Transvesical Laparoendoscopic Single-Site Management of Distal Ureter During Laparoscopic Radical Nephroureterectomy.

Objective: To describe the management of the distal ureter during radical nephroureterectomy with the transvesical laparoendoscopic single-site surgery (T-LESS) approach. Methods: Between January 2010 and October 2013, five patients underwent laparoscopic radical nephroureterectomy for upper urinary tract carcinoma (UTUC) with the T-LESS approach. Patients were placed in the supine position. A 2.5-cm skin incision was made in the line between the pubis and the umbilicus. The bladder was identified and a multiport was inserted into the bladder. The patients were repositioned to a lateral decubitus position; pneumovesicum was established and the ureteral openings were identified. We marked the bladder cuff with electrocautery all the way through to the extravesical fat. The bladder defect was sealed with sutures. After checking for any leak or bleeding, the multiport was removed and the bladder was closed. At this point, we continued with nephrectomy by standard laparoscopy or LESS. A 18F Foley catheter was placed into the bladder. Results: The mean age was 70 years (range 58-81 years), the mean operative time was 198 minutes (range 115-390 minutes), the mean time for the management of the distal ureter was 35 minutes (range 27-45 minutes), the mean estimated blood loss was 234 mL (range 60-850 mL), and the mean hospital stay was 3.8 days (range 2-8 days). In all patients the bladder cuff was free of disease. Conclusion: The transvesical laparoendoscopic single-site approach to the distal ureter for UTUC appears safe and reproducible, with faster closure of the bladder defect and improved cosmesis.

Robotic bilateral inguinal lymphadenectomy in penile cancer, development of a technique without robot repositioning: a case report.

INTRODUCTION: Inguinal lymphadenectomy is the treatment of choice for patients with penile cancer and inguinal lymph node metastases. We describe the performance of the robotic bilateral inguinal lymphadenectomy technique without repositioning the robot in a patient with penile carcinoma and high risk for nodal metastases and no palpable lymph nodes. MATERIALS AND METHODS: A 64-year-old male patient was diagnosed with penile cancer (TNM: T3 N 0 M 0) and underwent a total penectomy with perineal urethrostomy. We performed a robotic bilateral inguinal lymphadenectomy four weeks after the penectomy. RESULTS: The entire procedure was performed with the robot-assisted technique. The operative time, median estimated blood loss, and hospital stay was 360 min, 100 ml (50 ml in the right side and 150 ml in the left side), and three days, respectively. Metastatic nodes were present in both inguinal regions, with a yield of 19 lymph nodes on the right and 14 on the left. The patient presented with a left-side lymphocele that was drained at follow-up. No other complications were reported. CONCLUSION: Robotic bilateral inguinal lymphadenectomy secondary to penile cancer is feasible, safe, and provides a good performance. Prospective studies are required to include a larger number of patients and long-term monitoring to assess the results of this procedure in comparison with open and laparoscopic techniques.

Robot-assisted intrafascial simple prostatectomy: novel technique.

PURPOSE: We describe our initial experience with intrafascial robot-assisted simple prostatectomy (IF-RSP). Potential advantages include reduced blood loss, elimination of the need for postoperative bladder irrigation, and elimination of the risk of residual or future prostate cancer, without interrupting potency or continence. PATIENTS AND METHODS: From June 2011 to March 2012, 10 patients with symptomatic prostatomegaly on transrectal ultrasonography (TRUS) (mean 81 g) underwent IF-RSP. Three patients had acute urinary retention. Demographic perioperative and outcome data were recorded up to 1 month follow-up. RESULTS: Average age was 71.7 years (range 60-79 years), estimated blood loss was 375 mL (range 150-900 mL), operative time was 106 minutes (range 60-180 min), hospital stay was 1 day (range 0-3 days), and Foley catheter duration was 8.9 days (range 6-14 days). The drain was removed at a mean 2.8 days (range 0-8 days). Mean prostate volume on preoperative TRUS was 81 cc (range 47-153 cc). Mean specimen weight was 81 g (range 50-150 g). Improvement was noted in the International Prostate Symptom Score (preoperative vs postoperative 18.8 vs 1.7) and peak flow rate (12.4 vs 33.49 mL/min). Sexual Health Inventory for Men score ranged from 12 to 24. All patients were completely continent within 1 month postoperatively, and sexual function was preserved. One patient had urinary tract infection and one patient needed blood transfusion postoperatively. CONCLUSIONS: IF-RSP appears to be a feasible procedure in large-volume prostatomegaly. The entire prostate tissue is removed without compromising continence and potency. Larger series and longer-term follow-up are needed to evaluate the proper place of this approach.

