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v. 2 n. 4
AWRJ - Abdominal Wall Repair Journal
1
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v. 2 n. 4
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Volume 2 Número 4
Dezembro 2013 / Março 2014
Realização:
Editor–chefe • Editor-in-Chief
SÉRGIO ROLL (SP – Brazil)
Editores Associados • Associated Editors
JAMES SKINOVSKY (PR – Brazil)
JULIO CESAR BEITLER (RJ – Brazil)
RIGOBERTO ÁLVAREZ (Mexico)
Lapsurg International Institute
of Endoscopic Surgery
Av. Rep. Argentina, 665, Sl. 1202
Água Verde - Curitiba - PR - CEP 80.240-210
(55) (41) 3242-9257
www.lapsurg.com.br
[email protected]
Versão: Eletrônica
Periodicidade: Quadrimestral
ISSN 2317-5982
Apoio:
v. 2 n. 4
conselho Editorial • Editorial Board
ALEXANDER MORREL (SP)
ARTUR SEABRA (RS)
CRISTHIANO KLAUS (PR)
EDUARDO TANAKA (SP)
EDVALDO FAHEL (BA)
FLÁVIO MALCHER (RJ)
GUSTAVO CARVALHO (PE)
LEANDRO TOTTI CAVAZOLLA (RS)
MARCELO FURTADO (SP)
MARCUS VINICIUS DANTAS DE CAMPOS MARTINS (RJ)
MAURICIO CHIBATA (PR)
MIGUEL NÁCUL (RS)
PLÍNIO CARLOS BAÚ (RS)
RENATO MIRANDA DE MELO (GO)
RICARDO Z. ABDALLA (SP)
conselho Editorial Internacional • International Editorial Board
ADRIANA HERNANDEZ (Mexico)
ALFREDO CARBONELL II (USA)
ALFREDO MORENO EGEA (Spain)
ANDREW DE BOAUX (United Kingdom)
ARTHUR GILBERT (USA)
B. TODD HENIFORD (USA)
BRENT D. MATTHEWS (USA)
DAVIDE LOMANTO (Singapore)
EDUARDO PARRA-DAVILLA (USA)
GIOVANI DAPRI (Belgium)
JAN KUKLETA (Switzerland)
JOHANNES JEEKE (Netherlands)
JUAN CARLOS MAYAGOITIA GONZÁLES (Mexico)
MARC MISEREZ (Belgium)
Mariano Palermo (Argentina)
Mario Morino (Italy)
PARVIZ K. AMID (USA)
SALVADOR MORALES-CONDE (Spain)
3
Copyright© 2014 by LapSurg
Todos os direitos reservados a
LapSurg International Institute of Endoscopic Surgery
Produção: Primax Edições
Projeto Gráfico: Marco Antonio Levandovski
Editoração Eletrônica: Erik Ferreira
Bibliotecária Responsável: Joelma Marques – CRB 9/1290
Dados
Internacionais
de Catalogação
Catalogação na
na
Publicação
(CIP)
Dados
Internacionais de
Dados
Internacionais
naPublicação
Publicação(CIP)
(CIP)
AWRJ
[recurso eletrônico]
eletrônico] //
AWRJ –– Abdominal
Abdominal Wall
Wall Repair Journal [recurso
LapSurg
Endoscopic Surgery.
Surgery. ––Ano
Ano2,
1,n.4
n.1
LapSurg International
International Institute of Endoscopic
(dez. 2012/mar.
2013/mar. 2013)2014)- .―
Surg International
(dez.
.―Curitiba
Curitiba: Lap
: LapSurg
International
Institute of
of Endoscopic
Endoscopic Surgery, 2014Institute
2013- ..
Quadrimestral.
Quadrimestral.
Modo de
de acesso:
acesso: <http://www.lapsurg.com.br/front/awrj/index>
<http://www.lapsurg.com.br/front/awrj/index>
Modo
ISSN 2317-5982
1. Hérnia – Periódicos. 2. Hérnia – Cirurgia. 3. Hérnia –
1. Hérnia
– Periódicos. 2. Hérnia – Cirurgia. 3. Hérnia –
Tratamento.
I. Título.
Tratamento. I. Título.
CDD 617.557
CDD
CDU 617.557
616.34-007.43
CDU 616.34-007.43
4
v. 2 n. 4
sumário • Summary
Conselho Editorial ........................................................................................................... 01
Editorial ............................................................................................................................. 06
Artigos Originais - Originals Articles
• Avaliação das Aderências Intraperitoneais em Modelo de Hernioplastia
Experimental Onlay: Comparação entre o Uso de Tela de Polipropileno e
Tela de Monocryl-Polipropileno ..................................................................................... 11
Evaluation of Intraperitoneal Adhesions in Experimental Onlay Hernia Repair
Model: Comparison Between the Use of Polypropylene Mesh and
Polypropylene Composite Monocryl Mesh
Leonardo Alves Nery, Sergio Luis Mattos Tezza, Gabriela Jouglard Vasques, Geniffer Curtinaz Cardoso,
Joao Augusto Argenton Zortea, Danielle Cristinne Figueiró, Bibiana Borges Manna, Renata Baú,
João Vicente Machado Grossi, Leandro Totti Cavazzola
• Less Tapp Hernioplasty: The First Series.................................................................... 17
James Skinovsky, Mauricio Chibata, Marcus Vinicius Dantas de Campos Martins,
Sérgio Roll, Fernanda Tsumanuma, Rogério Cavalier, Francisco Almeida
Artigo de Revisão - Review Article
• Complicações das Hernioplastias Videolaparoscópicas da Parede Abdominal...... 22
Sérgio Roll, James Skinovsky
Entrevista com o Expert - Interview With The Expert
• Prophylactic Use of Meshes – State of Art...................................................................... 29
Uso Profilático das Telas – Estado Atual
Jan Kukleta
Anexo High Tech Surgery Journal - Appendix High Tech Surgery Journal
• Single Port Laparoscopic Appendectomy by Using Straight Instruments: a
Sample Before a Multicenter Randomized Control Trial................................................ 32
Mariano Palermo MD PhD FACS, Guillermo E. Duza MD, Enrique Buela MD,
Pablo A. Acquafesca MD, Luis A. Blanco MD, Constanza Abdenur MD, Hernan Ges MD,
Carlos A. Zorraquin MD, Francisco J. Tarsitano MD
• Single Port Laparoscopic Gastrostomy: a New Minimally Invasive Approach
for Enteral Feeding.............................................................................................................. 39
Mariano Palermo MD PhD FACS, Guillermo E. Duza MD, Enrique Buela MD,
Pablo A. Acquafesca MD, Luis A. Blanco MD, Constanza Abdenur MD, Hernan Ges MD,
Carlos A. Zorraquin MD, Francisco J. Tarsitano MD
v. 2 n. 4
5
EDITORIAL
A correção da hérnia inguinal é um dos procedimentos cirúrgicos mais
realizados no Brasil, Estados Unidos e Europa.
Nos últimos anos, as tentativas de avaliar os resultados de diferentes
técnicas cirúrgicas têm aumentado dramaticamente.
Diferentes métodos foram desenvolvidos e aperfeiçoados para avaliar a
qualidade de vida dos pacientes em pós-operatório de herniorrafias, com o
objetivo de determinar a eficácia do tratamento.
No período recente, com a disseminação do tema “segurança em cirurgia” nos congressos e simpósios, tem-se observado uma dedicação maior
na supervisão de jovens cirurgiões em treinamento no tratamento cirúrgico
da hérnia inguinal.
