Single-port Laparoscopic Liver Resection in Patients with Previous Abdominal Surgeries: Is it a Feasible Approach?

Single-port laparoscopic liver surgery has become an attractive procedure for many surgeons in order to decrease surgical aggression and the complications related to laparoscopic ports. The aim of this study is to assess the feasibility and efficacy of single-port laparoscopic liver resections in patients with previous upper or lower abdominal surgery. A series of ten patients with history of previous abdominal surgery who underwent single-port laparoscopic surgery for liver metastases, primary liver cancer or benign hepatic tumor, is being presented here. Several clinical and operative parameters were reviewed from a historical database of laparoscopic hepatectomy. Key Words: Laparoscopic liver surgery, Single-port, Previous abdominal surgeries.

Posición operatoria en cirugía colorrectal. La importancia de lo básico / Operating position in colorectal surgery. The importance of the basics

La posición operatoria en coloproctología es fundamental desde tres puntos de vista: correcto abordaje quirúrgico y exposición adecuada, requerimientos anestésicos y del mantenimiento de la vía aérea, y las complicaciones potenciales relacionadas con la propia posición. En el presente trabajo se revisan las indicaciones, colocación, ventajas e inconvenientes de cada posición operatoria, así como sus posibles complicaciones y cómo evitarlas. Éstas pueden ser de diversa índole, si bien las más frecuentes están relacionadas con lesiones por estiramiento o compresión de los nervios periféricos, seguidas por las tromboembólicas, hemodinámicas e isquémicas o síndromes compartimentales por isquemia-reperfusión tras un largo periodo en posición de Trendelenburg. Anestesistas y cirujanos deben coordinar y responsabilizarse de la posición operatoria de los pacientes (AU)

Intra-operative positioning in colorectal surgery is very important from three points of view: the proper surgical approach and exposure, adequate anaesthetic requirements with maintenance of the airway, and the potential complications related to the position. In the present study, we analyse the indications, positioning, advantages and disadvantages of each operative position, their potential complications and how to avoid them. These complications can be of a diverse nature, the most common being injuries related to stretching or compression of peripheral nerves, followed by thromboembolic, haemodynamic, and ischaemic or compartmental syndromes related to ischaemia-reperfusion after a long time in the Trendelenburg position. Anaesthetists and surgeons should coordinate and take responsibility for the position of surgical patients (AU)

[Operating position in colorectal surgery. The importance of the basics]. / Posición operatoria en cirugía colorrectal. La importancia de lo básico.

Intra-operative positioning in colorectal surgery is very important from three points of view: the proper surgical approach and exposure, adequate anaesthetic requirements with maintenance of the airway, and the potential complications related to the position. In the present study, we analyse the indications, positioning, advantages and disadvantages of each operative position, their potential complications and how to avoid them. These complications can be of a diverse nature, the most common being injuries related to stretching or compression of peripheral nerves, followed by thromboembolic, haemodynamic, and ischaemic or compartmental syndromes related to ischaemia-reperfusion after a long time in the Trendelenburg position. Anaesthetists and surgeons should coordinate and take responsibility for the position of surgical patients.

Donantes de ayer y de hoy: ¿han cambiado las características de los donantes de hígado durante los últimos 15 años? / Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?

Introducción. Los cambios sociosanitarios y demográficos de nuestra población y el crecimiento de las listas de pacientes en espera de un trasplante han condicionado ciertas variaciones en los criterios de selección de los donantes de órganos. Material y método. Estudio retrospectivo, descriptivo y comparativo de las características de los donantes cadáver de hígado utilizados en la Unidad de Trasplante Hepático del Hospital Universitario La Fe de Valencia en 2 períodos diferentes. Distribuimos los casos en 2 grupos: grupo A, los primeros 200 donantes (entre enero de 1991 y junio de 1995) y grupo B, 200 donantes más recientes (desde febrero de 2004 hasta diciembre de 2005). Resultados. El número de donaciones se ha incrementado desde los 18 donantes durante 1991 a los 106 en 2006. En el grupo A la edad media fue de 32,4 años, frente a 52,3 años del grupo B. En la serie A, la principal causa de muerte fueron los traumatismos craneoencefálicos y en el grupo B, los accidentes cerebrovasculares. El tiempo en la unidad de cuidados intensivos fue mayor en el segundo grupo, con una media de 67,2 h. En el grupo B el 17% presentaba aterosclerosis considerable de la aorta y el 29,5%, esteatosis hepática macroscópica, frente al 5 y el 12%, respectivamente, en el grupo A. Conclusiones. Actualmente, los donantes de hígado son de mayor edad, presentan más enfermedades crónicas, mueren por enfermedades cerebrovasculares, permanecen más tiempo en cuidados intensivos y sus hígados son macroscópicamente peores que los de donantes de años anteriores (AU)

