Extração de fitobezoar gástrico por videolaparoscopia: considerações técnicas originais

Videolaparoscopic surgery has been used for treatment of almost all surgical abdominal diseases, mainly where there are no large ressections, or operative field is limited. In these situations, laparoscopic surgery has the advantages of less morbidity, quick recovery and good cosmetic results. Bezoars removal, or its mobilization, is probably included in these possible proceedings. Three non-laparotomic procedures were described: 1. endoscopic-laparoscopic; 2. videolaparoscopy and mobilization of intestinal bezoar to the cecum; 3. laparoscopy and gastrotomy for bezoar removal, through suprapubic incision or the umbilical punction. There have been only two publications describing the videolaparoscopic method for bezoar removal, and the methods applied can be complications or morbidity related. We describe one case where the applied technique is simple and easy to perform, time saving and probably less complications-related. This technique, with four trocars, utilized a plastic bag besides the stomach to be opened, followed by gastrotomy, bezoar removal and immediate introduction in the plastic bag, suture of gastrotomy and removal through the left subcostal trocar. This technique was feasible and easy to perform, with short operative time, and there were no intra or post-operative complications; the patient was discharged in the second post-operative day, and is without further problems after one year follow-up. We believe that this could be an adequate technique to perform laparoscopic gastric bezoar removal, and the rigid sequence of operative events allows a quick procedure, with minimal contamination. The videolaparoscopy seems to be an adequate access to surgical treatment of gastro-intestinal bezoars, with or without obstruction, and should be the ellected the procedure of choice to begin the surgical treatment, with convertion to laparotomy in case of any intra-operative adversity.

Suturas mecânicas

The authors review the use of staplers in General Surgery, mainly in Gastroenterological Surgery highlighting safety and effectiveness. They emphasize that the mechanic anastomosis are a viable technique and in some conditions, the best way to perform the anastomosis. The use of staplers makes surgery faster and easier and complications are, generally related to surgeon's experience in using them. Although its costs are higher compared to handsewn suture, it can make the patient total cost lower.

Anastomose esôfago-jejunal látero-lateral com grampeador linear cortante complementada por sutura manual

One of the most difficult procedures in digestive-tract surgery is esophago-jejunal anastomosis following total gastrectomy. Cost/benefit analysis of this procedure justifies the use of mechanical staplers, in spite of their high cost. A technical variant of the side-to-side esophago-jejunal anastomosis is presented, which incorporates the use of a cutting linear stapler. Technical maneuvers are easy to perform, the cost of the cutting linear stapler is smaller than the circular ones, the amplitude of the anastomosis is wider and the likelihood of fistulae is smaller when compared to other techniques. The side-to-side esophago-jejunal anastomosis with the cutting linear stapler is always complemented by a manual suture.

Emprego da submucosa intestinal suína em uretroplastias complexas

We report the use of Porcine Intestinal Submucosa (PIS) in association with Johanson technique for urethroplasty, in the treatment of recurring urethral stenosis. The patient had obliterans xerotica balanitis and had previously undergone 15 internal uretotomies as well as various unsuccessful urethral dilations. As a result of stenotic extension, another surgery was planned using Johanson technique. During the first part of the surgery, intense local fibrosis was observed, which required greater care and protection to avoid fistulae formation. PIS was interposed to reduce the chances of the occurrence of this dreaded complication. During the second part of the surgery, a skin flap obtained from tissue parallel to the urethral plateau was used to prepare a neourethra according to the norms of this technique. PIS was fixed at its extremities, and interposed between the neourethral suture and the skin suture to prevent any contact between them. The procedure was completed with the use of meatoplasty and glandulaplasty. After 6-month follow up, clinical and urodynamic improvement could be seen. If these results can be confirmed by more extensive studies, PIS will provide new perspectives for complex urethroplasties.

Forma pseudotumoral intra-abdominal da esquistossomose mansônica

The authors present a case of non-frequent intra-abdominal pseudotumor form of mansoni schistosomiasis in which the only symptom was a dull pain in hypogastric. Both ultrasonography and tomography (CT san) demonstrated a solid mass on the left side of the bladder. At laparotomy a solid tumor was shown, pediculated and adhered to the sigmoid colon. A schistosomotic pseudotumor was revealed after microscopic pathological examination.