Laparoscopic anatrophic nephrolithotomy: developments of the technique in the era of minimally invasive surgery.

BACKGROUND AND PURPOSE: The complete removal of the stone is the ultimate goal in management, a result that might not be attained even after several sessions of percutaneous nephrolithotomy (PCNL) and/or extracorporeal shockwave lithotripsy (SWL) and/or retrograde intrarenal surgery (ureteroscopy). The objective of this study is to assess our technique of anatrophic nephrolithotomy, with decreased renal ischemia and reduced patient morbidity. PATIENTS AND METHODS: From 2007 to 2010, we performed eight anatrophic laparoscopic nephrolithotomies in adult patients with staghorn renal calculus. The mean patient age was 49 years (range 35-62 y). The mean stone size was 53 mm (range 35-70 mm). All patients had complex renal calculi, with stones occupying more than 80% of the caliceal system. In all cases, a Double-J stent was placed before surgery. After clamping the hilum, the incision was made laterally and longitudinally through full thickness of cortex using a laparoscopic scalpel. A running cortical suture was performed with Hem-o-lok reinforcement. Renal function was assessed in three patients, using renography with technetium-99m-diethylenetriaminepentacetic acid (99mTc-DTPA), before and 3 months after the surgery. RESULTS: Procedures for all patients were completed laparoscopically. The mean operative time was 142.5 minutes, and the mean warm ischemia time was 20.8 minutes. The estimated blood loss was 315 mL. The hospital stay average was 3.5 days. Only one patient had a complication--a vascular fistula with permanent postoperative hematuria. This patient subsequently underwent successful endovascular embolization. Residual stones were identified in 37% of cases (three patients) during follow-up imaging at 15 days. There were minimal changes on serum creatinine values. CONCLUSIONS: Laparoscopic surgery is feasible when anatrophic nephrolithotomy is indicated. This technique minimizes the barriers of an open flank incision, while achieving excellent stone-free rates. This minimally invasive technique should be considered for complex stones that would necessitate multiple renal access tracks and secondary procedures.

Robotic extended pyelolithotomy for complete staghorn calculus.

Staghorn stones represent a therapeutic challenge to urologists. We present our experience with laparoscopic extended pyelolithotomy for treatment of staghorn and complex renal calculi in highly selected cases. This approach provides the principles of open surgery with the advantages of minimally invasive surgery. We describe our experience with robot-assisted extended pyelolithotomy for complex coralliform calculi. Since January 2007, robotic extended pyelolithotomy has been performed by transperitoneal approach in two patients with complete coralliform lithiasis (calculi average size 8 cm). One patient had history of percutaneous nephrolithotomy. Demographic and operative data were collected. All procedures were technically successful without need for open conversion. Mean estimated blood loss was 175 ml (range 50-300 ml), and mean operative time was 150 min (range 120-150 min). A perinephric drain was employed in one patient with duration of 5 days. Postoperative imaging confirmed complete stone clearance. Robotic extended pyelolithotomy is a feasible and reproducible procedure for removal of complete and partial staghorn calculi in selected patients with complex nephrolithiasis. This approach might limit the role of open surgery for these calculi, but further publications with more cases are necessary to further define its utility.

