Revisiting microsurgical principles for the minimally invasive surgeon.

OBJECTIVE: To demonstrate basic microsurgical techniques and revisit the importance of following microsurgical principles in minimally invasive surgery. DESIGN: Video demonstration of various surgical cases portraying proper microsurgical techniques as well as the consequences of deviating from these principles. SETTING: Tertiary referral practice. PATIENT(S): Reproductive-aged women with a desire to preserve reproductive organs and fertility potential. INTERVENTION(S): We present surgical cases demonstrating the management of tubal and paratubal pathologies in which extra care must be taken to avoid inadvertent injuries of normal anatomic structures. We also portray the proper management of ovarian dermoid cysts and endometriomas to maximize the preservation of ovarian reserve and minimize complications. We have stressed the importance of ensuring safe tissue containment and extraction to avoid complications such as port site metastasis along with parasitic and iatrogenic myomas. MAIN OUTCOME MEASURE(S): Implementation of microsurgical techniques including delicate tissue handling, judicious use of energy sources, and proper tissue containment and extraction. RESULT(S): Nonadherence to microsurgical principles can result in detrimental surgical outcomes, including adhesions, parasitic myomas, port site metastasis, peritonitis, and compromised ovarian reserve. CONCLUSION(S): Microsurgical principles are of paramount importance to improve patient outcomes in reproductive surgeries. These tenets should be uniformly applied in all surgical procedures. As surgeons who perform minimally invasive surgeries, we must revisit these principles and advocate for their training and universal implementation.

Laparoscopic hepp couinaud for the treatment of caroli's disease: a case report / Hepp Couinaud laparoscópica para el tratamiento de la enfermedad de Caroli: reporte de caso

Caroli disease is a rare congenital disorder characterized by dilatation of intrahepatic bile ducts. The treatment could correspond to hepatic resection for localized disease. This paper describes a case of Caroli's disease in a 60 years old female patient, who presented jaundice and diffuse abdominal pain. Further examinations suggested the diagnosis of Caroli disease associated with cholestatic syndrome. We decided to perform a Hepp Couinaud biliodigestive bypass by video laparoscopy with Roux-en-Y reconstruction. There were no immediate complications and no longterm complications after 6 months of follow-up. The VLP biliodigestive bypass in patients with associated cholestatic syndromes should be considered a treatment prior to a more aggressive approach.

La enfermedad de Caroli es un raro trastorno congénito que consiste en una dilatación de las vías biliares intrahepáticas. Su tratamiento definitivo debe consistir en resección hepática por la enfermedad localizada. Este artículo describe un caso de enfermedad de Caroli en una paciente de sexo femenino de 60 años de edad, quien presentó ictericia y dolor abdominal difuso. Exámenes posteriores sugirieron el diagnóstico de enfermedad de Caroli asociada con síndrome colestásico. Los médicos decidieron realizar un bypass biliodigestivo de Hepp Couinaud mediante videolaparoscopia con reconstrucción en Y de Roux. No hubo complicaciones inmediatas ni complicaciones a largo plazo después de 6 meses de seguimiento. El bypass biliodigestivo VLP en pacientes con síndromes colestásicos asociados debe considerarse un tratamiento previo a un abordaje más agresivo.

[Laparoscopic transchiatal access in Boerhaave syndrome]. / Laparoskopicheskii transkhiatal'nyi dostup pri sindrome Burkhave.

Diagnosis of spontaneous rupture of the esophagus (Boerhaave syndrome) followed by purulent mediastinitis and pleural empyema has now been greatly simplified due to CT. The main thing is to suspect this syndrome in a timely manner. Methods of surgical treatment of this disease are still being discussed. We present successful laparoscopic treatment of spontaneous rupture of the esophagus.

[Diagnosis and treatment of patients with abdominal trauma]. / Puti sovershenstvovaniya diagnostiki i lecheniya postradavshikh s sochetannoi travmoi zhivota.

