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Esophagectomy is a major, invasive, and long-lasting surgery performed in patients with comorbidities and compromised nutritional conditions. The historical challenges of surgical treatment of esophageal cancer are to overcome mortality, improve survival, and decrease morbidity.
The aim of the study is to compare the intraoperative morbidity of two distinct surgical techniques of esophagectomy in esophageal cancer, transhiatal esophagectomy and video-assisted thoracoscopy in the prone position, analyzing intraoperative physiological parameters, scores on admission to the intensive care unit (ICU) (APACHE II, SOFA, and SAPS III), and postoperative evolution.
Retrospective, cross-sectional study evaluating patients admitted to the ICU in the immediate postoperative period of elective esophagectomy for esophageal neoplasia (squamous cell carcinoma and adenocarcinoma). Data were obtained from a computerized registry database of the ICU and from patient records.
Sixty-three patients over 18 years of age were evaluated and divided into two groups: 31 (49.21%) underwent transhiatal esophagectomy, and 32 (50.79%) underwent videoassisted thoracoscopic esophagectomy. No statistically significant difference was observed for length of ICU stay (p=0.5309), length of postoperative hospital stay (p=0.3066), or death in the perioperative period (30 days, p=0.6562). Regarding intraoperative parameters, no statistically significant difference was observed for patients who received blood transfusion (p=0.2097); amount in milliliters (p=0.2893); patients who used vasoactive drugs (VADs) (p=0.9243); time VAD use (p=0.9327); volume of fluids infused in milliliters (p=0.7825); or diuresis in milliliters (p=0.7286). A statistically significant difference was observed for surgical time (310 min in transhiatal esophagectomy vs. 373 min in video-assisted thoracoscopy, p=0.0012) and anesthetic time (385 minutes in transhiatal vs. 467 min in video-assisted thoracoscopy, p<0.0001). A statistically significant difference was observed in the number of patients extubated at the end of the procedure (48.38% in transhiatal vs. 9.37% in video-assisted thoracoscopy, p=0.0022). Regarding gasometric parameters at the end of the surgical procedure, only pO2 showed a statistically significant difference (p=0.0010). Regarding ICU admission scores, there were no differences regarding APACHE II (p=0.6542), SOFA (p=0.8949), and SAPS III (p=0.7656).
This study showed no differences between the transhiatal and thoracoscopic esophagectomy in the prone position, in prognostic score performance, studied operative parameters, ICU stay and hospital stay times, and perioperative mortality, in agreement with literature findings. The advent of minimally invasive techniques in video-assisted esophagectomies brought the same benefits as thoracotomy, offering greater safety in mediastinal dissection under direct vision, in addition to mitigating the physiological repercussions of thoracotomies.
Surgical resection represents the main treatment for resectable nonmetastatic gastric gastrointestinal stromal tumors. Despite the feasibility and safety of laparoscopic resection, its standard use in gastric tumors larger than 5 cm is yet to be established.
This study aimed to compare the current evidence on laparoscopic resection with the classical open surgical approach in terms of perioperative, postoperative, and oncological outcomes.
The PubMed, Scopus, and Web of Science databases were consulted. Articles comparing the approach to gastric gastric gastrointestinal stromal tumors larger than 5 cm by open and laparoscopic surgery were eligible. A post hoc subgroup analysis based on the extent of the surgery was performed to evaluate the operative time, blood loss, and length of hospital stay.
A total of nine studies met the eligibility criteria. In the study, 246 patients undergoing laparoscopic surgery and 301 patients undergoing open surgery were included. The laparoscopic approach had statistically significant lower intraoperative blood loss (p=0.01) and time to oral intake (p<0.01), time to first flatus (p<0.01), and length of hospital stay (0.01), compared to the open surgery approach. No significant differences were found when operative time (0.25), postoperative complications (0.08), R0 resection (0.76), and recurrence rate (0.09) were evaluated. The comparative subgroup analysis between studies could not explain the substantial heterogeneity obtained in the respective outcomes.
