Minilaparoscopy in urology: Systematic review. / Minilaparoscopia en urología: revisión sistemática.

CONTEXT: There has been a boom in recent years in urological procedures using minilaparoscopy (ML). OBJECTIVE: To conduct a systematic review of the published evidence on ML and its current role in urology. ACQUISITION OF EVIDENCE: We performed a search on MedLine spanning October 1983 to December 2016 according to PRISMA criteria. A total of 6 comparative articles and 13 series were selected for this manuscript. SUMMARY OF THE EVIDENCE: Only 1 study was randomised, 4 studies were prospective and comparative, and most were case series in which the operations were performed with 3-mm instruments. The most common procedures were adrenalectomy, followed by nephrectomy, living donor and pyeloplasty. Other minor conditions were also operated on, including cyst decortications, pyelolithotomies, lymphadenectomies, varicocelectomies and orchiectomies. DISCUSSION: There have been significant technical improvements in recent years in the materials of ML. Most procedures were for reconstructive surgery and by transperitoneal approach, with a gradually increasing number of cases of oncologic surgery. Only 36.8% of the series assessed the cosmetic results with validated questionnaires, and 68.4% of the studies used the visual analogue scale to measure pain during the postoperative period. CONCLUSIONS: The level of evidence of most published studies is low. ML is a reproducible technique for urological surgery and is safe even for operations on large surgical masses. The procedure's cosmetic and pain results after surgery are superior to those of conventional laparoscopy, although these conclusions should be taken with caution given the limitations of the current studies.

Segurança em cirurgia: água utilizada no centro de materiais e esterilização na higienização do material de manilaparoscopia

Desde a primeira colecistectomia, a técnica cirúrgica para este procedimento veio recebendo diversas modificações. Com o avanço dos equipamentos laparoscópicos e com o advento da minilaparoscopia, surge uma nova realidade para a realização dessa cirurgia: colecistectomia minilaparoscópica, o qual traz benefícios ao paciente. A crescente preocupação com o processo de limpeza de artigos médico-hospitalares desperta questionamentos em relação a qualidade da higienização nas instituições hospitalares. A água é um item crítico no processo de sanitização e antissepsia do instrumental cirúrgico em razão da procedência e do tipo de tratamento que a mesma é submetida. A combinação desses fatores pode danificar o aço inoxidável dos equipamentos cirúrgicos podendo manchar, reduzir sua resistência à corrosão, até o favorecimento de formação de fissuras em áreas tensionadas, acarretando rompimento do instrumental. Foi realizada uma revisão na literatura correlacionando a qualidade da água na limpeza do material minilaparoscópico e sua manutenção. Foi observado uma relação direta entre tempo de vida útil do material e, consequentemente, sua qualidade para fins cirúrgicos e a qualidade do sistema de higienização do material, sendo a água um dos fatores chave para a manutenção da qualidade e diminuição do risco de utilizar estes equipamentos. A segurança da colecistectomia minilaparoscópica tem como fator independente o tratamento empregado no material pelo Centro de Materiais de Esterilização, porém é necessário o amplo conhecimento do tipo de material envolvido e métodos de higienização para cada aparelho, individualizando o

Since the first cholecystectomy, the surgical technique for this procedure has received several modifications. With the advancement of laparoscopic equipment and the advent of minilaparoscopy, a new reality emerges for this surgery: minilaparoscopic cholecystectomy, which brings benefits to the patient. The growing concern with the cleaning process of medical-hospital articles raises questions regarding the quality of hygiene in hospital institutions. Water is a critical item in the sanitization and antisepsis process of the surgical instruments due to the origin and the type of treatment that is submitted. The combination of these factors can damage the stainless steel of the surgical equipment, which can stain, reduce its resistance to corrosion, favoring the formation of cracks in stressed areas, leading to rupture of the instruments. A literature review was carried out correlating the water quality in the cleaning of the minilaparoscopic material and its maintenance. A direct relationship between the life time of the material and, consequently, its quality for surgical purposes and the quality of the material hygiene system was observed, with water being one of the key factors for maintaining quality and reducing the risk of using these materials equipments. The safety of minilaparoscopic cholecystectomy has as an independent factor the treatment used in the material by the Center for Sterilization Materials, but it is necessary to have a thorough knowledge of the type of material involved and methods of hygiene for each appliance, individualizing the cleaning process.

Off-Clamp Renal Tumourectomy by Retroperitoneoscopy in Posterior Renal Tumours of Medium Complexity (Padua score 8-9).