Introduction. The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors. Material and method. A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005). Results. The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A. Conclusions. Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago (AU)

[Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?]. / Donantes de ayer y de hoy: han cambiado las características de los donantes de hígado durante los últimos 15 años?

INTRODUCTION: The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors. MATERIAL AND METHOD: A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005). RESULTS: The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A. CONCLUSIONS: Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago.

Reflexiones sobre 250 intervenciones de metástasis hepáticas de carcinoma colorrectal / Reflections on 250 interventions for colorectal carcinoma metastases to the liver

Introducción. Los mejores resultados en el tratamiento de las metástasis hepáticas de carcinoma colorrectal se obtienen con la resección quirúrgica, que debe realizarse con unos estándares de calidad. Objetivos. Presentar la experiencia de 11 años en el tratamiento quirúrgico de las metástasis hepáticas de carcinoma colorrectal en una unidad de referencia y comprobar si se cumplen los estándares actuales de calidad. Pacientes y método. Desde enero de 1995 hasta diciembre de 2005 se realizaron 250 intervenciones en 221 pacientes diagnosticados de metástasis hepáticas de origen colorrectal, con 201 resecciones hepáticas. Resultados. El 19% de los pacientes tenían una edad ≥ 70 años, con factores comórbidos asociados en el 54% de los casos. De las 201 resecciones, el 8,5% fue una segunda resección. En el 39% se realizó una hepatectomía mayor. La resección fue R0 en el 85% de los casos. No se transfundió en el 80% de los casos. La mediana de estancia postoperatoria fue de 6 días, la mortalidad postoperatoria fue del 0% y la morbilidad, del 19%. Se relacionaron con la morbilidad el número de segmentos resecados y la transfusión peroperatoria. Las supervivencias actuariales generales a 1, 3 y 5 años fueron del 96, el 69 y el 52% y las supervivencias actuariales libres de enfermedad para los mismos períodos fueron del 58, el 32 y el 24%, respectivamente. Conclusiones. La resección de las metástasis hepáticas de carcinoma colorrectal es una buena opción terapéutica cuando se cumplen los estándares de calidad actuales (AU)

Introduction. The best results in the treatment of colorectal cancer metastases to the liver are currently achieved with surgical resection performed under high quality standards. Objectives. To analyze the results and quality standards of the surgical treatment of colorectal cancer liver metastases in a referral liver unit over an 11-year period. Patients and method. From January 1995 to December 2005, 250 surgical interventions were performed in 221 patients diagnosed with colorectal cancer liver metastases, resulting in 201 hepatic resections. Results. Nineteen percent of patients were ≥ 70 years old and comorbidity was present in 54%. Of the 201 hepatic resections, 8.5% were second resections. Major hepatectomy was performed in 39% of the patients. R0 resection was achieved in 85% of the patients. Blood transfusions were not required in 80% of the patients. The median length of postoperative stay was 6 days. Postoperative mortality was nil and morbidity was 19%. Morbidity was associated with the number of resected segments and the need for blood transfusion. The estimated 1-, 3- and 5-year cumulative survival rates were 96%, 69% and 52%, respectively, while estimated disease-free survival rates were 58%, 32% and 24%, respectively. Conclusions. Resection of colorectal cancer liver metastases is an effective therapeutic alternative if high current quality standards are achieved (AU)

[Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids]. / Resultados de la anopexia grapada de Longo en el tratamiento quirúrgico ambulatorio de las hemorroides de grados III-IV.

INTRODUCTION: We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. METHOD: Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. RESULTS: Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81+/- 12 minutes with a mean length of hospital stay of 168.88 +/- 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. CONCLUSIONS: Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder.