Embora essa melhoria traga um claro beneficio para o paciente, a carga
de responsabilidade do preceptor tem aumentado e a autoconfiança do
jovem cirurgião, em realizar o procedimento de maneira independente, tem
se prolongado.
Nosso objetivo como educadores é de desenvolver um modelo de ensino que possa contribuir para a confiança, aperfeiçoamento e conhecimento dos cirurgiões em treinamento, com um foco especial sobre o ensino
de anatomia, suas relações espaciais, bem como os passos no processo do
reparo herniário; ao fazê-lo, nosso objetivo é aperfeiçoar o treinamento
de cirurgiões experientes e melhorar ainda mais a segurança do paciente, ajudando ao jovem cirurgião a progredir rapidamente na sua curva de
aprendizado.
Para que se alcance resultados significativos, temos que romper com o
modo formal de ensino e expandir o espaço que existe entre quatro paredes para uma aventura, na qual o próprio aluno é a fonte do saber.
O século XXI está repleto de alternativas para o conhecimento dentro
e fora de um espaço formal e temos que usar e abusar de toda esta tecnologia como o “e-learning”, simulação, modelos animados e inanimados, para
preparar estes cirurgiões iniciantes para o mundo que os espera, o qual, na
maioria das vezes é muito mais hostil do que podem imaginar.
Como educadores, temos que prepará-los para uma sociedade complexa e fazê-los compreender que terão que agir em equipe, contracenando
com outros profissionais, de diferentes áreas; somente assim a educação
poderá ocorrer e o trabalho social também. Os desafios atuais exigem que
trabalhemos em equipes, para que nossos projetos possam ser viabilizados.
Sérgio Roll, PhD – Editor-Chefe
6
v. 2 n. 4
EDITORIAL
The inguinal hernioplasty is one of the most frequently performed procedures in Brazil, the United States and Europe.
In recent years, attempts to evaluate the results of different surgical
techniques have dramatically increased.
Different methods have been developed and refined to assess the quality
of life of patients in post-operative hernia repair, with the objective of
determining the effectiveness of that treatment.
In recent years, with the spread of the theme “ safety in surgery “ at
conferences and symposia, it has been observed a stronger focus on supervision of young surgeons in training about the surgical treatment of inguinal
hernia .
Although this improvement bring a clear benefit to the patient, the
burden of responsibility of the preceptor has increased and self confidence
of the young surgeon in performing the procedure independently, has been
extended.
Our goal as educators is to develop a teaching model that can contribute
to confidence, improvement and knowledge of surgeons in training, with a
special focus on the teaching of anatomy, their spatial relationships, as well
as the steps in the hernia repair procedure; in doing so, our goal is to improve the training of experienced surgeons and further improve patient safety
by helping the young surgeon to progress quickly in their learning curve.
In order to achieve significant results, we have to break with the formal
mode of education and expand the space that exists between four walls
for an adventure in which the student himself is the source of knowledge.
The XXI century is full of alternatives to the knowledge inside and
outside of a formal space and we have to use and abuse all this technology
as “ e-learning “ , simulation , animate and inanimate models, to prepare
these surgeons beginners to the world that awaits them, which in most cases
is far more hostile than they can even imagine. .
As educators, we have to prepare them for a complex society and make
them understand that they have to act along with other professionals from
different fields; only then can education and social work also occur. Today’s
challenges require us to work in teams, so that our projects can be made
possible.
Sergio Roll - Editor-in-Chief
v. 2 n. 4
7
EDITORIAL
Com muito prazer iniciamos o segundo ano de nossa Abdominal Wall
Repair Journal. Em 2014 apresentaremos algumas novidades: estamos
adicionando a nova sessão “Entrevista com o Expert”, estreiando com o
Professor da Universidade de Zurich Jan Kukleta, conhecido mundialmente e que nos dá a sua opinião sobre um assunto bastante comentado na
atualidade, o uso profilático das próteses na síntese da parede abdominal.
A cada número traremos um expert mundial dando sua opinião sobre um
assunto importante no dia a dia cirúrgico; também iniciamos a produção
de um anexo da AWRJ, o High Tech Surgery Journal, dedicado a opiniões
e artigos sobre novas tecnologias, procedimentos e abordagens cirúrgicas.
Um veículo científico depende da colaboração acadêmica, portanto incitamos a todos que colaborem com a AWRJ, pois ela pertence a todos, a
cada leitor.
Agradecemos mais uma vez aos nossos colaboradores, ao nosso Board,
aos nossos parceiros e às sociedades apoiadoras, sem os quais certamente
esta obra não alcançaria seu primeiro aniversário.
Muito obrigado a todos!
James Skinovsky – Editor Associado
8
v. 2 n. 4
EDITORIAL
It’s a great pleasure to start the second year of our Abdominal Wall
Repair Journal. In 2014 we will present some news: a new session named
“ Interview with the Expert” is now available, debuting with the Professor
from University of Zurich Jan Kukleta, wellknown worldwide,giving us
your opinion about a much comment subject nowadays, the prophylactic use
of meshes in the abdominal wall closure. Each number will bring a world
expert giving his opinion about an important issue on the surgical day;
we also started the production of an AWRJ’s appendix, the High Tech
Surgery Journal, dedicated to new technologies, procedures and surgical
approaches.
A scientific journal depends on academic collaboration, so we ask for
everyone to cooperate with AWRJ sending your opinion and papers, because our journal belongs to all.
Thanks again to our readers, our Board, our partners and supporters
societies, without which this work would certainly would not achieved its
first birthday.
Thank you all!
James Skinovsky – Associated Editor
v. 2 n. 4
9
Artigos Originais
Original Articles
10
v. 2 n. 4
Avaliação das aderências intraperitoneais em
modelo de hernioplastia experimental
onlay - Comparação entre o uso de tela de
polipropileno e tela de monocryl-polipropileno
Evaluation of intraperitoneal adhesions in experimental onlay
hernia repair model - Comparison between the use of
polypropylene mesh and polypropylene composite monocryl mesh.
Leonardo Alves Nery1, Sergio Luis Mattos Tezza1, Gabriela Jouglard Vasques1, Geniffer Curtinaz Cardoso1,
Joao Augusto Argenton Zortea1, Danielle Cristinne Figueiró1, Bibiana Borges Manna1, Renata Baú2,
João Vicente Machado Grossi3, Leandro Totti Cavazzola4.
Graduate Student, Faculty of Medicine, ULBRA, Brazil, 2MD, Resident of General Surgery – ULBRA,
Canoas, Brazil. 3MD, Resident. Department of Surgery, Gastrointestinal Surgery Hospital São Lucas – PUC
Porto Alegre-RS, Brazil. Co-advisor research group MEREGES-ULBRA. 4PhD, Full Professor of
Morphology and Surgery, Faculty of Medicine, ULBRA. Full Professor of Human Anatomy, Federal University
of Health Sciences, Porto Alegre - RS, Brazil. Full supervisor research group-MEREGES.
1
AUTOR CORRESPONDENTE: João Vicente Machado Grossi. Rua Carlos Trein Filho 1271/401. Bela Vista.
Porto Alegre, RS – Brasil. Telefone +55(51)81550660. E-mail: [email protected]
FONTE DE FINANCIAMENTO: Este trabalho não teve qualquer fonte de financiamento.
CONFLITO DE INTERESSE: Os autores declaram não haver conflitos de interesse.