OBJECTIVE: To improve the results of diagnosis and treatment of patients with abdominal injuries through a wider introduction of laparoscopic methods. MATERIAL AND METHODS: We analyzed 3556 patients with concomitant abdominal injuries. All patients had damage to several organs and systems. Laparoscopy was performed in 1962 patients, laparotomy without previous laparoscopy - in 1594 patients. RESULTS: Laparoscopy found no abdominal injuries in 25.7% of patients, other 13.7% of patients required no surgery and follow-up was indicated. In 60.7% of patients, injuries required surgical correction. Among these lesions, 26.6% of injuries were successfully eliminated using laparoscopic approach. In some cases, more than one injury was corrected. Indications for laparotomy were overestimated in 30.2% of patients who underwent open surgery without previous laparoscopy. CONCLUSION: There is a tendency to decrease in the number of open and laparoscopic procedures for concomitant abdominal trauma over time that is associated with widespread introduction of modern diagnostic methods and accumulation of experience. Laparoscopy should be preferred for diagnosis of abdominal injuries in patients with concomitant trauma and no contraindications. This approach diagnoses no injuries or their mild nature in 39.3% of cases. Moreover, laparoscopy effectively eliminates certain lesions in 26.6% of cases.

Diagnostic methods and surgical treatment of patients with thoracoabdominal traumas (review of the literature).

Thoracoabdominal traumatism is a topical problem of modern medicine due to its wide prevalence, severe course and unfavorable outcome. This article presents an overview of the epidemiology, diagnosis, and surgical treatment of patients with thoracoabdominal injuries. It showed that the current incidence of thoracoabdominal injuries reaches 13.7-16.4% of all chest and abdominal injuries. Lethality in thoracoabdominal injuries ranges from 3.13% to 20%. In most cases these are patients of working age, with an average age of 27.5-34.8 years, men comprising 71.2%. Nowadays, the number of patients with thoracoabdominal injuries tends to increase in Uzbekistan and other economically developing countries of the world because of increasing transportation, construction and crime. Video-thoracoscopy and video-laparoscopy are among the widespread methods of diagnosis and treatment of thoracoabdominal traumas. According to many authors, the specificity of video-laparoscopy and video-thoracoscopy is 100%, and the sensitivity is 87.5-99.3%.

Impact of Grade I obesity on respiratory mechanics during video laparoscopic surgery: prospective longitudinal study / Impacto da obesidade Grau I na mecânica respiratória durante cirurgia videolaparoscópica: estudo longitudinal prospectivo

Abstract Introduction and objectives: The association pneumoperitoneum and obesity in video laparoscopy can contribute to pulmonary complications, but has not been well defined in specific groups of obese individuals. We assessed the effects of pneumoperitoneum in respiratory mechanics in Grade I obese compared to non-obese. Methods: Prospective study including 20 patients submitted to video laparoscopic cholecystectomy, normal spirometry, divided into non-obese (BMI ≤ 25 kg.m-2) and obese (BMI > 30 kg.mg-2), excluding Grade II and III obese. We measured pulmonary ventilation mechanics data before pneumoperitoneum (baseline), and five, fifteen and thirty minutes after peritoneal insufflation, and fifteen minutes after disinflation (final). Results: Mean BMI of non-obese was 22.72 ± 1.43 kg.m-2 and of the obese 31.78 ± 1.09 kg.m-2, p < 0.01. Duration of anesthesia and of peritoneal insufflation was similar between groups. Baseline pulmonary compliance (Crs) of the obese (38.3 ± 8.3 mL.cm H2O-1) was lower than of the non-obese (47.4 ± 5.7 mL.cm H2O-1), p = 0.01. After insufflation, Crs decreased in both groups and remained even lower in the obese at all moments assessed (GLM p < 0.01). Respiratory system peak pressure and plateau pressure were higher in the obese, albeit variations were similar at moments analyzed (GLM p > 0.05). The same occurred with elastic pressure, higher in the obese at all times (GLM p = 0.04), and resistive pressure showed differences in variations between groups during pneumoperitoneum (GLM p = 0,05). Conclusions: Grade I obese presented more changes in pulmonary mechanics than the non-obese during video laparoscopies and the fact requires mechanical ventilation-related care.

