Neumoperitoneo residual en laparoscopia: métodos de medición e implicaciones clínicas.

BACKGROUND: The presence of subdiaphragmatic air observed on a chest x-ray after a laparoscopic procedure is a common finding and can lead to clinical confusion. Measuring the volume of gas present may be a useful tool to determine if this could be associated to a surgical complication. OBJECTIVE: Describe the frequency of presentation of residual pneumoperitoneum in patients undergoing laparoscopy and emphasize the importance of measuring its volume with a simple method. METHOD: This is a retrospective study where 42 chest x-rays of patients operated by laparoscopy were reviewed. Cases with residual pneumoperitoneum were registered and subdiaphragmatic gas volume measured for each of them. Mean and standard deviation for the volume were calculated. Correlations between the variables of height, length and volume of the gas bubbles seen on each x-ray were established. RESULTS: The incidence of residual pneumoperitoneum was 0.55. Median for volume was 4 cm3 (mean of 9.5 cm3 with standard deviation of 14.8 cm3 and range between 0.09 a 62 cm3). Height and length of the arc both had positive correlations with volume of r = 0.74, p = 0.000 and r = 0.77, p = 0.000, respectively. Height and length had a correlation of r = 0.44, p = 0.03. CONCLUSIONS: More than 50% of the studied patients presented residual pneumoperitoneum. Correlation between the variables of height, length and volume were positive. According to the data in this study, the presence of > 40 cm3 of gas may be considered as abnormal.

ANTECEDENTES: La presencia de aire libre subdiafragmático en una radiografía de tórax es un hallazgo común después de un procedimiento laparoscópico y puede causar confusión clínica. La medición del volumen de gas puede ser una herramienta útil para determinar si éste pudiera corresponder a una complicación quirúrgica. OBJETIVO: Describir la frecuencia con que se presenta neumoperitoneo residual en pacientes sometidos a laparoscopia y enfatizar la importancia de medir su volumen con un método sencillo. MÉTODO: Estudio retrospectivo en el que se analizaron 42 radiografías de tórax de pacientes operados por laparoscopia. Se registraron los casos que presentaron neumoperitoneo residual y se midió el volumen de aire subdiafragmático en cada uno de ellos. Se calcularon el volumen promedio y su desviación estándar. Se calcularon las correlaciones entre las variables altura, longitud y volumen de las burbujas de aire medidas en las radiografías de tórax. RESULTADOS: La incidencia de neumoperitoneo residual fue de 0.55. La mediana del volumen fue de 4 cm3 (media de 9.5 cm3, desviación estándar de 14.8 cm3 y rango de 0.09 a 62 cm3). La altura y la longitud del arco tuvieron una correlación positiva con el volumen, con r = 0.74, p = 0.000, y r = 0.77, p = 0.000, respectivamente. Para la altura y la longitud, la correlación fue de r = 0.44, p = 0.03. CONCLUSIONES: Más de la mitad de los pacientes estudiados presentaron algún grado de neumoperitoneo residual. La correlación entre las variables altura, longitud y volumen fueron positivas. De acuerdo con los datos de esta serie, la presencia de un volumen de neumoperitoneo residual > 40 cm3 puede considerarse como anormal.

Pulmonary recruitment can reduce residual pneumoperitoneum and shoulder pain in conventional laparoscopic procedures: results of a randomized controlled trial.

BACKGROUND: This study is aimed to evaluate the pulmonary recruitment maneuver as a means to effectively reduce residual pneumoperitoneum and postoperative shoulder pain in patients undergoing conventional laparoscopic procedures and compare it to the instillation of intraperitoneal anesthetics. METHODS: Patients undergoing laparoscopic cholecystectomy, appendectomy or hernioplasty were randomized into two groups: pulmonary recruitment maneuver (PRM) and intraperitoneal anesthetic instillation (IAI). Six hours after surgery patients were asked to fill out a visual analog scale to identify shoulder pain and a chest X-ray was taken. Groups were analyzed for incidence of residual pneumoperitoneum and shoulder pain as well as for volume of residual subdiaphragmatic gas and intensity of pain. RESULTS: A total of 84 patients (42 per group) were included in the study. Patients in the PRM group had a lower incidence of subdiaphragmatic gas present in the chest X-ray (29% vs 55%) p = 0.01 and less volume of residual pneumoperitoneum (mean difference -.31(95%CI -7.36, 0.72), p = 0.02). They also were half as likely to present shoulder pain (24% vs 50%) p = 0.01 and showed less pain intensity than those in the IAI group (mean difference -2.04(95%CI - 3.25, - 0.84), p = 0.000). The risk of presenting shoulder pain when residual pneumoperitoneum was present showed an RR = 11.1, p = 0.0001 in the PRM group and an RR = 8.3, p = 0.000 in the IAI group. The volume of subdiaphragmatic gas was positively correlated with the intensity of shoulder pain (r = 0.54, p = 0.000). CONCLUSIONS: The pulmonary recruitment maneuver is effective in reducing the incidence and volume of residual pneumoperitoneum, as well as the incidence and intensity of shoulder pain in patients undergoing conventional laparoscopic procedures.