Resumo
Introdução: As aderências ocorrem devido à exposição de prótese para o conteúdo intra-abdominal e é
um fator importante para a sua ocorrência na clínica
das complicações cirúrgicas. Objetivo: Avaliar um modelo experimental de herniorrafia com a colocação onlay de uma tela de polipropileno (PP) e de tela composta de polipropileno leve e monocryl (UP). Materiais e
métodos: estudo experimental, com uma amostra de
28 ratas Wistar. Eles foram divididos aleatoriamente
em três grupos (um com 8 animais - controle e dois
grupos com 10 animais). Em todos os três grupos foi
criada um defeito de 1cm de diâmetro no músculo
reto. Os três grupos foram divididos em: fechamento
da pele (sham-8 animais), telas de PP e UP (10 animais
cada). As amostras foram analisadas para a presença de
aderências, força necessária para a sua ruptura e órgãos
v. 2 n. 4
envolvidos. A retração da tela foi analisada. Todos os
animais foram sacrificados 21 dias após o procedimento. Resultados: Todos os grupos apresentaram
aderências. Grupo PP teve pior grau de aderências
quando comparada com o grupo UP e sham. A força
de ruptura de adesão não diferiu entre as telas estudadas. Aderências envolvendo principalmente o omento
e apenas no grupo PP incluindo o ligamento redondo
(fígado) em 50 % e no intestino delgado, em 20 % dos
animais, p = 0,004. Área exposta do defeito foi de 0,83
± 0,18cm2 no grupo sham; 0,90 ± 0,09cm2 no grupo
PP e 0,60 ± 0,18cm2 em UP, p < 0,001. Conclusão:
Todos os grupos mostraram algum grau de aderências. Uma das explicações para o menor percentual de
aderências no grupo UP é a menor área exposta da
tela (com a maior retração do defeito) em comparação
com os outros grupos.
Palavras-chave: Hérnia. Monocryl. Wistar. Polipropileno. Tela. Aderência.
11
Artigo Original
Grossi et al.
Abstract
Background: Adhesions are due to the exposure of
prosthesis to the intra-abdominal contents and it is an
important factor to its importance in surgical complications clinic. Objective: To evaluate an experimental
model of hernioplasty with the placement of an onlay
polypropylene mesh (PP) or a composite lightweight
polypropylene and monocryl mesh (UP). Methods:
An experimental study, with a sample of 28 female
Wistar rats. They were randomized into 3 group (1
with 8 animals - control and 2 groups with 10 animals).
In all three group a 1 cm diameter defect was created
in the rectus muscle. The 3 groups were divide as: skin
closure (sham - 8 animals), PP mesh and UP (10 animals each). Samples were analyzed for the presence of
adhesions, it’s extent, the strength necessary for their
rupture and involved organs. Retraction of the mesh
was analyzed . All animals were killed 21 days after the
procedure. Results: All groups showed adhesions. PP
group had worst extension of adhesions when compared to UP and sham group. The force for adhesion
rupture did not differ between meshes studied. Adhesions involved mostly the omentum and only in the PP
group there were adhesions with the round ligament
(liver) in 50 % and small bowel in 20 % of the animals,
p = 0.004 . Exposed area of the defect was 0.83 ± 0.18
cm2 in the sham group; 0.90 ± 0.09 cm2 in the PP
group and 0.60 ± 0.18 cm2 in UP - p < 0.001. Conclusion: All groups showed some degree of adhesions.
One of the explanations for the lowest percentage of
adhesions in the UP group is the smaller exposed area
(with the greatest retraction of the mesh) compared to
the other groups.
Keywords: Hernia. Monocryl. Mesh. Polypropylene.
Wistar. Adhesions.
Introdução
A grande maioria das hérnias está localizada na região
inguinal, e derivam normalmente de uma protrusão do
peritônio parietal e das vísceras, como por exemplo, o
intestino delgado.2 Cerca de 80-90% das hérnias abdominais estão situadas na região inguinal, sendo os dois
tipos principais: hérnia inguinal direta e indireta, a qual
mais de dois terços são hérnias indiretas. O restante,
em torno de 10-15%, são as chamadas hérnias incisionais, causadas por um procedimento cirúrgico prévio,
sendo necessária a sua reparação por técnicas de cirur-
12
gia aberta com sutura, cirurgia aberta com colocação
de tela, colocação de tela por videolaparoscopia.3
A tela cirúrgica tem sido utilizada para cobrir o defeito pós-incisão na correção de hérnia abdominal. O
grau de recorrência diminui de 49% para 10% quando
se usa a técnica de utilização de tela em hérnias incisionais.4 As publicações mais recentes mostram que as
próteses nas hérnias, tanto primárias quanto secundárias, têm sido muito mais eficazes que o reparo anatômico (apenas com sutura).5
As aderências em virtude da exposição da prótese ao
conteúdo intra-abdominal são fatores a serem investigados devido a sua importância clínica-cirúrgica. O
processo inflamatório varia de acordo com o posicionamento, área exposta e tipo de malha utilizada.6
Apesar de oferecer grandes benefícios, a utilização
de materiais sintéticos para a correção de hérnias não
constitui uma técnica isenta de complicações, sendo a
infecção bacteriana uma das mais frequentes e preocupantes.7 Outra preocupação frequente é a formação
de aderências intra-abdominais. Os fatores de risco
associados à formação de aderências são, basicamente, procedimentos cirúrgicos prévios, reação de corpo
estranho, isquemia e infecção.8
Desde modo, o objetivo deste estudo é avaliar a formação de aderências após o uso de tela de polipropileno
na parede anterior, no espaço pré-fascial, comparativamente com a tela de malha leve composta de polipropileno e monocryl (UP), em ratos wistar.
Métodos
O presente trabalho de pesquisa foi realizado na forma
de um estudo experimental que foi desenvolvido no
Biotério da Universidade Luterana do Brasil (ULBRA),
mediante a utilização de protocolos por este órgão estabelecidos para modelos experimentais com animais
de laboratório. A pesquisa foi composta de ratas da
raça Wistar, devidamente acondicionadas e alimentadas conforme os padrões do local de realização do trabalho. O tamanho da amostra foi calculado de acordo
com trabalhos e dados da literatura provenientes da
mesma linha pesquisa.9,10,16,19
Estudo experimental, longitudinal, composta de 28 ratas Wistar, pesando em torno de 200-300 gramas cada.
Foram randomizadas em 3 grupos com 10 animais
no grupo PP e UP e 8 animais no grupo controle (P
Sham).
Todas as telas utilizadas mediam 2x2cm2. Os animais
foram anestesiados usando injeção intramuscular de
v. 2 n. 4
Avaliação das aderências intraperitoneais em modelo de hernioplastia experimental
onlay - Comparação entre o uso de tela de polipropileno e tela de monocryl-polipropileno
xilasina (0,1ml de solução 2% diluída em 0,2ml de solução fisiológica 0,9%) na dose 5mg/kg e uma injeção
intramuscular de ketamina (0,35ml de solução a 50mg/
ml) na dose de 50mg/kg. A seguir, fez-se uma incisão
com 3-4cm de comprimento na pele, dissecção do tecido subcutâneo, exposição e incisão da linha alba e
acesso à cavidade peritoneal.
No grupo (Sham) foi feita uma incisão mediana medindo 4cm, com dissecção do tecido subcutâneo e
abertura da cavidade peritoneal através da linha alba
e criado um defeito de parede de 1cm. Neste grupo
não houve implantação de tela, apenas fechamento da
pele(couro).
O grupo (PP) foi submetido à incisão mediana medindo 4cm, com dissecção do tecido subcutâneo através
da linha alba e fixado a prótese de polipropileno com
fio de polipropileno 3-0 nos 4 quadrantes da tela, anterior ao defeito da parede criado de 1cm, no espaço
pré-fascial.
