DOES MALE GENDER INCREASE THE RISK OF LAPAROSCOPIC CHOLECYSTECTOMY?

BACKGROUND: Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial. AIM: To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy. METHOD: All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols. RESULTS: Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0). CONCLUSION: Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

SYSTEMIZATION OF LAPAROSCOPIC INGUINAL HERNIA REPAIR (TAPP) BASED ON A NEW ANATOMICAL CONCEPT: INVERTED Y AND FIVE TRIANGLES.

BACKGROUND: Laparoscopic inguinal hernia repair has been shown to be superior than open repairs with faster return to daily activities and decrease in the occurrence of chronic pain. However, higher direct costs and mandatory use of general anesthesia are arguments against their use. In addition, increased complexity of surgery resulting from an anatomy that is unusual to general surgeons prevents the widespread adoption of laparoscopic approach. AIM: To propose a technical systematization for transabdominal laparoscopic repair (TAPP) of inguinal hernias based on anatomical concepts. METHOD: To offer a systematization of TAPP repair based on well defined anatomic landmarks, describing the concept of "inverted Y", identification of five triangles and three zones of dissection, to achieve the "critical view of safety" for laparoscopic inguinal hernia repair. RESULTS: Since this standardization was developed five years ago, many surgeons were trained following these precepts. Reproducibility is high, as far as, it´s rate of adoption among surgeons. CONCLUSION: The concept of the "inverted Y", "Five triangles" and the dissection based in "Three Zones" establish an effective and reproducible standardization of the TAPP technique.

Does male gender increase the risk of laparoscopic cholecystectomy? / O gênero masculino aumenta o risco de colecistectomia laparoscópica?

ABSTRACT Background: Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial. Aim: To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy. Method: All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols. Results: Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0). Conclusion: Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

RESUMO Racional: A colecistectomia laparoscópica é o tratamento de escolha para colecistite crônica ou aguda. Alguns fatores podem aumentar a taxa de conversão para colecistectomia laparotômica e de complicações perioperatórias. O papel do gênero, como um fator de risco para colecistectomia laparoscópica, é controverso. Objetivo: Avaliar o papel do gênero nos achados operatórios e no desfecho da colecistectomia laparoscópica. Métodos: Todos os pacientes que foram submetidos à colecistectomia laparoscópica por colecistite crônica ou aguda foram incluídos. Dados demográficos, clínicos, laboratoriais, de imagem, intraoperatórios e pós-operatórios foram obtidos e analisados. Os dados foram obtidos retrospectivamente a partir de prontuários eletrônicos e protocolos de estudo. Resultados: De um total de 1.645 pacientes que foram submetidos à colecistectomia laparoscópica, 540 (32,8%) eram homens e 1.105 (67,2%) mulheres. A idade média foi semelhante em ambos os gêneros (p=0,817). O tempo operatório foi maior nos homens (72,48±28,50) do que nas mulheres (65,46±24,83) (p<0,001). A taxa de colecistite aguda foi maior no grupo masculino (14,3%) do que no feminino (5,1%, p<0,001). Não houve diferença entre os gêneros quanto à taxa de conversão (p=1,0), complicação intraoperatória (p=1,0), complicação pós-operatória (p=0,571) e mortalidade operatória (p=1,0). Conclusão: O gênero masculino não é fator de risco independente para a conversão laparoscópica e complicações perioperatórias.

Systemization of laparoscopic inguinal hernia repair (tapp) based on a new anatomical concept: inverted y and five triangles / Sistematização do reparo da hérnia inguinal laparoscópica (tapp) baseada em um novo conceito anatômico: y invertido e cinco triângulos

ABSTRACT Background: Laparoscopic inguinal hernia repair has been shown to be superior than open repairs with faster return to daily activities and decrease in the occurrence of chronic pain. However, higher direct costs and mandatory use of general anesthesia are arguments against their use. In addition, increased complexity of surgery resulting from an anatomy that is unusual to general surgeons prevents the widespread adoption of laparoscopic approach. Aim: To propose a technical systematization for transabdominal laparoscopic repair (TAPP) of inguinal hernias based on anatomical concepts. Method: To offer a systematization of TAPP repair based on well defined anatomic landmarks, describing the concept of "inverted Y", identification of five triangles and three zones of dissection, to achieve the "critical view of safety" for laparoscopic inguinal hernia repair. Results: Since this standardization was developed five years ago, many surgeons were trained following these precepts. Reproducibility is high, as far as, it´s rate of adoption among surgeons. Conclusion: The concept of the "inverted Y", "Five triangles" and the dissection based in "Three Zones" establish an effective and reproducible standardization of the TAPP technique.

