparoscopic surgeons. The special characteristics of the spleen, a fragile solid organ with a rich vascularization, pose a number of technical questions (patient position, organ mobilization and retrieval) which have been successfully resolved during the last few years and permit the advantages of laparoscopic surgery to become available to patients that need splenectomy.

Total bilateral laparoscopic adrenalectomy in patients with Cushing's syndrome and multiple endocrine neoplasia (IIa).

BACKGROUND: The benefit of simultaneous bilateral laparoscopic adrenalectomy in patients with Cushing's syndrome and pheochromocytoma associated with multiple endocrine neoplasia (MEN) is unknown. METHODS: Ten patients underwent laparoscopic adrenalectomy (LpA) with CO2 pneumoperitoneum for Cushing's syndrome. One MEN patient underwent simultaneous bilateral laparoscopic adrenalectomy with helium pneumoperitoneum for bilateral pheochromocytoma. A comparison was made between unilateral LpA and simultaneous bilateral laparoscopic adrenalectomy in patients with Cushing's syndrome. Plasma catecholamines were correlated with hemodynamic changes in the patient with pheochromocytoma. RESULTS: Simultaneous bilateral laparoscopic adrenalectomy in the patient with pheochromocytoma lasted 330 min. The substantial increase in plasma catecholamines was not associated with cardiovascular instability. Operative time (270 +/- 3 vs 120 +/- 4 min), blood loss (365 +/- 1 vs 210 +/- 1 ml), hospital stay (7.6 +/- 1.5 vs 4.6 +/- 1 days), and normal activity (19.3 +/- 2 vs 10.4 +/- 4.4 days) were, in patients with Cushing's syndrome, significantly (p < 0.05) higher after simultaneous bilateral laparoscopic adrenalectomy than after unilateral LpA; the differences were not significant in the analgesic requirements (7.6 +/- 1 vs 4.6 +/- 1 doses). One patient with unilateral LpA was converted to open surgery. CONCLUSION: Simultaneous bilateral laparoscopic adrenalectomy is safe, and associated with short hospital stay and lessening of the time needed to achieve normal activity.

Laparoscopic unilateral and bilateral adrenalectomy for Cushing's syndrome. Transperitoneal and retroperitoneal approaches.

OBJECTIVE: This prospective randomized study compares the safety and efficacy of transperitoneal laparoscopic adrenalectomy (TLPA) and retroperitoneal approach (RLPA) in obese patients with Cushing's syndrome. SUMMARY BACKGROUND DATA: Recently, a retroperitoneal laparoscopic approach has been described with benefits of avoiding the respiratory and hemodynamic effects of carbon dioxide (CO2) pneumoperitoneum and giving direct access without the need to mobilize abdominal organs. METHODS: Twenty-one adrenalectomies were performed in 9 patients (2 men, 7 women; mean age, 46.33 +/- 19.41 years old; range, 16 to 74 years old) with Cushing's adenoma and in 6 women (mean age, 41.83 +/- 9.97 years old; range, 34 to 62 years old) with Cushing's disease. Randomization gave 10 TLPA and 11 RLPA. Arterial blood gas samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. RESULTS: The partial pressure of carbon dioxide (PaCO2) increased in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values (p < 0.01), and the TLPA showed a greater rise in the PaCO2 level compared with the RLPA at 30 minutes (p < 0.05); simultaneously, a significant increase (p < 0.05) of mean arterial pressure was observed in the TLPA compared with RLPA. No significant changes in heart rate were observed in both groups. The operative time with the TLPA and RLPA in patients with adenoma was 88.75 versus 105 minutes, respectively (p = not significant [NS]), and in patients with bilateral hyperplasia was 271.66 versus 305 minutes, respectively (p = NS). No patients required blood transfusions. The number of doses of analgesic with TLPA and RLPA in patients with adenoma was 3.25 versus 3.5, respectively (p = NS), and in patients with bilateral hyperplasia was 7.66 versus 7.33, respectively (p = NS). The hospital stay with TLPA and RLPA in patients with adenoma was 3.0 versus 2.75 days, respectively (p = NS), and in patients with bilateral hyperplasia was 6.0 versus 6.66 days, respectively (p = NS). The days to return to normal activity with TLPA and RLPA in patients with adenoma were 12.5 versus 12.25, respectively (p = NS), and in patients with bilateral hyperplasia were 19.66 versus 19.33, respectively (p = NS). Two patients with bilateral hyperplasia and TLPA had urinary infection. CONCLUSIONS: Transperitoneal laparoscopic adrenalectomy and RLPA may become the techniques of choice for surgical removal of the adrenal lesions in Cushing's syndrome. The retroperitoneoscopic approach might be a better option in patients with previous abdominal surgery and in patients with pre-existing cardiorespiratory disease.