Uso de língua bovina na prática de técnicas de sutura

The authors present a method of teaching of suture techniques being used instrumental surgical and bovine tongue used in the evaluation of the graduation students' learning. The evaluation of the technique, used since January 2000, considering students' motivation, learning curve, practical applicability, quality of the biological material used and similarity to the human tegument. The acceptance for the students was very good and the bovine tongue was shown material of easy acquisition and extremely useful in the teaching of suture techniques. The presented method is simple, easily reproductible and interesting. The bovine tongue is similar to the skin and the subcutaneous tissue, providing more enlightening and stimulants practical lessons.

O retalho pleural na perfuração do esôfago torácico

The thoracic esophageal perforations frequently complicate with fistula when submitted to primary suture. The use of autogenous tissues, like pleura, to reinforce the primary suture has proved to be useful in reduce the incidence of fistulas or at least the severity of the leaks in case they occur. The mortality has reduced too, consequently. A case of an extensive esophageal perforation is presented, where the use of pleural wrap to reinforce the esophagorrafy was very important to contain the leak and to permit a good evolution of the patient.

Sarcoidose testicular: um diagnóstico a ser considerado

Sarcoidosis is a disease of unknown etiology, characterized by the presence of noncaseating granulomas in multiple organs. We present a case of testicular sarcoidosis in a white, 55-year-old man who has come to our department complaining of bilateral testicular discomfort and weight loss.

Leiomioma uretral durante a gravidez: relato de caso

The authors report a case of urethral leiomyoma diagnosed during pregnancy, which was conservatively treated up to the 38th week, when the pregnancy was interrupted. Thirty days after delivery, exeresis of the lesion was performed from the upper border of the urethral meatus and sutured with interrupted delayed-absorbable suture. The patient evolved favorably and presented no lesion recurrence during three months of follow up.

Inguinal hernias in patients of 50 years and above. Pattern and outcome

OBJECTIVE: to evaluate a one year experience with inguinal hernia repair, in patients of > 50years, with respect to the type of inguinal hernia, type of surgery, postoperative complications and recurrence. METHODS: a prospective descriptive study of patients (n=57) > 50 years operated for inguinal hernia during a one year period. Tension-free meshplasty and herniorrhaphy, using 3"x6" polypropylene mesh and 2-0 polypropylene suture, were performed in elective and emergency surgery respectively. Follow-up visits were scheduled at six weeks, three and six months postoperatively. RESULTS: the most representative age group was 61-70 years, and all patients were male. 52 (91.22%) patients had unilateral inguinal hernias, while five (8.77%) had bilateral hernias. In 50 (87.71%) patients, the hernia was uncomplicated, while seven (12.28%) patients presented with some complication such as obstruction or strangulation. Elective surgery was performed in 50 (87.71%) patients while seven (12.28%) patients were operated in emergency. Postoperatively, 50 (87.7%) patients had uneventful recovery, while seven (12.28%) patients developed some complications which were treated conservatively. Mean hospital stay was six days. One recurrence was observed and there was no peri/postoperative death. CONCLUSION: tension-free meshplasty and herniorrhaphy are safe, simple and applicable even in elderly patients after adequate pre-operative assessment and optimization. Although associated with longer hospital stay, the mortality rate is nil and complication as well as recurrence rate is low. Hence, timely repair is necessary in elderly patients even in those with comorbid conditions.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