The laparoscopic approach in gastric gastrointestinal stromal tumors larger than 5 cm compared to the open surgical approach is a technically safe and feasible surgical method with similar oncological results.
Robotic-assisted surgery research has grown dramatically in the past two decades and the advantages over traditional videolaparoscopy have been extensively debated. For hernias, the robotic system can increase intraoperative strategies, especially in complex hernias or incisional hernias.
This study aimed to compare the direct cost differences between robotic and laparoscopic hernia repair and determine each source of expenditure that may be related to the increased costs in a robotic program from the perspective of a Brazilian public institution.
This study investigated the differences in direct costs from the data generated from a trial protocol (ReBEC: RBR-5s6mnrf). Patients with incisional hernia were randomly assigned to receive laparoscopic ventral incisional hernia repair (LVIHR) or robotic ventral incisional hernia repair (RVIHR). The direct medical costs of hernia treatment were described in the Brazilian currency (R$).
A total of 19 patients submitted to LVIHR were compared with 18 submitted to RVIHR. The amount spent on operation room time (RVIHR: 2,447.91±644.79; LVIHR: 1,989.67±763.00; p=0.030), inhaled medical gases in operating room (RVIHR: 270.57±211.51; LVIHR: 84.55±252.34; p=0.023), human resources in operating room (RVIHR: 3,164.43±894.97; LVIHR: 2,120.16±663.78; p<0.001), material resources (RVIHR: 3,204.32±351.55; LVIHR: 736.51±972.32; p<0.001), and medications (RVIHR: 823.40±175.47; LVIHR: 288.50±352.55; p<0.001) for RVIHR was higher than that for LVIHR, implying a higher total cost to RVIHR (RVIHR: 14,712.24±3,520.82; LVIHR: 10,295.95±3,453.59; p<0.001). No significant difference was noted in costs related to the hospital stay, human resources in intensive care unit and ward, diagnostic tests, and meshes.
Robotic system adds a significant overall cost to traditional laparoscopic hernia repair. The cost of the medical and robotic devices and longer operative times are the main factors driving the difference in costs.
Results on quality of life after inguinal hernia surgery, such as esthetics, postoperative pain, period of absence from activities, and recurrence are a relevant topic since inguinal hernia affects 27% of men and 3% of women at some point in their lives, and should guide health policies to allocate resources more efficiently.
To evaluate the quality of life in the late postoperative period of inguinal herniorrhaphy regarding recurrence, pain, esthetics, and restriction in activities, comparing the minimally invasive techniques — the transabdominal preperitoneal (TAPP) and the conventional Lichtenstein.
A cross-sectional observational clinical study was conducted with the EuraHS-QoL questionnaire validated and translated into Portuguese, applied to patients after an average of 65 months postoperatively. Forty-five patients were assessed, 28 undergoing Lichtenstein and 17 undergoing TAPP. All were males aged between 18 and 87 years with a primary unilateral inguinal hernia. Recurrent or bilateral hernias, other concomitant abdominal wall hernias, patients who chose not to participate or who were not found, and female patients were excluded from the study.
Regarding the domains pain, restriction, and esthetics, there was no difference between the two groups when examining quality of life. Neither group presented recurrence in the studied period.
Both TAPP and Lichtenstein techniques presented similar results concerning quality of life when compared in the long-term.
Minimally invasive laparoscopic liver surgery is being performed with increased frequency. Lesions located on the anterior and lateral liver segments are easier to approach through laparoscopy. On the other hand, laparoscopic access to posterior and superior segments is less frequent and technically demanding.
Technical description for laparoscopic transthoracic access employed on hepatic wedge resection.
Laparoscopic transthoracic hepatic wedge resection on segment 8.
Transthoracic approach allows access to the posterior and superior segments of the liver, and should be considered for oddly located tumors and in patients with numerous previous abdominal interventions.
The incidence of esophageal cancer is high in some regions and the surgical treatment requires reference centers, with high volume, to make surgery feasible.
To evaluate patients undergoing minimally invasive esophagectomy by thoracoscopy in prone position for the treatment of esophageal cancer and to recognize the experience acquired over time in our service after the introduction of this technique.