Resumo Justificativa e objetivos: Em videolaparoscopias, a associação de pneumoperitônio e obesidade pode contribuir para complicações pulmonares, mas não está bem definida em grupos específicos de obesos. Avaliamos os efeitos do pneumoperitônio na mecânica respiratória dos obesos Grau I em comparação aos não obesos. Métodos: Estudo prospectivo envolvendo 20 pacientes submetidos à colecistectomia videolaparoscópica, com espirometria normal, separados em não-obesos (IMC ≤ 25 kg.m-2) e obesos (IMC > 30 kg.mg-2), excluídos obesos Grau II e III. Mensuramos dados da mecânica ventilatória pulmonar antes do pneumoperitônio basal, após cinco, quinze e trinta minutos da insuflação peritoneal e quinze minutos após a desinsuflação final. Resultados: O IMC médio dos não obesos foi de 22,72 ± 1,43 kg.m-2 e dos obesos 31,78 ± 1,09 kg.m-2, p < 0,01. A duração da anestesia e da insuflação peritoneal foram semelhantes entre os grupos. A complacência pulmonar (Crs) basal dos obesos (38,3 ± 8,3 mL.cm H2O-1) foi inferior aos não obesos (47,4 ± 5,7 mL.cm H2O-1), p = 0,01. Após a insuflação, a Crs diminuiu nos dois grupos e permaneceu ainda mais baixa nos obesos em todos os momentos avaliados (GLM p < 0,01). A pressão de pico e a pressão de platô do sistema respiratório foram mais elevadas nos obesos, mas apresentaram semelhantes variações nos momentos analisados (GLM p > 0,05). O mesmo ocorreu com a pressão elástica, mais elevada nos obesos em todos tempos (GLM p = 0,04), e a pressão resistiva apresentou diferenças nas variações entre os grupos durante o pneumoperitônio (GLM p = 0,05). Conclusão: Obesos Grau I apresentam maiores alterações na mecânica pulmonar que os não obesos em videolaparoscopias e este fato recomenda cuidados relacionados a ventilação mecânica.

[Impact of Grade I obesity on respiratory mechanics during video laparoscopic surgery: prospective longitudinal study]. / Impacto da obesidade Grau I na mecânica respiratória durante cirurgia videolaparoscópica: estudo longitudinal prospectivo.

INTRODUCTION AND OBJECTIVES: The association pneumoperitoneum and obesity in video laparoscopy can contribute to pulmonary complications, but has not been well defined in specific groups of obese individuals. We assessed the effects of pneumoperitoneum in respiratory mechanics in Grade I obese compared to non-obese. METHODS: Prospective study including 20 patients submitted to video laparoscopic cholecystectomy, normal spirometry, divided into non-obese (BMI ≤ 25kg.m-2) and obese (BMI > 30kg.mg-2), excluding Grade II and III obese. We measured pulmonary ventilation mechanics data before pneumoperitoneum (baseline), and five, fifteen and thirty minutes after peritoneal insufflation, and fifteen minutes after disinflation (final). RESULTS: Mean BMI of non-obese was 22.72 ± 1.43kg.m-2 and of the obese 31.78 ± 1.09kg.m-2, p < 0.01. Duration of anesthesia and of peritoneal insufflation was similar between groups. Baseline pulmonary compliance (Crs) of the obese (38.3 ± 8.3mL.cm H2O-1) was lower than of the non-obese (47.4 ± 5.7mL.cm H2O-1), p = 0.01. After insufflation, Crs decreased in both groups and remained even lower in the obese at all moments assessed (GLM p < 0.01). Respiratory system peak pressure and plateau pressure were higher in the obese, albeit variations were similar at moments analyzed (GLM p > 0.05). The same occurred with elastic pressure, higher in the obese at all times (GLM p = 0.04), and resistive pressure showed differences in variations between groups during pneumoperitoneum (GLM p = 0,05). CONCLUSIONS: Grade I obese presented more changes in pulmonary mechanics than the non-obese during video laparoscopies and the fact requires mechanical ventilation-related care.

Complicación tardía por clips y cálculo, en paciente colesistectomisada / Late complication due to a clip and gallstone in a patient who underwent a cholecystectomy

RESUMEN Se presentó un caso con complicación tardía de una colecistectomía video-laparoscópica, cuatro años después de una colecistectomía laparoscópica. Se procedió a realizar la colangiopancreatografia retrograda endoscópica mediante la técnica convencional, por un especialista en Gastroenterología. Se procedió a realizar pre-corte papilar y se logró extraer el clip con pinza de biopsia. Se produjo la expulsión espontánea de un litio oscuro de aproximadamente 1 cm de diámetro (AU).

ABSTRACT We presented a case with late complication of a video-laparoscopic cholecystectomy, occurring four years after a laparoscopic cholecystectomy. A specialist in Gastroenterology carried out an endoscopic retrograde cholangiopancreatography using the conventional technique. A papillary pre-cut was done and the clip was extracted with biopsy clamp. A dark stone of around 1 cm of diameter was spontaneously passed (AU).