BACKGROUND: The guidelines recommend partial surgery for T1 renal tumours. Various aspects of this surgery have evolved in recent years, including the clamping method and duration, enucleation, the retroperitoneoscopic approach and the use of 3mm ports. We present our initial series on laparoscopic renal tumourectomy by retroperitoneoscopy (LRTR) and analyse our learning curve and use of 3-mm instrumentation. MATERIAL AND METHODS: From January 2011 to January 2015, we performed LRTR on 50 patients with posterior or convex T1 renal tumours. After 10 cases, the technique changed to off-clamp, and 11 cases were subsequently performed with 3mm instrumentation. RESULTS: The mean tumour size was 34.36 mm (14-62), with a mean PADUA score of 8.42 (5-12). The mean operative time was 163.1 minutes (75-300), and the mean warm ischaemia time was 4.21 minutes (0-28). The main renal artery was not clamped in 41 (82%) patients, and no vessel (zero ischaemia) was clamped in 39 (78%) patients. Seven cases had positive margins (6 focal). Eleven LRTRs were performed with 3mm instrumentation, with shorter surgical times, less intraoperative bleeding and shorter hospital stays. CONCLUSIONS: Retroperitoneoscopy coupled with enucleation enables the extirpation without clamping of posterior renal tumours, with a relatively short learning curve. The 3-mm material enables the technique to be performed, although in our experience it has resulted in a higher rate of positive surgical margins.

[Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial]. / Colecistectomía laparoscópica ambulatoria por minilaparoscopia versus colecistectomía laparoscópica ambulatoria multipuerto tradicional. Estudio prospectivo aleatorizado.

OBJECTIVE: Difference analysis of ambulatorization rate, pain, analgesic requirements and daily activities recovery in patients undergoing laparoscopic cholecystectomy with standard multiport access (CLMP) versus a minilaparoscopic, 3mm size, technique. METHODS: Prospective randomized trial of 40 consecutive patients undergoing laparoscopic cholecystectomy. Comparison criteria included predictive ultrasound factors of difficult cholecystectomy, previous history of complicated biliary disease and demographics. Results are analyzed in terms of ambulatorization rate, pain, analgesic requirements, postoperative recovery, technical difficulty, hemorrhage intensity, overnight stay, readmission rate and total or partial conversion. RESULTS: Both procedures were similar in surgery time, technical score and hemorrhage score. MLC was associated with similar ambulatorization rate, 85%, and over-night stay 15%, with only 15% partial conversion rate. MLC showed less postoperative pain (P=.026), less analgesic consumption (P=.006) and similar DAR (P=.879). CONCLUSIONS: MLC is similar to CLMP in terms of ambulatorization with less postoperative pain and analgesic requirements without differences in postoperative recovery.

[Mini-laparoscopic cholecystectomy as an innovative method in minimally invasive abdominal surgery]. / A minilaparoscopos cholecystectomia mint innovatív eljárás a minimálisan invasiv hasi sebészetben.

INTRODUCTION: In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC. PATIENTS AND METHODS: During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results. RESULTS: There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group. CONCLUSION: Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Daño tisular en cirugía laparoscópica / Tissue damage in laparoscopic surgery

bjetivo: Comparar las técnicas laparoscópicas emergentes demayor popularidad en el ámbito quirúrgico, aplicando modelosmatemáticos­teóricos para el cálculo del daño tisular, de manerade poder identificar y predecir que técnicas causan menor traumaparietal y menor morbilidad en el paciente para un procedimientoquirúrgico en común. Métodos:Estudio comparativo, descriptivoy observacional. Se agrupan 13 técnicas de cirugía de mínima inva-sión aplicadas para un procedimiento en común, "colecistecto-mía", con la finalidad de comparar el daño tisular que ocasionacada una de las mismas, calculado por modelos teóricos-matemá-ticos diseñados para tal fin, bajo normas estandarizadas por ungrupo de expertos en el tema, "Consenso de Mazatlán 2013", conel fin de estandarizar las técnicas de medición de las incisiones einstrumentos, de manera de obtener resultados acordes con la rea-lidad en cada uno de los procedimientos. Resultados:La técnicaNOTES presenta los índices más bajos de daño tisular parietal alno producir trauma alguno en su variedad pura y al no utilizar lapared abdominal para la extracción de la pieza quirúrgica en susvariedades híbridas. Las técnicas abordaje abdominal (no LESS),reducen a menos del 50% el daño tisular que ocasiona la laparos-copia tradicional, sin diferencia significativa entre ellas. Las plata-formas multivalvulares no muestran reducción del daño parietalfrente a la colecistectomía laparoscopia tradicional. Conclusión:Las técnicas laparoscópicas que reducen significativamente el trau-ma parietal frente al estándar de oro para colecistectomía aplicanuno o más de las siguientes consideraciones: Extracción de losórganos o piezas quirúrgicas por orificios naturales, sustitución depuertos por dispositivos magnéticos y/o agujas percutáneas, usode óptica con canal operatorio, y utilización de puertos e instru-mentos de menor calibre(AU)