NOTES hybrid transvaginal radical nephrectomy for tumor: stepwise progression toward a first successful clinical case.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. OBJECTIVE: To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. DESIGN, SETTING, AND PARTICIPANTS: The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MEASUREMENTS: All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. RESULTS AND LIMITATIONS: Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. CONCLUSIONS: We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

Laparoendoscopic single-site surgery simple prostatectomy: initial report.

OBJECTIVES: To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy. METHODS: A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing. RESULTS: An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Q(max.) of 85 mL/s. CONCLUSIONS: We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia.

[Laparo-endoscopic single site (LESS)]. / Laparo-endoscopia por acceso único: experiencia inicial.

OBJECTIVE: We present our initial experience in laparo-endoscopic single site (LESS) surgery, through multichannel port, articulated instruments and standard instruments adapted others adapted for the procedures. MATERIALS AND METHODS: Between February and October 2008, 28 LESS surgical procedures with multi-port were performed (Transumbilical simple prostatectomy (PSTU) and transvesical (PSTV), simple nephrectomy (NS), Enterocystoplasty augmentation (ECA) and simple hysterectomy (HS)). The clinical data were collected prospectively and analyzed retrospectively. Was used access device Multichannel (R-Port). The procedures were performed for a single surgeon (RS). The surgical technique was the same route used by conventional laparoscopic. RESULTS: Twenty-eight surgeries were performed: PSTU (01), PSTV (20), NS (01), ECA (01), HS (05). The incision was performed umbilical or infraumbilical. Only one case (nephrectomy) needed it placement of an additional trocar. The average age by procedure was PSTU and PSTV, 67- and 68-year-old (57-89 y) respectively; NS 12 year-old; RCT 20-year-old; HS 46.4-year-old (41 - 54 y). The operative time was: PSTU 120 minutes, PSTV 91 minutes (45-210 min); NS 120 minutes: RCT 300 minutes; HS 112 minutes(90-160 min). The operative bleeding was PSTU and PSTV 200 cc. and 337 cc (50-1500 cc) respectively; NS 100 cc; EAC 100 cc; HS 118 cc (100-160 cc). The complication was haematury in two cases of PSTV, both patients required exploration postoperative endoscopic with satisfactory evolution. CONCLUSIONS: LESS is a feasible and reproducible surgical option in uro-gynecologic surgical treatment. Further studies, experience and follow-up will provide an objective assessment of the technique.

Laparoscopic augmentation enterocystoplasty through a single trocar.

OBJECTIVES: To report on the initial case and surgical technique of laparoendoscopic, single-site, subtotal cystectomy and augmentation enterocystoplasty performed through a single multichannel transumbilical port in a patient with neurogenic bladder. METHODS: Laparoendoscopic, single-site, subtotal cystectomy and augmentation enterocystoplasty was performed in a 20-year-old woman with neurogenic bladder secondary to congenital sacral lipoma that had been operated on at 2 years of age. The patient had a long history of urinary incontinence and frequent and urgent urination. The imaging and urodynamic studies revealed a 100-mL bladder capacity with thickened walls, countless diverticula, and low compliance. The procedure was performed exclusively using a novel multichannel access port. Additional instruments included the 5-mm video laparoscope, SonoSurge, and flexible scissors. Subtotal cystectomy was initially performed by resecting 70% of the bladder. The ileal loop was exteriorized through the single port by detaching the valve, and the ileal pouch and bowel continuity were restored extracorporeally. The vesicoileal anastomosis was performed laparoscopically. RESULTS: The operating time was 300 minutes, and the blood loss was <100 mL. No intraoperative or postoperative complications developed. The hospital stay was 6 days. The drain and Foley catheter were removed at 7 and 21 days postoperatively, respectively. Postoperative cystography confirmed a watertight anastomosis and increased bladder capacity. At last follow-up, the patient was performing intermittent self-catheterization to complete emptying. CONCLUSIONS: Our initial experience with laparoendoscopic, single-site, subtotal cystectomy and enterocystoplasty through a single port was encouraging. The use of the larger diameter port significantly facilitated extracorporeal bowel reconstruction and can be used for various minimally invasive surgical procedures.