[Cyst of Nucks canal associated with recurrent inguinal hernia]. / Quiste del canal de Nuck asociado con hernia inguinal recurrente.

Cysts of a permeable vaginal process or cysts of Nuck are a rare entity in women and have a similar embryologic and etiologic origin as that of inguinal hernias. They should be considered a differential diagnosis when an inguinal mass is present or during a diagnostic laparoscopy in which a peritoneal defect or open inguinal ring is found. We report the case of a woman with a cyst of Nuck that presented as a recurrent inguinal hernia. Discussion is centered on the embryologic, anatomic, clinical and therapeutic aspects of this condition.

[Case report. Post cesarean section laparoscopic cholecystectomy for hydrocholecystitis]. / Colecistectomía laparoscópica poscesárea por hidrocolecisto. Reporte de un caso.

BACKGROUND: Acute cholecystitis is the second most common surgical emergency in pregnant women. Although laparoscopic cholecystectomy has been described previously in these cases, there is still controversy regarding the most appropriate moment in which to perform the procedure. OBJECTIVE: To describe the clinical presentation and management of a female with 36.6 weeks of pregnancy and clinical signs of acute cholecystitis. Cesarean section to deliver a healthy newborn was immediately followed by laparoscopic cholecystectomy without complications. A 10 year literature review complements the analysis and discussion of the case. CLINICAL CASE: A 33 year-old female with 36.6 weeks of gestation presented a history of 24 hours with right upper quadrant and epigastric abdominal pain, nausea and vomiting. Symptoms were precipitated by cholecystokinetics and did not subside after expectant and pharmacologic medical treatment. The medical group decided with the patient's consent to interrupt the pregnancy via Cesarean section immediately followed by laparoscopic cholecystectomy. RESULTS: After Cesarean section through a Pfannenstiel incision, laparoscopic trocars were placed and cholecystectomy performed without complications. The postsurgical course was favorable and both patient and newborn were discharged on day four. CONCLUSIONS: Laparoscopic surgery cholecystectomy during pregnancy and in the immediate puerperium is feasible and safe. These combined procedures: rapid pregnancy interruption followed by a minimal invasive approach gives the benefits of laparoscopic surgery in these patients.

[Pelvic solitary fibrous nodule, incidental finding and laparoscopic resection. Case report]. / Nódulo fibroso solitario pélvico, hallazgo incidental y resección laparoscópica. Reporte de un caso.

The solitary fibrous nodule is a rare clinical disease that mainly affects the pleura, but has been occasionally described in other anatomical sites. This type of tumors can have malignant components and therefore it is important to differentiate them from other retroperitoneal masses. We describe the case of a patient with ectopic pregnancy in whom a solitary fibrous nodule with laparoscopy was found. A peritoneal pelvic tumor with smooth surface, 20,2 g, firm was detected. The mass was independent of colon, uterus, ovaries or salpinx and was very near to the iliac vessels on the right side. A small fragment was biopsied and sent to trans surgical histopathology study and the rest of the mass was removed completely without complications. The histopathologic report described that the tumor contained sclerosed cells with collagenous bands and sings of hemorrhage and calcification, compatible with a benign pelvic solitary fibrous tumor. The solitary fibrous nodule is a rare, benign disease, but with malignant potential. These tumors must be resected when they are incidentally found during other surgical procedures or if diagnosed preoperatively. The laparoscopic approach has advantages in the identification and resection these tumors.