From January 2012 to August 2021, all patients who underwent the minimally invasive esophagectomy for esophageal cancer were retrospectively analyzed. In order to assess the factors associated with the predefined outcomes as fistula, pneumonia, and intrahospital death, we performed univariate and multivariate logistic regression analyses, accounting for age as an important factor.
Sixty-six patients were studied, with mean age of 59.5 years. The main histological type was squamous cell carcinoma (81.8%). The incidence of postoperative pneumonia and fistula was 38% and 33.3%, respectively. Eight patients died during this period. The patient's age, T and N stages, the year the procedure was performed, and postoperative pneumonia development were factors that influenced postoperative death. There was a 24% reduction in the chance of mortality each year, associated with the learning curve of our service.
The present study presented the importance of the team's experience and the concentration of the treatment of patients with esophageal cancer in reference centers, allowing to significantly improve the postoperative outcomes.
Laparoscopic cholecystectomy has traditionally been performed with four incisions to insert four trocars, in a simple, efficient and safe way.
To describe a simplified technique of laparoscopic cholecystectomy with two incisions, using basic conventional instrumental.
In one incision in the umbilicus are applied two trocars and in epigastrium one more. The use of two trocars on the same incision, working in "x" does not hinder the procedure and does not require special instruments.
Simplified laparoscopic cholecystectomy with two incisions is feasible and easy to perform, allowing to operate with ergonomy and safety, with good cosmetic result.
Laparoscopic surgery is a reality in almost all surgical centers. Although with initial greater technical difficulty for surgeons, the rapid return to activities, less postoperative pain and higher quality aesthetic stimulates surgeons to evolve technically in this area. However, unlike open surgery where learning opportunities are more accessible, the laparoscopic training represents a challenge in surgeon formation.
To present a low cost model for laparoscopic training box.
This model is based in easily accessible materials; the equipment can be easily found based on chrome mini jet and passes rubber thread and a webcam attached to an aluminum handle.
It can be finalized in two days costing R$ 280,00 (US$ 90).
It is possible to stimulate a larger number of surgeons to have self training in laparoscopy at low cost seeking to improve their surgical skills outside the operating room.
Laparoscopic pancreatectomy is currently a widely used approach for benign and malignant lesions of the pancreas.
This study aimed to describe how to perform a laparoscopic distal pancreatectomy using The Clockwise Technique.
An 18-year-old female patient presented with a well-defined tumor in the pancreatic body with 4 cm in diameter that suggested a diagnosis of solid pseudopapillary tumor (Frantz’s tumor). The patient was recommended for laparoscopic distal pancreatectomy by using The Clockwise Technique.
The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure.
A laparoscopic distal pancreatectomy performed using The Clockwise Technique provides satisfactory outcomes.
Solid pseudopapillary pancreatic neoplasia is usually a large well-circumscribed pancreatic mass, with cystic and solid areas more frequently found in young women. It is a benign pancreatic neoplasia in most cases, therefore minimally invasive surgery could be an interesting approach.
Evaluate the results of minimally invasive surgery for this neoplasia.
Patients with this tumor who underwent minimally invasive pancreatectomies between 2009 and 2015 in a single institution, were analyzed regarding demographic, clinical-pathological futures, post-operative morbidity and disease-free survival.
All were women, and their median age was 39 (18-54) years. Two patients with tumor in the head of the pancreas underwent laparoscopic pancreaticoduodenectomy, and another one underwent laparoscopic enucleation. Two patients with tumor in the neck underwent central pancreatectomy. Distal pancreatectomies were performed in the other five, one with splenic preservation. None required blood transfusion or conversion to open surgery. Two (20%) developed clinical relevant pancreatic fistulas, requiring readmission. Median length of postoperative hospital stay was five days (2-8). All resection margins were negative. Patients were followed for a median of 38 months (14-71), and there was no recurrence.
Minimally invasive surgery for solid pseudopapillary pancreatic neoplasia is feasible for tumors in different locations in the pancreas. It was associated with acceptable morbidity and respected the oncologic principles for treatment.
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