RESUMO Racional: O reparo laparoscópico da hérnia inguinal tem se mostrado superior aos reparos abertos, com retorno mais rápido às atividades diárias e diminuição na ocorrência de dor crônica. No entanto, custos diretos mais altos e o uso obrigatório de anestesia geral são argumentos contra seu uso. Além disso, o aumento da complexidade da operação resultante de uma anatomia incomum aos cirurgiões gerais impede a ampla adoção da abordagem laparoscópica. Objetivo: Propor uma sistematização técnica para reparo laparoscópico transabdominal (TAPP) de hérnias inguinais com base em conceitos anatômicos. Método: Oferecer sistematização do reparo do TAPP baseado em pontos anatômicos bem definidos, descrevendo o conceito de "Y invertido", identificação de cinco triângulos e três zonas de dissecação, para alcançar a "visão crítica de segurança" para o reparo de hérnia inguinal laparoscópica. Resultados: Desde que essa padronização foi desenvolvida há cinco anos, muitos cirurgiões foram treinados seguindo esses preceitos. A reprodutibilidade é muito alta, assim como a taxa de adoção entre cirurgiões. Conclusão: O conceito de "Y invertido", dos "Cinco triângulos" e a dissecção baseada em "Três Zonas" estabelecem uma padronização efetiva e reprodutível da técnica TAPP.

Surgical Management of Solid Pseudopapillary Tumor of the Pancreas.

BACKGROUND AND OBJECTIVES: Although solid pseudopapillary tumor (SPT) of the pancreas is rare, its diagnosis has increased severalfold in the past decades. We present our experience in the management of SPT, including a patient who experienced tumor rupture during laparoscopy pancreatic resection. METHODS: Data on all patients with SPT who were subjected to surgical treatment were retrospectively obtained. RESULTS: Of 20 patients evaluated, 17 (85%) were females. The mean age was 31 years. Tumor size varied from 2.7 × 1.5 to 13.5 × 10.0 cm, with a mean of 6.4 × 7.6 cm. The most common location was the tail and/or body of the pancreas (14 patients [70%]). Pancreatic tumor resection was performed in 19 patients (50%). The type of resection depended on tumor location and size: distal pancreatectomy (n = 13), pancreatoduodenectomy (n = 5), and central pancreatectomy (n = 1) Pancreatic resection was performed via laparoscopy in 7 patients who underwent distal pancreatectomy. Tumor resection was not performed in only 1 patient (5%), due to invasion of mesenteric vessels and presence of liver metastases. One patient had tumor rupture during laparoscopic resection, with no apparent macroscopic dissemination of the tumor. All 19 patients who underwent SPT resection had no tumor recurrence, including a patient with capsule invasion and another patient with tumor rupture during surgical dissection. The mean follow-up time was 38 months (range, 6-72 months). CONCLUSION: Complete SPT resection is possible in most patients, with a low recurrence rate. Because of its large size, laparoscopic resection of SPT's should be performed only by experienced surgeons to avoid tumor rupture.

Umbilical hernia in patients with liver cirrhosis: A surgical challenge.

Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

Indicação e tratamento dos tumores benignos do fígado / Indication and treatment of benign hepatic tumors