Importance of flexible bronchoscopy in decannulation of tracheostomy patients

OBJECTIVE: To evaluate the importance of flexible bronchoscopy in tracheostomy patients in the process of decannulation to assess the incidence and types of laryngotracheal injury and compare the presence of such lesions with clinical criteria used for decannulation. METHODS: We studied 51 tracheostomized patients aged between 19 and 87 years, with tracheal stent for a mean of 46 ± 28 days and with clinical criteria for decannulation. They were submitted to tracheostomy tube occlusion tolerance testfor 24 hours, and then to flexible bronchoscopy. We described and classified the diagnosed laryngotracheal changes. We compared the clinical criteria for decannulation indication with the bronchoscopy-diagnosed laryngotracheal injuries that contraindicated decannulation. We identified the factors that could interfere in decannulation and evaluated the importance of bronchoscopy as part of the process. RESULTS: Forty (80.4%) patients had laryngotracheal alterations. Of the 40 patients considered clinically fit to decannulation, eight (20%) (p = 0.0007) presented with laryngotracheal injuries at bronchoscopy that contraindicated the procedure. The most frequent laryngeal alteration was vocal cords lesion, in 15 (29%) individuals, and granuloma, the most prevalent tracheal lesion, in 14 (27.5%) patients. CONCLUSION: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.

Use of surgical mesh of different compositions in the correction of the abdominal wall defect in rats

Objective: To analyze the performance of two surgical meshes of different compositions during the defect healing process of the abdominal wall of rats. Methods: thirty-three adult Wistar rats were anesthetized and subjected to removal of an area of 1.5 cm x 2 cm of the anterior abdominal wall, except for the skin; 17 animals had the defect corrected by edge-to-edge surgical suture of a mesh made of polypropylene + poliglecaprone (Group U - UltraproTM); 16 animals had the defect corrected with a surgical mesh made of polypropylene + polidioxanone + cellulose (Group P - ProceedTM). Each group was divided into two subgroups, according to the euthanasia moment (seven days or 28 days after the operation). Parameters analyzed were macroscopic (adherence), microscopic (quantification of mature and immature collagen) and tensiometric (maximum tension and maximum rupture strength). Results : there was an increase in collagen type I in the ProceedTM group from seven to 28 days, p = 0.047. Also, there was an increase in the rupture tension on both groups when comparing the two periods. There was a lower rupture tension and tissue deformity with ProceedTM mesh in seven days, becoming equal at day 28. Conclusion : the meshes retain similarities in the final result and more studies with larger numbers of animals must be carried for better assessment.

Single access laparoscopic cholecystectomy: technique without the need for special materials and with better ergonomics

The authors describe a surgical technique which allows, without increasing costs, to perform laparoscopic cholecystectomy with a single incision, without using specific materials and with better surgical ergonomics. The technique consists of a longitudinal umbilical incision, navel detachment, use of a permanent 10mm trocar and two clamps directly and bilaterally through the aponeurosis without the use of 5mm trocars, transcutaneous gallbladder repair with straight needle cotton suture, ligation with unabsorbable suture and umbilical incision for the specimen extraction. The presented technique enables the procedure with conventional and permanent materials, improving surgical ergonomics, with safety and aesthetic advantages.

Abordagem laparoscópica do câncer de endométrio

Objetivo: apresentar uma nova abordagem laparoscópica para tratamento do câncer de endométrio. Métodos: de fevereiro de 1996 à fevereiro de 1998, doze pacientes com câncer de endométrio, diagnosticadas por histeroscopia e biópsia, foram submetidas a linfadenectomia pélvica associada à histerectomia e salpingooforectomia por laparoscopia. A média de idade das pacientes foi de 58,1 anos; o número médio de gestações foi 2,3 e o índice de massa corpórea médio foi de 28,6. Resultados: o tempo anestésico médio foi de 4,8 horas. O tempo médio de internação foi de 3,3 dias. O número total de linfonodos retirados foi de 176, sendo 104 (59,1%) do lado direito e 72 (40,9%) do lado esquerdo. Não foram encontrados linfonodos comprometidos. O número médio de linfonodos retirados por paciente foi de 18,5. Foram observadas duas complicações: em um caso houve necessidade de abandonar o procedimento por aumento da pressão endotraqueal e uma das pacientes evoluiu com formação de granuloma em cúpula vaginal. Conclusões: nesta avaliação preliminar dos resultados de histerectomia total com anexectomia bilateral e lifadenectomia laparoscópica para o tratamento do câncer de endométrio, obtivemos resultados satisfatórios quanto ao estadiamento da neoplasia ao número de linfonodos retirados e quanto às complicações cirúrgicas observadas.