Does hormonal function of the tumor influence the outcome of laparoscopic adrenalectomy?

BACKGROUND: Patients with hypertension, with catecholamine hypersecretion, and with cortisol excess may associate intraoperative cardiovascular instability and postoperative complications. METHODS: To compare the outcome of laparoscopic adrenalectomy (LpA) in patients with aldosterone adenoma (11), Cushing's adenoma (six), Cushing's disease (four), pheochromocytoma (Pheo) (11), and nonfunctioning tumor (five). Intra- and postoperative parameters were studied and in patients with Pheo intraoperative catecholamine plasma levels were correlated with cardiovascular derangements. RESULTS: Operative time, estimated blood loss, hospital stay, analgesic requirements, and time to return to normal activity were significantly higher in patients undergoing total bilateral adrenalectomy for Cushing's syndrome compared with other groups undergoing unilateral adrenalectomy, but these latter groups showed no significant differences among themselves in all parameters analyzed. One patient with nonfunctioning tumor and another with Cushing's adenoma were converted to open surgery, and two patients with Cushing's disease had urinary infection. Isolation of Pheo was associated with significant release of catecholamines but not with hemodynamic changes. CONCLUSION: LpA may be the most suitable method for removing functioning adrenal tumors.

Laparoscopic approach to pheochromocytoma: hemodynamic changes and catecholamine secretion.

This study compares the outcome of laparoscopic adrenalectomy (LpA) in 23 patients using CO2 insufflation with the outcome of this procedure in another 8 patients with pheochromocytoma (7 unilateral, 1 bilateral) using helium for pneumoperitoneum. The adrenal lesions in the first group included nonfunctional adenoma (n = 3), aldosterone adenoma (n = 11), Cushing's adenoma (n = 6), and Cushing's disease (n = 3). The latter patients were compared with a third group of 8 patients with pheochromocytoma undergoing conventional transabdominal adrenalectomy (CTA). With both procedures, intraoperative changes in plasma catecholamine levels were studied during pheochromocytoma removal and the changes correlated with intraoperative cardiovascular derangements. LpA was successfully performed in 95% of patients with adrenal lesions and in 100% of patients with pheochromocytoma. There was no significant difference in laparoscopic adrenalectomy for pheochromocytoma compared to that for other adrenal lesions in terms of operative time, blood loss, hospital stay, analgesic requirements, and return to normal activity. The outcome was less favorable in pheochromocytoma patients undergoing CTA. The largest increase of catecholamine levels in pheochromocytoma patients occurred during tumor manipulation with both LpA (17.4-fold for epinephrine and 8.6-fold for norepinephrine) and CTA (34.2-fold for epinephrine and 13.7-fold for norepinephrine), but cardiovascular instability was associated only with CTA. LpA may become the technique of choice for surgical removal of adrenal lesions and may also become the preferred method for removing pheochromocytoma.

Pheochromocytoma: laparoscopic approach with CO2 and helium pneumoperitoneum.