Chicken gizzard: a new training model for laparoscopic urethrovesical anastomosis.

OBJECTIVE: To create a simple, inexpensive, and reproducible animal model to provide a new training option for performing urethrovesical anastomosis during laparoscopic radical prostatectomy. MATERIAL AND METHODS: Development and testing were carried out in 2008. The materials used included a laparoscopic training box, video camera, monitor, needle holder, sutures, and non-eviscerated chickens weighing more than 2 kilograms. The model was prepared with a new perception of a structure similar to the human pelvis. To create the anastomosis, we used the gizzard (bladder neck) and the rectum (urethra). Once the model was placed in the box, the anastomosis was performed under very similar anatomical conditions to real procedures. Anastomosis quality was assessed by means of a permeability test and transanal endoscopy. RESULTS: The operating field is very similar to the human pelvis. The tissues have a quality, texture, and diameter resembling those of the urethra (rectum) and the bladder neck (gizzard), and offer the opportunity to practise anastomosis and anterior racket. CONCLUSIONS: The model for urethrovesical anastomosis using the chicken gizzard and rectum is simple, easily available, inexpensive and reproducible. The anatomy of the chicken and the characteristics of its tissues allow for training under conditions very similar to those present in human cases.

Single-port transvesical simple prostatectomy: initial clinical report.

INTRODUCTION: To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. METHODS: Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. RESULTS: Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. CONCLUSIONS: Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia.

Robotic repair of rectovesical fistula resulting from open radical prostatectomy.

OBJECTIVES: Rectovesical fistula (RVF) is a rare complication of radical prostatectomy. A 57-year-old man underwent open radical prostatectomy with recognized rectal injury, primary closure of the rectal wall, and loop colostomy. The patient developed urine leakage per rectum after colostomy closure. We diverted the fecal stream with end colostomy and placed a suprapubic tube. An open transsacral (Kraske) repair failed 1 month later. We have previously described the laparoscopic approach, and report the technique and results of our first robotic assisted operation. METHODS: The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization (3) five-port transperitoneal laparoscopic initial dissection (4) mobilization of omental pedicle flap, (4) cystotomy extending toward the fistulous tract, (5) robot docking (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, and (10) drain placement. RESULTS: Operative time was 180 minutes. Hospital stay was 1 day. The suprapubic tube was removed at 2 months after normal cystography. Bowel continuity was restored at 4 months, with no fistula recurrence at 1-month follow-up. CONCLUSIONS: We await longer follow-up and experience in larger series. For now, robotic repair of rectovesical fistula appears feasible and represents an attractive alternative to open and laparoscopic approaches.

Laparoscopic repair of rectourethral fistulas after prostate surgery.

OBJECTIVES: To present our experience with laparoscopic rectourinary fistula (RUF) repair. RUF is a rare entity that can develop after ablative or extirpative prostate surgery. Successful management often requires an aggressive approach. Several techniques have been described for surgical correction. METHODS: From October 2004 to October 2005, 3 patients were treated for RUF. The mean age was 63 years (range 58 to 68). RUF developed after open simple prostatectomy, open radical prostatectomy, and transurethral prostate resection. The operative steps were dependent on the location of the fistulous tract (bladder-prostate-urethra). When the fistula involved the prostatic capsule, the technique included capsulectomy and urethrovesical anastomosis. When the bladder was involved, a transvesical approach was used, involving dissection of the fistulous tract, closure of the rectum, tissue interposition, and bladder closure. RESULTS: The mean operative time was 247 minutes (range 230 to 270). The mean hospital stay was 2.6 days (range 2 to 3). No complications occurred. At a mean follow-up of 12 months (range 7 to 19), all patients were free of fistula recurrence. CONCLUSIONS: Laparoscopic repair of RUF is feasible and represents an attractive alternative to the standard approaches. The laparoscopic technique facilitates concomitant colostomy and tissue interposition without the need for patient repositioning or an additional incision.