Laparoscopic T-tube choledochotomy for biliary lithiasis.

T-tube choledochotomy has been an established practice in common bile duct exploration for many years. Although bile leaks, biliary peritonitis, and long-term postoperative strictures have been reported and are directly associated with the placement or removal of the T-tube, the severity of these complications may often be underestimated by surgeons. We present the case of a 31-year-old male patient who developed biliary peritonitis and septic shock after removal of a T-tube and illustrate one of the catastrophic events that may follow such procedures. Literature shows that these complications may occur more frequently and have higher morbidity and mortality than other less invasive procedures. This article reviews the advances in laparoscopic and endoscopic techniques, which provide alternative therapeutic approaches to choledocholithiasis and allow the surgeon to avoid having to perform a choledochotomy with T-tube drainage.

Rectorragia como complicación del síndrome de Klippel-Trenaunay / Rectal bleeding as a complication of Klippel-Trenaunay syndrome

Objetivo: describir la presentación clínica y el tratamiento de dos pacientes con síndrome de Klippel-Trenaunay referidos a nuestro hospital por rectorragia y revisar la literatura para establecer las modalidades actuales de diagnóstico y tratamiento que se le pueden ofrecer a estos pacientes. Caso 1: paciente masculino de 15 años de edad con síndrome de Klippel-Trenaunay y antecedente de anemia crónica. Internado por cuadro de rectorragia severa. Caso 2: paciente femenino de 19 años de edad con el mismo síndrome y dos años de evolución con rectorragia intermitente, anemia y trombocitopenia. El protocolo diagnóstico de cada paciente mostró várices colónicas como la causa de la rectorragia además de otras alteraciones vasculares propias del síndrome. Tratamiento: el primer caso fue tratado con hemicolectomía izquierda y colorrecto anastomosis. Cuatro años después volvió a presentar rectorragia leve y se realizó esclerosis de várices rectales residuales con formol al 40 por ciento. El segundo caso fue tratado con hemicolectomía izquierda y colostomía. Se le han realizado dos sesiones de esclerosis con alcohol absoluto en las várices del muñón rectal y se encuentra en espera del cierre de la colostomía. Conclusión: el síndrome de Klippel-Trenaunay es una enfermedad poco frecuente, con afección vascular en varios niveles. Un porcentaje bajo de pacientes presenta hemorragia a través de las várices colónicas que puede condicionar anemia crónica o hemorragia aguda con compromiso hemodinámico. Esta complicación amerita tratamiento quirúrgico con resección del segmento afectado, complementado con alguna medida local para las várices residuales en el recto

Riesgo de neoplasia en adultos con quiste de colédoco / Risk of neoplasia in adults due to choledochal cyst

Objetivo: describir la presentación clínica del quiste de colédoco en un paciente adulto y revisar la literatura respecto al riesgo de malignidad que se asocia a esta patología. Caso clínico: mujer de 50 años de edad con quiste de colédoco y antecedente familiar de cáncer en vías biliares. Biometría hemática y pruebas de función hepática normales. Por ultrasonografía se observó vesícula biliar alitiásica, con un pólipo en su interior y colédoco de 27 mm de diámetro en su porción distal. Colangiográficamente se corroboró quiste de colédoco tipo I. Se realizó colecistectomía con excisión completa del quiste y anastomosis hepático-duodeno. El análisis histopatológico demostró vesícula alitiásica, sin pólipos ni datos de malignidad. A dos años de la cirugía la paciente sólo ha sufrido un cuadro de colangitis, que se resolvió médicamente. Discusión: el promedio de edad para presentación del quiste de colédoco es de 34 años y el riesgo de malignidad se incrementa con la edad: 0.7 por ciento en pacientes menores de 10 años; 6.8 por ciento, de 11 a 20 años, y 14.3 por ciento, en mayores de 20 años. La incidencia de neoplasia en enfermos con quiste de colédoco es de 23 a 39.4 por ciento, mientras que en la población general es de 0.003 a 0.004 por ciento. Conclusión: el paciente adulto con quiste de colédoco tiene elevado riesgo para presentar cáncer de vías biliares. En este caso el tratamiento de elección es la excisión total del quiste y debe mantenerse seguimiento estrecho a largo plazo porque existe la posibilidad de neoplasia metacrónica