No grupo (UP) foi colocada sobre o defeito da parede de 1cm de diâmetro no músculo reto abdominal,
expondo as vísceras abdominais à tela. Após a exposição da cavidade, foi implantada a prótese (monocryl/
polipropileno) medindo 2x2cm, no espaço pré-fascial,
com fixação nos 4 quadrantes da tela.
Em todos os animais a parede abdominal foi fechada
com fio de polipropileno 4-0.
Após o procedimento cirúrgico, os animais receberam reidratação subcutânea com injeção de 0,5ml de
solução salina 0,9%, e colocados separadamente em
ambiente aquecido para recuperação pós-operatória.
Quando completamente recuperados da anestesia,
foram recolocados no ambiente pré-operatório, com
água e comida ad libitum.
Todos os animais foram mortos com monóxido de
carbono, no vigésimo primeiro dia de pós-operatório.
Imediatamente foram avaliados para formação de aderências, utilizando uma incisão abdominal mais ampla
em forma de U. As variáveis estudadas foram: a) aderências: presentes ou ausentes; b) grau de aderência:
leve, moderado e grave; c) intensidade das aderências:
0- 5 Newtons; d) porcentagem recoberta: menos de
50% ou mais de 50%; e) localização das aderências:
periférica ou central.
O grau de aderência pode ser classificado de acordo
com uma classificação pré-padronizada e descrito em
outros estudos similares, como: 0: nenhuma: ausência
de aderências; 1: leve- aderências finas e de fácil liberação; 2: moderada- aderências que necessitam de dissecção romba para liberação e 3: intensa- aderências
v. 2 n. 4
firmes onde a lise só pode ser feita com a aplicação de
força maior com lesão parcial ou total da víscera.
Variáveis contínuas foram expressas com média e desvio-padrão. Variáveis categóricas foram descritas com
números e percentagens. O teste exato de Fisher foi
usado para determinar associação entre variáveis categóricas. Para a verificação de diferenças nas forças média e desvio padrão (DP) entre os grupos, foi utilizada
a análise de variância (ANOVA).
Este projeto foi submetido e aprovado pelo Comitê de
Ética da Universidade Luterana do Brasil. Os experimentos seguiram as normas e protocolos exigidos pela
instituição. Protocolo – 2013-4P.
Resultados
Todos os animais foram analisados após 21 dias. Em
todos os grupos foram encontrados formação de aderências. Quando analisados os 3 grupos, os resultados
foram que o grau de aderências no grupo PP foi de
2 (leve a moderado) e nos grupos UP e Sham apenas
grau 1 (leve), com significância estatística, p=0,006.
A força para ruptura, em Newtons, da aderência apresentou no grupo PP mediana de 0,6N e amplitude de
(0-4). Já no grupo UP a força de ruptura foi mediana
de 1,13 e amplitude de (0-2). No grupo Sham a força
de ruptura foi de mediana de 1,95 e amplitude de (1-3),
diferença significante em relação ao grupo com telas,
p=0,018.
Todas as aderências fixaram a tela com o omento nos
3 grupos. Além disso, no grupo PP houve aderências
no ligamento redondo (fígado) 50%, com significância
estatística; alça intestinal e cólon em 20% cada uma,
sem significância estatística. No grupo controle houve
aderências em alça intestinal em 12,5%. No grupo UP
não houve aderências em fígado, alça intestinal e cólon.
Quando analisamos o fechamento do defeito na parede anterior formado o grupo UP com 0,60 cm de média mostrou uma redução estatisticamente significativa
em relação aos grupos PP e Sham, 0,90 e 0,83 cm de
média, respectivamente, p< 0,001.
13
Grossi et al.
Artigo Original
Tabela 1 – Tabela comparativas dos grupos controle(sham), polipropileno(PP) e monocril/polipropileno(UP)
* teste de Kruskal-Wallis ou ANOVA one way para as variáveis contínuas ou ordinais e teste qui-quadrado de Pearson para as categóricas a,b Letras iguais não diferem pelo teste de Wilcoxon (após o teste Kruskal-Wallis), Tukey (post-hoc de Tukey) ou resíduos
ajustados (após o teste qui-quadrado e Pearson)
Tabela 2 – Avaliação comparativa entre as telas utilizadas
* teste t-student ou Mann-Whitney para as variáveis contínuas ou ordinais e teste exato de Fisher para as categóricas
14
v. 2 n. 4
Avaliação das aderências intraperitoneais em modelo de hernioplastia experimental
onlay - Comparação entre o uso de tela de polipropileno e tela de monocryl-polipropileno
Discussão
A utilização de tela para a correção de hérnias é objeto
de estudo e busca constante da sociedade médica, já
que seu uso contribuiu significativamente para a redução de recidiva de hérnias e sucesso no procedimento
cirúrgico10.
Com isso, cada vez mais a tela cirúrgica deve preencher
critérios quanto à mínima reação tecidual inflamatória,
sendo biologicamente inerte; onde produza o mínimo
ou nenhuma aderência intraperitoneal11. (Figura1).
Figura 1– Mostra a fixação da tela monocryl/polipropileno
A hérnia incisional é uma complicação comum após a
cirurgia abdominal com uma incidência entre 11 e 20
por cento11-12. Tais hérnias podem causar sérias complicações como estrangulamento ou encarceramento11.
Muitas técnicas estão atualmente em uso para reparar
hérnias incisionais. Reparação com sutura primária
tem sido amplamente usada, mas resulta numa elevada
taxa de recorrência entre 24% e 54%12,13. Com o desenvolvimento de novos materiais sintéticos, do uso de
próteses, além da malha leve (semiabsorvível composta uma camada de monocryl e outra camada não absorvível, composta de polipropileno), houve diminuição da recidiva de hérnias. Esta malha leve (Ultrapro®)
ganhou espaço no tratamento da hérnia incisional e
ventral14. Ela facilita a integração com o tecido, minimiza a tensão sobre a linha de sutura, e garante alta
resistência à ferida, diminuindo a deiscência de sutura
e a taxa de recorrência15.
Vários estudos foram realizados com o intuito de encontrar a tela16 e a técnica ideal para implante18,19. A
v. 2 n. 4
técnica onlay (colocação de tela anterior ao defeito no
espaço pré-fascial) e a sublay (colocação de tela no espaço pré-peritonial) são utilizadas na reparação com
tela. Ambas as técnicas mostram bons resultados, mas
a técnica sublay parece superior em relação às complicações e taxa de recorrência17,19.
O tamanho da prótese também é importante para a
recorrência de hérnia incisional.9,12 As malhas disponíveis diferem umas das outras na sua composição, na
estrutura e na sua reação tecidual decorrente do material têxtil e a absorção13. A avaliação da tela para correção de hérnia incisional é de especial interesse porque
são diferentes na sua biocompatibilidade e na taxa de
complicações18.
No presente estudo, o fechamento do defeito formado
foi maior no grupo UP, comparativamente aos grupos
PP e Sham, o que mostra que a tela composta de monocryl-polipropileno (UP) foi superior em relação a do
grupo PP. Esta tela macroporosa, monofilamentada,
parcialmente absorvível, maleável, pode proporcionar
o reforço da parede abdominal ao mesmo tempo em
que se adapta às propriedades anatômicas e biomecânicas do abdômen, diminuindo a reação de corpo
estranho, facilitando e acelerando o fechamento do
defeito criado.