Assay standardization bias: different prostate cancer detection rates and clinical outcomes resulting from different assays for free and total prostate-specific antigen.

OBJECTIVES: Numerous commercial assays are available for measuring total and free prostate-specific antigen (PSA) levels in serum. These assays can be referenced to different laboratory standards, and interassay variability occurs. Patients and physicians might be affected by the variability between PSA assays that results from the use of different PSA standards. METHODS: We prospectively compared the free and total PSA measurements obtained using two commercially available PSA assays in 103 participants from a prostate cancer screening program in Caracas, Venezuela. We recommended biopsy to men with a total PSA level of 3 to 10 ng/mL and a free/total PSA ratio of 20% or less with either assay. We compared the sensitivity, specificity, and concordance index between the two assays to assess the effects of interassay variability on the cancer detection rate and clinical outcomes. RESULTS: Although the total PSA results were similar between the assays, the free PSA level was significantly greater with one assay. Therefore, the free/total PSA ratio was discordant between the two assays, resulting in different biopsy recommendations and cancer detection rates. CONCLUSIONS: Using a free/total PSA ratio of 20% or less as the threshold for biopsy, the differences in assay sensitivity and specificity for detecting prostate cancer are significant. Commercially available assays for PSA and its derivatives are not necessarily interchangeable, and these differences might lead to different clinical outcomes. When using free and total PSA measurements to make clinical decisions, patients and physicians should be aware of the potential standardization bias and which assay is being used.

Cáncer del tracto gastrointestinal: estudio del ganglio centinela / Cancer of the gastrointestinal tract: study of the ganglion sentinel

El estudio del ganglio centinela es un procedimiento actualmente válido para melanoma y cáncer de mama. Su utilidad en el cáncer gastrointestinal aún está en investigación, sin embargo, su aplicación podría mejorar la estadificación ganglionar, influyendo en la terapéutica y el pronóstico en este tipo de cáncer. Evaluamos la factibilidad del método en pacientes con diagnóstico de cáncer gastrointestinal. En el período comprendido entre agosto de 2001 y mayo de 2004, se incluyeron pacientes con diagnóstico histológico de adenocarcinoma gástrico y colónico en estadios tempranos. Al inicio de la cirugía, se inyectó en forma peritumoral y subserosa 1 mL de azul patente. Una vez identificado y extirpado el ganglio centinela, se procedió a la cirugía habitual. A los ganglios centinela cuyo estudio histopatógico con coloración con hematoxilina y eosina fue negativo, se les realizaron estudios de inmunohistoquímica. Se incluyeron nueve pacientes, de los cuales, cinco con adenocarcinoma gástrico y cuatro con adenocarcinoma de colon. El porcentaje de detección del ganglio centinela fue de 66,6 por ciento. El promedio de ganglios centinela por paciente fue 1,16. Dos ganglios centinela (33 por ciento) fueron positivos, uno de ellos (16 por ciento) por inmunohistoquímica. Se observó 16 por ciento de metastasis en salto. No hubo falsos negativos ni drenaje linfático aberrante. El mapeo linfático es un procedimiento factible y sencillo que incrementa la posibilidad de detección de micrometástasis

Uso de cianocrilato en la síntesis de las fimosectomías / Cianocrilato use in the synthesis of the phymosectomy