INTRODUÇÃO: Os tumores hepáticos benignos ocorrem em 9 por cento da população. A grande maioria dessas neoplasias é diagnosticada em pacientes assintomáticos durante a realização de exames de imagem de rotina. OBJETIVO: Apresentar os principais aspectos das indicações e tratamento dos tumores hepáticos benignos. MÉTODOS: Foi realizada revisão de literatura baseada em pesquisa no PubMed, Bireme e Scielo cruzando os descritores neoplasia hepática, hemangioma, adenoma e hiperplasia nodular focal. Foram selecionados, estudos de técnicas cirúrgicas e acrescentada a experiência dos autores. O hemangioma é o tumor hepático mais comum, sendo identificado entre 5 por cento e 7 por cento das necropsias. É mais comum nas mulheres entre as 3ª e 5ª décadas da vida e pode aumentar de tamanho na gravidez e com a administração de estrogênios. Apesar de não estabelecida, a sua causa está relacionada com os hormônios sexuais. As complicações incluem inflamação, coagulopatia, sangramento e compressão de estruturas vizinhas. Rotura espontânea é excepcional, com somente 35 casos descritos na literatura internacional. O adenoma e a hiperplasia nodular focal predominam no sexo feminino e na faixa etária de 20 a 40 anos. Enquanto o primeiro requer ressecção hepática pelo risco de sangramento e malignização, o segundo deve ter conduta expectante. CONCLUSÕES: Os tumores hepáticos benignos mais comuns são em ordem decrescente de frequência o hemangioma, hiperplasia nodular focal e o adenoma. A diferenciação entre tumores benignos e malignos é geralmente realizada com segurança com base nos dados clínicos e nos exames de imagem. O hemangioma e a hiperplasia nodular focal geralmente tem conduta expectante, enquanto que o adenoma requer ressecção pelo risco de hemorragia e de transformação em carcinoma.

BACKGROUND: Benign hepatic tumors occur in 9 percent of the population. The majority is diagnosed in asymptomatic patients during routine imaging exams. AIM: To present the main aspects of indications and treatment of benign hepatic tumors. METHODS: A review was conducted based on literature search in PubMed, Scielo and Bireme crossing the headings liver cancer, hemangioma, adenoma and focal nodular hyperplasia. Was selected studies of surgical techniques and added the experience of the authors. Hemangioma is the most common hepatic tumor. It is identified in 5 percent to 7 percent of the autopsies. It is more common between the 3rd and 5th decades of the life and in female. This tumor may increase in size during pregnancy and with administration of sexual hormones. Although the etiology is not known, it is related with sexual hormones. Complications include inflammation, coagulopathy, bleeding and compression of neighboring organs. Spontaneous rupture is exceptional, with only 35 cases described in the literature. Adenoma and focal nodular hyperplasia are more common in young women, aged 20 to 40 years. Adenomas are treated by hepatic resection due to the risk of malignant transformation and bleeding. Focal nodular hyperplasia does not require treatment. CONCLUSIONS: The most common benign hepatic tumors are hemangioma, focal nodular hyperplasia, and adenoma. The differentiation between benign and malign tumors is usually based on clinical data and imaging exams. Hemangioma and focal nodular hyperplasia usually do not need treatment, while adenoma requires hepatic resection due to the risk of malignant transformation and bleeding.

Complications of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection.

BACKGROUND: Although laparoscopic inguinal herniorrhaphy is considered safe, several complications may occur. This study aimed to evaluate the complications observed in 780 laparoscopic inguinal herniorrhaphies at the authors' hospital. METHODS: All the patients who underwent laparoscopic inguinal herniorrhaphy at the authors' hospital during a period of 11 years were enrolled retrospectively in this study. Patient demographics, operative data, and intra- and postoperative complications were evaluated. RESULTS: A total of 569 patients underwent 780 laparoscopic inguinal herniorrhaphies. The male-to-female ratio was 8.8 to 1, and the mean age was 54.8 ± 15.7 years. Hernia recurrence was recognized in 14 patients (2.5%). Intra- and postoperative complications were diagnosed in 28 (4.9%) and 35 (6.2%) patients respectively. There was no mortality. The most common intraoperative complication was extensive subcutaneous emphysema. Two patients with extensive subcutaneous emphysema had cardiac arrhythmia. Small bowel perforation and bladder perforation occurred in one patient each. One patient had extensive preperitoneal infection caused by Mycobacterium massiliense, which required mesh removal, tissue debridement, and prolonged antibiotic therapy. CONCLUSIONS: Although the mortality rate is low, potentially life-threatening complications such as small bowel and bladder perforation may be experienced by patients subjected to laparoscopic herniorrhaphy.

Late laparoscopic reoperation of failed antireflux procedures.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.