Quando comparado os grupos PP e UP isoladamente,
em relação à área exposta da tela à aderência, houve
significância muito relevante, com p <0,001, demonstrando que no grupo UP, além do fechamento do
defeito formado ter sido mais rápido com a tela UP
(semi-absorvível), esta mostrou uma integração maior
com a parede abdominal, funcionando como um material mais inerte ao corpo, o que contribui para uma
menor resposta inflamatória14.
O grupo de animais de tela UP teve menor grau de
aderências, comparado com a tela de polipropileno.
Em alça intestinal e cólon não foram encontradas aderências. Outras variáveis estudadas, como retração de
tela, força de ruptura, não demonstraram significância
relevante.
A limitação desse estudo é o fato de ser um estudo experimental e ser difícil extrapolar os resultados para os
seres humanos. Outras pesquisas são necessárias para
avaliarem-se as consequências, em longo prazo, do
contato da tela com o conteúdo intraperitoneal. Para
estudos posteriores recomenda-se que se busquem
novas telas semi-absorvíveis e também métodos onde
a tela não seja considerada um corpo estranho pelo
15
Artigo Original
Grossi et al.
corpo, através de, por exemplo, criação de biofilme
proveniente de células-tronco. Há apenas poucos estudos prospectivos que avaliam a influência da textura
de malha na qualidade de vida em seres humanos18.
Ainda não está claro se a aplicação de parte dos componentes absorvíveis pode contribuir para a melhora
da biocompatibilidade das telas de polipropileno e se
tal melhoramento irá diminuir a incidência no número
total de infecções ou outras complicações20.
De acordo com os achados concluímos que no modelo proposto houve uma maior retração do defeito produzido utilizando a tela com monocryl/polipropileno.
A menor área de exposição do material protético ao
conteúdo intraperitoneal resultou em um grau diminuído de aderências.
referências
1. Minossi JG, Silva AL, Spadella CT. O uso da prótese na correção
das hérnias da parede abdominal é um avanço, mas seu uso indiscriminado, um abuso. Rev. Col. Bras. Cir. 2008;(6)35: 416-24.
2. Matapurkar BG, Bhargave A, Dawson L, Sonal B. Regeneration of
Abdominal Wall Aponeurosis: New Dimension in Marlex Peritonial
Sandwich Repair of Incisional Hernia. World J. Surg. 1999;23: 446-51,
3. Cassar K, Munro A. Surgical Treatment of incisional hernia. British Journal of Surgery 2002,89, 534-45.
4. Arnaud JP, Eloy R, Adloff M, Grenier JF. Critical evaluation of
prosthetic materials in repair of abdominal wall hernias. Am J Surg
1977; 133: 338-45.
5. Greca FH, Paula JB, Biondo-Simões MLP, Costa FDA, Silva
APG, Time S, Mansur A. The influence of differing por sizes on the
biocompatibility of two polypropylene meshes in the repair of abdominal defects: experimental study in dogs. Hernia 2001; 5: 59-64.
6. Debord JR. The historical development of prosthetics hernia surgery. Surg Clin North Am. 1998 Dec;78(6):973-1006
7. Brown-Eris M, Cutshall WD, Hiles MC. A new biomaterial derived from small intestine submucosa and developed into a wound
matrix device. Wounds 2002; 14 (4): 150-66.
8. Barbosa CA. Histologia do saco herniário das hérnias inguinais
16
indiretas, diretas, recidivadas e encarceradas em adultos e crianças:
identificação de fibras musculares lisas [Tese-Doutorado]. Faculdade
de Medicina da Universidade Federal de Minas Gerais; 2000
9. Kist C, Manna BB, Montes JHM, Bigolin AV, Grossi JVM, Cavazzola LT. Estudo comparativo de aderências intraperitoneais associadas ao uso tela de polipropileno e de malha leve revestida de polipropileno com ácido graxo ômega-3. Revista Colégio Brasileiro de
Cirurgiões. 2012; 39(3)201-6.
10. Lontra MB, Bigolin AV, Costa RG, Grossi JV, Scalco P, Roll S,
Cavazzola LT. Efetividade do uso combinado de filme de ácido
lático e tela de polipropileno na formação de aderências intraperitoneais- um método experimental em ratos. Revista Col. Bras Cir.
2010; 37(5) 364-9.
11. Lao Hamy A, Paineau J, Savigny J, Vasse N, Visset J. Sigmoid perfuration, an exceptional late complication of peritoneal prosthesis
for treatment of inguinal hernia. Int Surg. 1997;82(3):307-8.
12. Franklin MEJr, Gonzalez JJJr, Michelson RP, Glass JL, Chock
DA. Preliminary experience with a new bioactive prosthetic for repair of hernias in infected fields. Bloomington. 2002;6(4):171-4.
13. Evans MJ, Kaufman MH. Establishment in culture of pluripotential cells from mouse embryos. Nature. 1981;292:154-6.
14. Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel JJ, Marshal VS, et al. Embryonic Stem Cell Lines Derived from
Hum an Blastocysts. Science. 1998; 282:1145-47.
15. Barry FP, Murphy JM. Mesenchymal stem cells: Clinical applications and biological characterization. Int J Biochem Cell Biol.
2004;36: 568-8417.
16. Montes JHM, Bigolin AV, Baú R, Nicola R, Grossi JMV, Loureiro CJ, Cavazzola LT. Análise das aderências resultantes de fixação de
telas cirúrgicas com selantes de fibrina e sutura- modelo experimental intraperitoneal. Revista Colégio Bras Cir. 2012;(6) 509-14.
17. Kern S, EichlerI H, Stoeve J, Kluter H, Bieback K. Comparative
analysis of mesenchymal stem cells from bone marrow, umbilical
cord blood, or adipose tissue. Stem Cells. 2006;24:1294-301.
18. Seiler C, Baumann P. A randomised, multi-centre, prospective,
double blind pilot-study to evaluate safety and efficacy of the nonabsorbable Optilene® Mesh Elastic versus the partly absorbable Ultrapro® Mesh for incisional hernia repair. BMC Surgery 2010, 10:21
19. Lamber B, Grossi JMV, Manna BB, Montes JHM ,Bigolin AV,
Cavazzola LT. Pode a tela de poliéster coberta com colágeno diminuir as taxas de aderências intraperitoneais na correção de hérnia
incisional? ABCD Arq Bras Cir Digestiva. 2013; 26(1):13-17.
20. Pittenger MF, Mackay AM, Beck SC, Jaiswal RK, Douglas R,
Mosca JD, et al. Multilineage potential of adult human mesenchymal
stem cells. Science. 1999;284:143-7.
v. 2 n. 4
LESS TAPP HERNIOPLASTY: THE FIRST SERIES
James Skinovsky1, Mauricio Chibata2, Marcus Vinicius Dantas de Campos Martins3,
Sérgio Roll4, Fernanda Tsumanuma5, Rogério Cavalier6, Francisco Almeida7
PhD, Head of Surgery Department, Red Cross Hospital and Positivo University, Curitiba, Brazil.
Chairman LapSurg International Institute of Endoscopic Surgery. 2MD, Surgery Department,
Red Cross Hospital, Positivo University, Curitiba, Brazil. 3MD – Professor, Surgery Department,
Estácio de Sá University, Rio de Janeiro, Brazil. 4PhD – President of the Americas Hernia Society.
5
Surgery Department, Red Cross University Hospital, Curitiba, Brazil. 6Surgery Department, Red Cross
University Hospital, Curitiba, Brazil. 7Surgery Department, Red Cross University Hospital, Curitiba, Brazil.