El objetivo de este trabajo es investigar la utilidad del uso de Cianocrilato en la síntesis de heridas de fimosectomías realizadas en el Hospital "Miguel Pérez Carreño" durante el período de enero a diciembre de 2003. Se realizó estudio prospectivo, procediéndose a la síntesis de heridas de fimosectomías con Cianocrilato en 10 pacientes y comparándose en 10 pacientes en quienes la síntesis se realizó con Catgut Crómico, tomando en cuenta el tiempo utilizado en la síntesis, dolor, complicaciones y el tiempo para reinicio de relaciones sexules. Con el uso de Cianocrilato no se evidenciaron cicatrices hipertróficas. El tiempo utilizado en la síntesis con Cianocrilato fue significativamente menor que con la sutura (P<0,0001), al igual que el dolor a las dos semanas de postoperatorio (p<0,000092) y el tiempo de reinicio de relaciones sexuales (P<0,00033) con un valor de 4.87 y 11.03 días más corto

Reemplazo colónico en pacientes con atresia esofágica / Colon interposition in patients with esophageal atresia

La reconstrucción del esófago en la edad pediátrica representa un reto para los cirujanos infantiles por las múltiples complicaciones que pueden ocurrir, a pesar de las diversas técnicas disponibles. Se presenta el caso de preescolar femenino de 2 años de edad con atresia esofágica sin fístula que se corrigió por reemplazo de colon descendente, usando la vía transhiatal sin complicación

Presentación clínica inusual de aneurisma aórtico abdominal: presentación de un caso / Unusual clinical presentation of abdominal aortic aneurysm

El aneurisma aórtico abdominal (AAA) roto es considerado un serio problema con un desenlace fatal en la mayoría de los casos. Más de la mitad de los pacientes que experimentan ruptura de un AAA mueren antes de ser llevados a la mesa operatoria y la mitad de los que son operados de emergencia mueren en ella o en los 30 primeros días del postoperatorio. La "triada clínica clásica" de hipotensión, dolor lumbar, y masa abdominal palpable y pulsátil están solo presentes en el 50 por ciento de los pacientes con AAA roto. Presentamos un caso de un paciente masculino de 52 años de edad quien consulta a la emergencia del Centro Médico de Caracas en abril de 1998 por presentar dolor incapacitante en el miembro inferior izquierdo de 5 días de evolución, de fuerte intensidad, irradiado a la totalidad del miembro, que limitaba la deambulación. Es evaluado por neurocirugía, quienes plantean el diagnóstico presuntivo de compresión radicular del plexo lumbo-sacro. La resonancia magnética nuclear y la tomografía axial computarizada demostraron un AAA infrarrenal gigante 10.6 cm. fisurado al músculo psoas ilíaco izquierdo

Emponzoñamiento Escorpiónico: casuistica del Hospital de Niños "J.M. de los Ríos" en 12 años / Scorpion poisoning: casuistic of the childrens of Hospital \"J.M. de los Ríos\" in 12 years

Se realizó un análisis retrospectivo en el Hospital de Niños "J.M. de los Ríos" desde Enero de 1985 a Diciembre de 1997 en 18 pacientes con diagnóstico de emponzoñamiento escorpiónico, con la finalidad de actualizar la incidencia, distribución por edad, procedencia, clínica, hallazgos de laboratorio, complicaciones y el tratamiento instaurado. La mayoría de los casos eran referidos de otros centros asistenciales y el 88,8 por ciento pertencía al Estado Miranda. Los preescolares el grupo de edad más afectado y las manifestaciones clínicas más frecuentes fueron los vómitos y el dolor abdominal. Se encontró hiperglicemia e hiperamilasemia en el 77,8 por ciento de los casos y en el EKG se evidenció bradicardia sinusal en 3 casos. El 77,8 por ciento de los pacientes presentaron pancreatitis y el 50 por ciento ameritó cuidados intensivos. El tratamiento administrado consistió en medidas generales y específicas, con evolución satisfactoria en el 94,4 por ciento de los casos. Se concluyó que la antivenina dispone de un alto índice de confiabilidad en el manejo de estos pacientes