Objective: To compare the most popular emerging surgical lapa-roscopic techniques, applying models for mathematicians-theore-tical for the calculation of the tissue damage, in order to be ableto identify and predict which techniques cause reduced parietaltrauma and less morbidity in the patient for a surgical procedurein common. Methods: Comparative, descriptive and observationalstudy. There were grouped 13 minimally invasive surgery techni-ques applied to a procedure in common, "cholecystectomy", inorder to compare the tissue damage that causes each of them, cal-culated by theoretical-mathematicians models designed for thispurpose, under standardized rules by a group of experts in thefield, "Mazatlan Consensus 2013", to standardize measurement ofincisions and instruments techniques, in order to get results com-mensurate with the reality in each of the procedures. Results:Thetechnique NOTES presents the lowest rates of parietal tissuedamage by not producing any trauma in its sheer variety and doesnot use the abdominal wall for the extraction of the surgical spe-cimen in its hybrid varieties. The technical approach to abdominal(not LESS), reduced to less than 50% the tissue damage that cau-ses traditional laparoscopy, without significant difference betweenthem. Multivalvulars platforms are not against traditional laparos-copy cholecystectomy parietal harm reduction. Conclusion:Thelaparoscopic techniques that significantly reduce the parietal trau-ma against the gold standard for cholecystectomy apply one ormore of the following considerations: removal of organs or surgicalparts through natural openings, replacement of ports by percuta-neous needle or magnetic devices, use of optics with operativechannel, and use of ports and instruments for the smaller caliber

MANOS: colecistectomías transvaginales: reporte preliminar

Objetivo: Comunicar las primeras colecistectomías transvaginales realizadas en humanos en Cuba. MétodosSe realizó un estudio prospectivo, longitudinal y de intervención que incluyó a 7 pacientes portadoras de litiasis vesicular sintomática, desde el 11 de marzo al 7 de mayo de 2008, a las que se realizaron colecistectomías transvaginales asistidas por minilaparoscopia. Criterios de inclusión: mujeres con edades entre 18 y 65 años y diagnóstico de enfermedades que requieran colecistectomías. Los criterios de exclusión fueron Asa III y IV; obesidad mórbida (IMC >35); portadoras de enfermedades venéreas; infecciones inecológicas asociadas agudas o crónicas; pacientes con procesos malignos; pacientes vírgenes y pacientes gestantes. Las intervenciones quirúrgicas fueron realizadas por cirujanos generales utilizando los mismos instrumentos rígidos empleados en la cirugía laparoscópica. Se estudiaron el tiempo quirúrgico, la necesidad de analgésicos en el postoperatorio y las complicaciones postoperatorias. ResultadosLas edades de las pacientes fluctuaron entre 33 y 62 años, con una media de 47,7 años. El tiempo quirúrgico medio fue de 72,4 (61–86)min, y disminuyó con la práctica de la técnica. En el postoperatorio no hubo que administrar a ninguna de las pacientes analgésicos parenterales ni orales. El alta hospitalaria se dio antes de las 24h del procedimiento y no se presentaron complicaciones postoperatorias luego de un seguimiento mínimo de 30 días.Conclusiones. La colecistectomía transvaginal asistida por minilaparoscopia es un método factible y seguro que puede ser realizada por cirujanos generales con experiencia en la cirugía de mínima invasión, empleando los mismos instrumentos rígidos que se utilizan en la cirugía laparoscópica. La cirugía a través de orificios naturales asistida por minilaparoscopia (MANOS) puede ser un paso intermedio entre la cirugía laparoscópica y NOTES(AU)