Resultados de la anopexia grapada de Longo en el tratamiento quirúrgico ambulatorio de las hemorroides de grados III-IV / Results of Longo’s stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids

Introducción. Evaluación prospectiva de los resultados de la anupexia grapada en el tratamiento de las hemorroides de grados III-IV en régimen ambulatorio. Método. Estudio prospectivo de 85 pacientes con hemorroides de grados III-IV, tratados ambulatoriamente mediante la técnica de anopexia grapada con PPH01 en el Servicio de Cirugía Ambulatoria del Hospital General de Valencia. Se incluyó a pacientes sintomáticos, ASA I-II, que aceptaran del método ambulatorio (vehículo, acompañante adulto, domicilio con teléfono, ascensor e higiene básica). Resultados. El 39% eran mujeres y el 61%, varones, con una media de edad de 47,6 años. El 85,9% presentó hemorroides de grado IV y el 14,1%, de grado III. El tiempo medio quirúrgico fue de 29,81 ± 12 min, con una media de estancia hospitalaria de 168,88 ± 88 min. Intraoperatoriamente observamos 16 (18,8%) hemorragias de la línea de grapado y 5 hemorragias por desgarro mucoso. Durante los primeros 8 días la complicación más frecuente fue el dolor (45,9%), y sólo el 7,1% necesitó el uso de opiáceos; 1 paciente debió ingresar durante 24 h. En 10 pacientes hubo hemorragia; en 5 de ellos fue leve con la defecación y cedió espontáneamente, y los otros 5 requirieron ingreso tras revisión quirúrgica, con alta en 24 h. Ingresaron 9 (10,6%) pacientes, 3 por hemorragia intraoperatoria, 5 por hemorragia postoperatoria y 1 por dolor. En el 8,2% fue necesaria una nueva intervención. Conclusiones. La anupexia grapada es un procedimiento aplicable en régimen ambulatorio. Aunque técnicamente sencillo y con una curva de aprendizaje corta, no está exento de complicaciones. Una adecuada selección de pacientes, una correcta información perioperatoria y un seguimiento estricto son necesarios en el manejo ambulatorio de esta afección (AU)

Introduction. We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. Method. Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. Results. Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81± 12 minutes with a mean length of hospital stay of 168.88 ± 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. Conclusions. Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder (AU)

Endometriosis incisional. Un hallazgo infradiagnosticado en cirugía general / Incisional endometriosis. An underdiagnosed event in general surgery

La endometriosis incisional es una patología poco frecuente hallada en cirugía general, muchas veces confundida con otras entidades clínicas más presentes en nuestro ámbito quirúrgico, como la hernia incarcerada, el lipoma o el cuerpo extraño. Su diagnóstico es fundamentalmente clínico, sobre todo si la presentación es cíclica en relación con la menstruación. El tratamiento definitivo es quirúrgico y, en ocasiones, requiere una exéresis con márgenes de seguridad seguida de una plastia con malla para cubrir el defecto aponeurótico. Presentamos 3 casos clínicos nuevos, de mujeres en edad fértil, con antecedentes quirúrgicos ginecológicos previos que presentan tumoraciones incisionales en la cicatriz de un Pfannenstiel; en el primero de ellos se planteó el diagnóstico diferencial entre granuloma a cuerpo extraño y hernia incarcerada, pero en los restantes, debido al carácter cíclico del dolor asociado a la tumoración, se pensó en una posible endometriosis incisional. Los diagnósticos definitivos los proporcionó la anatomía patológica tras la exéresis de los tumores. En dos casos se requirió una plastia con malla

Incisional endometriosis is a rare finding in general surgery and is often mistaken for other clinical entities that are more common in our surgical setting such as incarcerated hernia, lipoma or foreign body. Diagnosis is based on clinical findings, especially if the presentation is cyclical and related to menstruation. The definitive treatment is surgery, and a mesh plasty is sometimes required to cover the aponeurotic defect left after excision with safety margins. We present three new cases in women of reproductive age with previous gynecological surgery who developed incisional tumors at the Pfannenstiel incision site. The first case posed a differential diagnosis between a granuloma to a foreign body versus an incarcerated hernia. In the remaining cases, because the tumor-associated pain was cyclical, a possible diagnosis of incisional endometriosis was considered. However, the definitive diagnoses were given by histology after excision of the specimen. In two patients a mesh plasty was required