1
The study took place at the Red Cross Hospital, Curitiba – PR
Abstract
Objectives: To present the first transabdominal pre-peritoneal (TAPP) Laparo-Endoscopic Single-Site
Surgery (LESS) inguinal hernioplasties series. Patients and Methods: From June 2011 to February
2013 the first 20 LESS TAPP inguinal hernioplasties
were performed at the Red Cross University Hospital
in Curitiba, Paraná, Brazil. The Single Trocar Access
(SITRACC™) platform (EDLO, Brazil) was used in all
procedures. All patients were male and their ages ranged from 18 to 52 years old. Twelve patients presented NYHUS II hernias and eight of them presented
NYHUS III a groin hernias. Results: The mean operative time was 39 minutes. None of the surgeries required an extra trocar or conversion to a conventional
laparoscopic procedure. All patients were discharged
within 24 hours. Aesthetic results were considered quite good by the patients, without healing complications.
There was no precocious hernia recurrence, with 1 to
20 months follow up, average 13 months. Conclusions: The TAPP inguinal hernioplasty using a LESS
approach is feasible and safe. It constitutes a new option in the scarless surgery field, as well as a new technique in the ongoing pursuit of surgical innovation
that benefits our patients. Keywords: Minimally invasive surgery. LESS. Inguinal hernioplasty. SITRACC.
with speed and enthusiasm.
The permanent improvement of the optical equipment and the instruments used in videosurgery have
allowed several complex operations to be performed
by the minimally invasive method.
Simultaneously, new technologies and approaches
have been developed such as the Surgery by Natural
Orifices (NOTES), the Needlescopy and the Laparo-Endoscopic Single Site Surgery – LESS.
Several platforms to perform LESS have been made
available over the recent years. One of them is SITRACC™ - Single Trocar Access (Edlo Company,
Brazil – FIGURE 1), a multiport trocar, disposable,
which uses instruments specially designed for this approach.
Figure 1 – SITRACC™ LESS System, Edlo, Brazil
Introduction
Since 1987, with the introduction of the videosurgery
into the surgical field and the concept of minimally
invasive surgery, it has been amply demonstrated that
this new approach has brought less suffering, milder
metabolic changes, faster recovery and better aesthetic results for patients, spreading by the surgical world
v. 2 n. 4
17
Artigo Original
Skinovsky et al.
Surgery through LESS has emerged as an alternative to
NOTES, where one input device, multichannel in general, is inserted through a single incision, where specialized instruments are positioned for the proposed
procedure. Several surgical methods have been successfully performed by this approach, from cholecystectomy to bariatric surgery1-10,11-16.
This paper presents one of the first world series performing TAPP laparoscopic hernioplasty using LESS
approach.
Figure 2 – Hernia sac dissection using distal articulated instrument
Patients and Methods
From June 2011 to February 2013, 20 LESS groin
TAPP hernioplasties were performed at the Red Cross
University Hospital, in Curitiba-PR, after the approval
of the standard protocol in the Red Cross / Positivo
University Hospital Ethics Committee.
The SITRACC™ platform (Edlo Company, Brazil)
was utilized in all procedures. This new device consists
in a four channels trocar, where special articulated instruments and an optical 5 mm device are introduced.
Articulated graspers, scissors, hook and clip appliers
had developed specially for this approach.
The patients´ age ranged between 18 and 52 years old
and all of them were male. Twelve of them had unilateral groin hernias type Nyhus II and eight of them type
NYHUS III a.
All patients were submitted to a classic Trans-Abdominal Pre-Peritoneal TAPP Inguinal Hernioplasty, using
polypropylene light meshes, fixated with Protack™ endofixating system (both by Covidien™, USA), (Figures
2, 3, 4).
Figure 3 – Placement and mesh fixation
Figure 4 – Placement and mesh fixation
Results
The average surgical time was 39 minutes. All patients
left the hospital in at most 24 hours after the surgeries,
with pattern administration of pain killers. All of them
returned on the seventh day and also on the thirtieth
day after the procedures, without major post-operative
complications. No additional trocar was necessary.
Aesthetic results were considered quite good by the
patients, without healing complications (FIGURE 5).
There was no precocious hernia recurrence, with 1 to
20 months follow up, average 13 months.
18
v. 2 n. 4
LESS TAPP Hernioplasty – The First Series
Figure 5 – Aesthetic result right after the procedure
DISCUSSION
As previously stated, in the last years the interest in
new minimally invasive approaches has been rising in
the scientific field around the world.
The advantages of LESS surgical path are similar to
NOTES, such as painless, fast recovery and excellent
aesthetic results, without the disadvantages of the endolumenal surgery.
Because of the limitations of NOTES (access, orientation, infection, difficult visceral closure and so on),
LESS may be an excellent option to perform scarless
abdominal surgery.
Wheeless is credited as being the first to use the principles of single access surgery, in 1969, performing a
tubal ligation17.
LESS, then, entered a period of latency, resurfacing in
2007, when Zhu published his first experience using
the umbilical scar as an only access to the peritoneal cavity, having performed a fenestration of hepatic
cyst, followed by abdominal exploration and appendectomy, designating this new technique as Transumbilical Endoscopic Surgery (TUES)18,19,20.
In 2007, the pioneering attempt to develop a platform
for single access surgery, called SITRACC™ (Single
Trocar Access, Edlo, Brazil), began in Brazil. It consisted of trocar with four working channels (three of 5
mm and one of 10 mm or four of 5 mm). After studies
in experimental animals, in the following year the first
case of SITRACC cholecystectomy performed in humans21,22,23 was published.
In 2010 Ishikawa et al24 reported the performance of
laparoscopic hernioplasty by TAPP technique, and
Agrawal et al25 performed the treatment for hernia by
TEP technique, both using a multiport trocar.
v. 2 n. 4
The main difficulty to be overcome is the need to work
on single axis of action, with the instruments disposed
in parallel. The attempt to surpass this challenge is represented by the mentioned development of flexible
and/or articulated instruments, allowing some degree
of triangulation, even more limited when compared to
conventional laparoscopic surgery26,27.
The internal instrumental movement, even adapted
for LESS, is arduous, and it must be remembered that,
when moving a single instrument, the whole tends to
move in a single axis, requiring a trained and experienced team for this technique. The use of optics with at
least 30 degrees angulation is strongly recommended,
providing a better visualization of the operative object.
The training requires patience and time since, as previously shown, it is not a simple variation of laparoscopy, but a new and different approach. Practice in
courses with experimental animals as well as in simulations are essential for future good results in human
surgery.
While big surgical series with this approach have not
been accomplished, published and validated by worldwide surgical community, we can only suppose what
the preliminary data has shown to us: LESS is a good
choice to perform minimally invasive procedures, with
all the advantages that this king of procedure brings to
the patients, from excellent aesthetics results to milder
post operative pain and a faster return to the routine
activities of the patients28.
LESS procedures must be remembered as part of a
surgical armamentarium, passing through open surgery, videosurgery and who knows NOTES, in the
future. Each patient is unique, as well as their disease.
It is up to surgeons to determine the best approach
method that will bring a mix of security and good operative and aesthetic results.
TAPP hernioplasty by LESS method represents an
advance, especially for those patients who have to be
submitted by two or more procedures at the same
time, as inguinal and umbilical hernioplasties.
Conclusion
TAPP groin hernioplasty by LESS approach is feasible
and safe, representing a new important option in the
surgical arsenal. This is a new technique and needs to
be compared to conventional laparoscopy in the near
future.
19
Artigo Original
Skinovsky et al.