A number of different surgical approaches have been devised for adrenalectomy in patients with pheochromocytoma. The anterior transabdominal approach was at one time considered a source of postoperative morbidity; the advent of laparoscopy however, may result in a resurgence in its use. The laparoscopic approach was used with a CO2 pneumoperitoneum in one patient with a left pheochromocytoma, and using a helium pneumoperitoneum in another with bilateral pheochromocytoma. The left adrenalectomy took 135 minutes to perform and the total bilateral adrenalectomy 330 minutes. No transfusion was necessary. The postoperative stay was 4 days for both patients. To prevent the risk of CO2 retention during extended laparoscopic procedures, helium can serve as an alternative gas, as was documented in the patient who underwent total adrenalectomy. Unilateral or bilateral resection of pheochromocytoma can safely be performed laparoscopically and has the advantage of avoiding both the muscular trauma related to laparotomy and the rib resection necessary for the extraperitoneal approach.

Technical aspects of adrenalectomy via operative laparoscopy.

Adrenalectomy is usually performed through a transabdominal or a posterior approach. These approaches are associated with a painful syndrome postoperatively and long hospital stay. We report a series of five successful laparoscopic adrenalectomies, performed on: a 35-year-old male with a 5-cm right nonfunctioning tumor; a 32-year-old female with a 1.8-cm right aldosterone-producing adenoma; a 17-year-old female with a 4-cm right adrenocortical adenoma; and a 33-year-old female with bilateral 3.5-cm right and 4.5-cm left pheocromocytoma. Single right adrenalectomy lasted between 2 h and 2 h 30 min and bilateral adrenalectomy 5 h and 30 min. No transfusion was required. The hospital stay was between 3 and 4 days. This technique adequately removes adrenal tumors surgically and results in less postoperative pain and rapid recovery.

Immunocytochemical study of pancreatic islet revascularization in islet isograft. Effect of hyperglycemia of the recipient and of in vitro culture of islets.

We studied the revascularization process of isogeneic islets grafted into the kidney subcapsular space of streptozotocin-induced diabetic and nondiabetic rats by a double-labeling, indirect immunofluorescence technique using a rabbit antiserum to human factor VIII-related antigen (which identifies endothelial cells) and a guinea pig anti-insulin antiserum (which labels pancreatic beta cells). Freshly isolated islets contained a network of capillary endothelial cells, whereas 1-week-cultured islets at 37 degrees C have completely lost their intra-islet endothelial cells. Overnight cultured islets contained only occasional endothelial cells. When these islets were grafted under the kidney capsule of nondiabetic rats, they rapidly acquired a new endothelial cell lining as demonstrated by the positivity of staining for factor VIII-related antigen at day 5 after implantation. On the other hand, 1-week-cultured islets failed to become fully revascularized until day 7 after transplantation. Streptozotocin-induced diabetic rats grafted with 1000 islets normalized their blood glucose values (< 11 mM/L) 2-4 weeks after implantation, whereas transplantation of 2500-3000 islets resulted in normoglycemia after 4.7 +/- 2 days (mean +/- SD). Nevertheless, hyperglycemia of the recipient did not adversely affect the process of revascularization of islet isografts which initiated at day 3 and was almost completed by day 5 after implantation.

Laparoscopic approach to the adrenal tumors.

Over the years, a number of different surgical approaches to the adrenal glands have been devised. The anterior transabdominal approach is considered to be a source of postoperative morbidity. However, this conviction can be changed. The laparoscopic approach was used in four patients. One had a right 5 cm nonfunctioning tumor, the second had a 1.8 cm right aldosterone-producing adenoma, the third patient had a 4 cm adrenocortical adenoma, and the fourth patient had a bilateral pheochromocytoma (tumor size was 3.5 cm and 4.5 cm in the right and left adrenals, respectively). Carbon dioxide pneumoperitoneum was used in three patients, but helium pneumoperitoneum was used in the patient with bilateral pheochromocytoma to prevent CO2 retention. Single right adrenalectomy lasted between 2 h and 2 h 30 min, and bilateral adrenalectomy lasted 5 h 30 min. The hospital stay was between 3 and 4 days. Unilateral or bilateral adrenalectomy through laparoscopy can be performed safely and has the advantage of avoiding the muscular trauma related to laparotomy or rib resection necessary for the extraperitoneal approach.