OBJECTIVE: To present the first transvaginal cholecystectomies performed in Cuba. METHODS: This is a study involving 7 female patients. The ages of the patients varied from 33 to 62 years of age, with an average age of 47.7. All of them had symptomatic cholelithiasis performed between March 11, 2008 and May 7, 2008. The operation performed in each case was a transvaginal cholecystectomy assisted with minilaparoscopy. Inclusion criteria: Females between 18 and 65 years old; diagnosis of disease which requires cholecystectomy. The exclusion criteria included ASA III and IV, morbidly obese patients (BMI > 35), venereal diseases, acute and chronic pelvic inflammatory diseases, virgins and pregnant patients. The operations were performed by general surgeons using rigid laparoscopic instruments. Studied: operating room time; analgesia required and post-operative complications. RESULTS: The operating room time was between 61 and 86 min, with an average of 72.4 min. Patients required no analgesia during the post-operative period. They were discharged in less than 24h following surgery. We found no complications in follow-up visits for up to one month after surgery. CONCLUSIONS: Minilaparoscopic-assisted transvaginal cholecystectomy is a feasible and safe method for expert laparoscopic surgeons. This technique was, and could be, performed using rigid, currently available laparoscopic instruments. Minilaparoscopic- assisted natural orifice surgery (MANOS) could be an intermediate step between Laparoscopic surgery and NOTES(AU)

Microlaparoscopia en trauma penetrante de abdomen procedimiento en la sala de emergencia con anestesia local / Minilaparoscopy in penetrating abdominal trauma emergency room procedure with local anesthesia

ANTECEDENTES: En el trauma penetrante de abdomen, existe un número de laparotomías innecesarias, con un porcentaje de complicaciones no despreciable. Cuando se identifica lesión del peritoneo, debe ser evaluada la exploración quirúrgica del abdomen. OBJETIVO: Evaluar la penetración del peritoneo, utilizando un método de diagnostico de visión directa. LUGAR DE APLICACIÓN: Hospital de Urgencias de Córdoba. Hospital de trauma. DISEÑO: Se realizó laparoscopia con anestesia local en pacientes con heridas penetrantes de abdomen, que no presentaran evidencias de injuria de órganos intraabdominales en los estudios de imágenes y los cuales se planteaban dudas en el examen físico, para evidenciar lesión del peritoneo. Estudio retrospectivo. POBLACION: Pacientes con trauma penetrante de abdomen, tratados entre mayo de 2004 y enero de 2005, con diagnostico dudoso de violación peritoneal. METODO: Con sedación y anestesia local a nivel umbilical,se coloco un laparoscopio de visión directa, de 5mm y 90°, con el cual se pudo observar todo el peritoneo anterior, los flancos y el diafragma, buscando la herida peritoneal o líquido libre. RESULTADOS: En cuatro pacientes pudo evitarse la laparotomía. Los cuatro restantes se convirtieron a cirugía abierta o videolaparoscopía, de los cuales dos presentaban lesión de víscera hueca, uno hemoperitoneo y otro lesión hepática mínima. No hubo complicaciones en ambos grupos. La estadía del primer grupo fue 13 horas de promedio. CONCLUSIONES: En pacientes seleccionados, la minilaparoscopía resultó útil en disminuir el porcentaje de laparotomías innecesarias y anestesia general y sus complicaciones.

BACKGROUND: There are a number of unnecessary laparotomies in penetrating trauma, with a non worthless percentage of complications. When the peritoneal injury is identified, surgical exploration of the abdomen should be evaluated. OBJECTIVE: Evaluate the penetration of the peritoneum, using a diagnose method with direct vision. SETTING: Hospital de Urgencias de Córdoba. Trauma Hospital. DESIGN: To evidence peritoneum trespassing, laparoscopy was performed with local anaesthesia in patients with penetrating abdominal trauma without signs of abdominal injury in the imaging methods and doubts in the physical examination, in a prospective setting. POPULATION: Patient with penetrating abdominal trauma, treated between May 2004 to January 2005, with doubtful diagnose of peritoneal violation. METHOD: Under sedation and local anaesthesia, a 5 millimetres laparoscope with 90 degrees vision was placed at umbilicus. The anterior abdominal wall, flanks and diaphragm were exanimate, looking for the peritoneal wound or free fluid. RESULTS: Laparotomy could be avoided in four patients. In the four remaining, laparoscopy or conventional surgery was performed. Two presented hollow viscera injury, one hemoperitoneo and the other, minimum liver damage. There were not complications in both groups. The average hospital stay of the first group was 13 hours. CONCLUSIONS: In selected patients, the minilaparoscopy is useful in decreased the percentage of unnecessary laparotomies and general anaesthesia, and its complications.