References
1. Romanelli JR, Earle DB. Single-port laparoscopic surgery: an
overview. Surg Endosc. 2009 Jul;23(7):1419-27.
2. Kala Z, Hanke I, Neumann C. [A modified technic in laparoscopy-assisted appendectomy: a transumbilical approach through a
single port]. Rozhl Chir. 1996 Jan;75(1):15-8.
3. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg. 1997
May;84(5):695.
4. Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Praveenraj P. Transumbilical endoscopic appendectomy
in humans: on the road to NOTES: a prospective study. J Laparoendosc Adv Surg Tech A. 2008 Aug;18(4):579-82.
5. Desai MM, Rao PP, Aron M, Haber GP, Desai M, Mishra S,
Kaouk JH, Gill IS. Scarless single port transumbilical nephrectomy
and pyeloplasty: first clinical report. BJU Int. 2008 Jan;101(1):83-8.
6. Castellucci SA, Curcillo PG, Ginsberg PC, Saba SC, Jaffe JS,
Harmon JD. Single-port access adrenalectomy. J Endourol. 2008
Aug;22(8):1573-6.
7. Bucher P, Pugin F, Morel P. Single port access laparoscopic right
hemicolectomy. Int J Colorectal Dis. 2008 Oct;23(10):1013-6.
8. Saber AA, Elgamal MH, Itawi EA, Rao AJ. Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique. Obes Surg.
2008 Oct;18(10):1338-42.
9. Reavis KM, Hinojosa MW, Smith BR, Nguyen NT. Single laparoscopic-incision transabdominal surgery sleeve gastrectomy.
Obes Surg. 2008 Nov;18(11):1492-4.
10. Teixeira J, McGill K, Binenbaum S, Forrester G. Laparoscopic
single-site surgery for placement of an adjustable gastric band: initial experience. Surg Endosc. 2009 Jun;23(6):1409-14.
11. Saber AA, El-Ghazaly T, Minnick D. Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS
port: first reported case. Surg Innov. 2009 Dec;16(4):343-7.
12. Z Podolsy ER, Rottman SJ, Curcillo PG. Single Port Access.
(SPATM) gastrostomy tube in patients unable to receive percutaneous endoscopic gastrostomy placement. Surg Endosc. 2009
May;23(5):1142-5.
13. Targarona EM, Balaque C, Martinez C, Pallares L, Estalella L,
Trias M. Single-Port Access: a feasible alternative to conventional
laparoscopic splenectomy. Surg Innov. 2009 Dec;16(4):348-52.
14. Kaouk JH, Haber GP, Goel RK. Single-port laparoscopic surgery in urology: initial experience. Urology 2008;71(1):3-6.
15. Busher P, Pugin F, Morel P. Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case
report. Surg Endosc. 2009 Jul;23(7):1667-70.
16. Targarona EM, Pallares JL, Balague C, Luppi CR, Marinello
FP, Hernández Martìnez C, Trias M. Single incision approuch for
splenic diseases: a preliminary report on a series of 8 cases. Surg
Endosc. 2010 Sep;24(9):2236-40.
20
17. Wheeless CR. A rapid, inexpence and effective method of surgical sterilization by laparoscopy. J Reprod Med. 1969;5:255.
18. Zhu JF. Scarless endoscopic surgery: NOTES or TUES. Surg
Endosc. 2007 Oct;21(10):1898-9.
19. Zhu JF, Hu H, Ma YZ, Xu MZ, Li F. Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc. 2009
Apr;23(4):813-7.
20. Dantas MVDC, Skinovsky J, Coelho DE, Torres MF. SITRACC – Single Trocar Access: a new device for a new surgical
approach. Bras J Video-Sur, 2008;1(2):61-3.
21. Martins MVD, Skinovsky J, Coelho DE. Colecistectomia videolaparoscópica por trocarte único (SITRACC®): uma nova opção.
Rev Col Bras Surg. 2009;36(2):177-9.
22. Martins MVC, Skinovsky J, Coelho DE, Ramos A, Galvão Neto
MP, Rodrigues J, de Carli L, Totti Cavazolla L, Campos J, Thuller F,
Brunetti A. Cholecystectomy by single trocar access (SITRACC):
the first multicenter study. Surg Innov. 2009 Dec;16(4):313-6.
23. Ishikawa N, Kawaguchi M, Shimizu S, Matsunoki A, Inaki N,
Watanabe G. Single-incision laparoscopic hernioplasty with the assistance of the Radius Surgical System. Surg Endosc. 2010;24:730-1.
24. Agrawal S, Shaw A, Soon Y. Single-Port laparoscopic totally extraperitoneal inguinal hernia repair with the TriPort system: initial
experience. Surg Endosc. 2010 Apr; 24(4):952-6.
25. Dominguez G, Durand L, De Rosa J, Danguise E, Arozamena
C, Ferraina PA. Retraction and triangulation with neodymiun magnetic fórceps for single-port laparoscopic cholecystectomy. Surg
Endosc. 2009; 23:1660-6.
26. Galvão Neto M, Ramos A, Campos J. Single port laparoscopy
Access surgery. Tech Gastrointest Endosc. 2009;11(2):84-93.
27. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos C, Benetatos N, Mavridou P, Manataki A. Different pain scores
in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controled
Trial. Surg Endosc. 2010;24:1842-8.
Corresponding Author:
James Skinovsky
Av Iguaçú 2713 ap 503, Água Verde, Curitiba(PR), Brazil
Zip Code 80240-030
E-mail: [email protected]
v. 2 n. 4
Artigo de revisão
Rewiew Article
v. 2 n. 4
21
COMPLICAÇÕES DAS HERNIOPLASTIAS
VIDEOLAPAROSCÓPICAS DA PAREDE ABDOMINAL
Sérgio Roll1, James Skinovsky2
Doutor em Cirurgia. Past President America’s Hernia Society.
Doutor em Cirurgia. Professor Titular do Curso de Medicina da Universidade Positivo – Curitiba(PR).
Coordenador das Residências Médicas em Cirurgia Geral e Cirurgia do Aparelho Digestivo do
Hospital da Cruz Vermelha – Universidade Positivo – Curitiba(PR).
1
2
INTRODUÇÃO
A cirurgia videolaparoscópica adicionou às complicações conhecidas das operações a céu aberto para correção das hérnias da parede abdominal aquelas relacionadas à via laparoscópica.
Algumas complicações relatadas ocorrem exclusivamente na abordagem videocirúrgica, como aquelas
relacionadas diretamente à visualização laparoscópica,
à introdução dos trocárteres ou mesmo ao pneumoperitôneo.
Como sempre, a adequada utilização de material, discriminados aí o equipamento de videocirurgia como um
todo e as próteses (telas) adequadas, colocadas em locais anatômicos propícios, diminui ao máximo possível
estas condições indesejadas.
Ao longo deste capítulo discorreremos sobre as principais complicações relacionadas à abordagem videocirúrgica das hérnias da parede abdominal (Quadros 2
e 3).
COMPLICAÇÕES LOCAIS
As complicações locais das hernioplastias laparoscópicas são as mesmas da cirurgia convencional, como
infecção e hematoma da ferida operatória, hematoma
da região inguinal, lesões das estruturas do cordão espermático, atrofia testicular, neuralgia pós-operatória,
rejeição da tela e recidiva do defeito herniário. As mais
comuns são representadas pelos seromas e hematomas
inguinais e escrotais.1,2,3
As maneiras de evitá-las incluem cuidados básicos referentes a quaisquer operações como uso de técnica
delicada, material adequado, cuidados de assepsia e antissepsia.