Complicación tardía por clips y cálculo, en paciente colesistectomisada / Late complication due to a clip and gallstone in a patient who underwent a cholecystectomy

RESUMEN Se presentó un caso con complicación tardía de una colecistectomía video-laparoscópica, cuatro años después de una colecistectomía laparoscópica. Se procedió a realizar la colangiopancreatografia retrograda endoscópica mediante la técnica convencional, por un especialista en Gastroenterología. Se procedió a realizar pre-corte papilar y se logró extraer el clip con pinza de biopsia. Se produjo la expulsión espontánea de un litio oscuro de aproximadamente 1 cm de diámetro (AU).

ABSTRACT We presented a case with late complication of a video-laparoscopic cholecystectomy, occurring four years after a laparoscopic cholecystectomy. A specialist in Gastroenterology carried out an endoscopic retrograde cholangiopancreatography using the conventional technique. A papillary pre-cut was done and the clip was extracted with biopsy clamp. A dark stone of around 1 cm of diameter was spontaneously passed (AU).

Complicaciones de la extubación traqueal en el período posoperatorio inmediato de la colecistectomía laparoscópica / Complications of the tracheal extubation in the early postoperative period of laparoscopic cholecystectomy

Se realizó un estudio descriptivo y prospectivo de 112 pacientes colecistectomizados por videolaparoscopia con anestesia general orotraqueal en el Hospital Clinicoquirúrgico Docente "Dr. Joaquín Castillo Duany" de Santiago de Cuba, desde diciembre del 2010 hasta marzo del 2011, a fin de determinar la incidencia de complicaciones asociadas a la extubación traqueal en el periodo posoperatorio inmediato. En la serie predominaron los afectados de 31-45 años (43,7%) y la taquicardia (19,6 %) como la complicación más frecuente. Asimismo, la edad, la obesidad y el tabaquismo favorecieron el desarrollo de complicaciones atribuibles a la extubación traqueal, las cuales tuvieron mayor frecuencia en la medida que el paciente estuvo más despierto al realizar la misma.

A descriptive and prospective study was carried out in 112 patients undergoing cholecystectomy by video laparoscopy under general orotracheal anesthesia in "Dr. Joaquín Castillo Duany" Teaching Clinical Surgical Hospital of Santiago de Cuba, from December 2010 to March 2011, to determine the incidence of complications associated with tracheal extubation in the early postoperative period. In the series patients of 31-45 years (43.7%) and tachycardia (19.6 %) as the most frequent complication prevailed. Also, age, obesity and smoking habit favored the occurrence of complications attributable to tracheal extubation, which were more frequent as the patient was more awake when performing it.

Colangiografia peroperatória sistemática em colecistectomia videolaparoscópica / Systematic cholangiography during laparoscopic cholecystectomy

OBJETIVO: Analisar os resultados de colangiografias peroperatórias (CPO), realizadas sistematicamente durante colecistectomias videolaparoscópicas (CVL). MÉTODO: No período de janeiro de 1998 a dezembro de 1999, foram realizadas CVL em 250 pacientes não selecionados, 65 (26 por cento) do sexo masculino e 185 (74 por cento) do sexo feminino, independente da presença ou não de sinais clínicos, laboratoriais, ultra-sonográficos ou de outros métodos diagnósticos, indicativos de coledocolitíase ou outras doenças da via biliar principal. RESULTADOS: A CPO pôde ser realizada em 237 (94,6 por cento) pacientes. Foram encontradas 31 (13 por cento) alterações, entre as quais seis (2,5 por cento) casos de coledocolitíase e 25 (10,5 por cento) casos de anomalias anatômicas. CONCLUSÃO: A CPO, durante a CVL, mostrou-se um procedimento seguro, sem complicações relacionadas ao exame, definindo a anatomia, prevenindo as lesões biliares e permitindo a detecção de coledocolitíase insuspeitada.

BACKGROUND: We present our results from peroperative cholangiography (POC) systematically performed during video laparoscopic cholecystectomies (VLC). METHOD: From January 1998 to December 1999, VLP was performed in 250 non-selected patients from both sexes, being 65 males (26 percent) and 185 females (74 percent), independent of the presence or not of clinical signals, laboratorial and ultrasonographics results or of other diagnostic method, indicatives of choledocholithiasis or other biliary ducts pathologies. RESULTS: POC could be performed in 94,6 percent of the cases. It was found 31 modifications (13 percent), being the most important six cases of choledocholithiasis (2,5 percent) and 25 cases of anatomical anomalies (10,5 percent). CONCLUSIONS: POC during VLC showed to be a safe procedure, with no complications, defining anatomy, forewarning biliary injuries and allowing assymptomatic choledocholithiasis detection.