Hematoma
A incidência de hematomas pós-operatórios varia con-
22
sideravelmente e usualmente não é relatado em muitas
séries, entretanto é reportada entre 1-15% dos pacientes19,20. Podem ocorrer devido a punção de pequenos
vasos superficiais da parede abdominal, da musculatura ou mesmo de vasos epigástricos inferiores. A entrada na parede inguinal e abdominal com trocárteres
cortantes aumentam o risco deste evento. Geralmente
são autolimitados.
Seroma
A maioria dos seromas se desenvolvem acima da tela
e relacionados ao saco herniário retido21. Em reparos
abertos de grandes hérnias, o espaço morto resultante
entre as camadas da parede geralmente é tratado profilaticamente pela colocação de drenos de sucção fechados, de modo que o seroma resultante é aspirado. Na
laparoscopia, devido aos drenos não serem costumeiramente utilizados, seromas são mais frequentemente
identificados. A taxa de formação de seroma é relatada
em várias séries, dependendo de quando os investigadores a avaliaram. A taxa média, na avaliação realizada
entre 4 e 8 semanas foi de 11,4%, nas séries estudadas.
No maior trial multi-institutional, seromas que foram
clinicamente aparentes por mais de 8 semanas foram
considerados uma complicação e ocorreram em 2,6%
dos casos. Apesar de tratados com aspiração estéril ou
simplesmente deixados para serem absorvidos, seromas raramente resultam em problemas a longo prazo. É imperativo que os pacientes sejam informados
pré-operatoriamente sobre a possibilidade de seroma
e que, se o mesmo se tornar clinicamente perceptível
após a cirurgia, ele será manejado de maneira expectante, a não ser que se torne desconfortável e/ou persistente. Afortunadamente, grandes seromas são incomuns; entretanto, eles podem causar tensão na pele,
causando necrose com o risco associado de infecção
na prótese. A aspiração é recomendada para seromas
grandes ou persistentes, antes que eles ocasionem tais
tipos de problemas22.
v. 2 n. 4
Complicações das Hernioplastias Videolaparoscópicas da Parede Abdominal
NEURALGIA E DOR PERSISTENTE
A neuralgia é complicação temida, não pela sua gravidade mas sim devido à dificuldade de manuseio e
resolução. Sua ocorrência pode ser minimizada pelo
conhecimento anatômico do cirurgião. Deve-se obrigatoriamente evitar o manuseio excessivo, utilização do
cautério (especialmente monopolar) e grampeamento
abaixo do trato íleo-púbico, no chamado “Triângulo
da Dor” em especial. Na fatalidade de lesão aparente
nestes nervos, pode-se optar pela tentativa de retirada
cirúrgica dos grampos e/ou até mesmo neurectomia,
para alívio da dor severa e parestesia1,4,10,14,17 (Figura 1).
Este tipo de dor geralmente é descrita como aguda,
intermitente e intensa, podendo ser exacerbada pelo
movimento, respiração profunda ou tosse. Se esta condição se apresenta, inicialmente o local deve ser avaliado com ecografia ou tomografia para a eliminação
da ocorrência de seroma ou recorrência herniária, que
poderiam explicar a sintomatologia dolorosa.
Esta complicação ocorre em aproximadamente 1-3%
dos pacientes submetidos à hernioplastia laparoscópica, menor do que a via convencional, cuja incidência
deste incômodo problema gira em torno de 3-5%3,4.
Figura 1 – Lesão de nervos por clipagem direta
COMPLICAÇÕES RELACIONADAS AO USO
DAS TELAS
Estudo anterior, realizado em cirurgias convencionais,
com colocação da tela no espaço pré-peritoneal relatou que, em 7133 casos, os índices de infecção foram
de 0,028% e que não se observaram casos de rejeição4.
v. 2 n. 4
Em estudos realizados com a abordagem videolaparoscópica os dados foram, em sua grande maioria, bastante favoráveis. Fitzgibbons et al 5, em clássico exemplo,
relataram infecção da tela em apenas um caso, de 816
pacientes.
Um dos maiores benefícios da abordagem herniária laparoscópica é a redução da ferida, com consequente
diminuição de complicações infecciosas. Colocando a
tela intra-abdominal, com a utilização de um trocárter,
a menor manipulação tissular, com consequente menor
desvascularização das fáscias, contribuem sobremaneira para a diminuição dos problemas relacionados às
feridas operatórias e próteses. A infecção da tela permanece uma complicação séria, apesar de apresentar
pequena incidência, com consequências severas. Patógenos da pele são os responsáveis pela maior parte
das infecções de tela. Todo esforço deve ser feito para
evitar o contato das próteses com a pele. Infecções das
telas de polipropileno pode ser manejadas localmente
com drenagem cirúrgica e excisão das telas expostas,
com segmentos não incorporados.
Uma compilação de séries reportaram taxa de infecção
de telas de 20 por 3276 casos, ou 0,6%22,25. Celulite nos
sítios de trocárter, resolvidas com antibióticos, ocorreram em 35 casos, ou 1,1%. Quando incluídas todas as
complicações de ferida e telas, a taxa de ocorrência foi
1,7%. Esta porcentagem é favorável, quando comparada àquela oriunda da relatada com referência às hernioplastias com uso de próteses, a céu aberto, ou seja
12 a 18%26,27,28.
Torna-se importante salientar a importância de que a
prótese de polipropileno puro, de longe a mais utilizada atualmente no mundo, seja de alta ou baixa gramatura, não deve permanecer em contato com vísceras
intra-abdominais, devido ao alto risco de aderências e
fístulas. Quando este contato torna-se imperativo, por
falta de opção anatômica ou exigência da técnica (hernioplastias incisionais videolaparoscópicas) devem ser
utilizadas telas apropriadas para este fim, ditas separadoras de tecidos ou simplesmente “de dupla face”,
cuja superfície que fará contato visceral apresenta biomaterial apropriado, tais como PTFe e colágeno, entre
outros15,16.
Próteses de polipropileno, em especial as de alta gramatura (microporosas e pesadas), ocasionam grande reação inflamatória com consequente fibrose importante,
podendo ocasionar o que se convencionou chamar de
“meshoma”, verdadeiras tumorações ocasionadas pela
reação a corpo estranho e contração da tela, ocasionando ao paciente dor e sensação de corpo estranho,
23
Skinovsky et al.
Artigo de Revisão
muitas vezes palpável (Figuras 2, 3, 4, 5, 6, 7, 8). No
quadro abaixo é descrita a sequência de eventos locais
que leva a formação destas complicações (Quadro 1).
Figura 5 – Fibrose intensa
Quadro 1 - Sequência de eventos locais deletérios ocasionados pela tela
Figura 6 – Cisto hemático
Figuras 2 e 3 – Intensa fibrose ocasionada por tela de polipropileno
Figura 7 – Encapsulação e cisto hemático
Figura 4 – “Meshoma”
24
Figura 8 – Fibrose, contração, deslocamento da tela
v. 2 n. 4
RECIDIVAS
]
Figuras 10a e 10b – Obstrução intestinal por aderência na tela
O ponto crítico do sucesso do tratamento herniário
é representado pelo índice de recidivas. A ocorrência
desta depende da experiência do cirurgião (curva de
aprendizado), de fatores diversos como fixação errônea, pequeno tamanho da tela e identificação inadequada do defeito herniário12,13,18. Lembramos que, tanto
na TAPP (Trans–abdominal Pré-peritoneal) quanto
na TEP (Totalmente Extra-peritoneal) a tela deve ter
tamanho suficiente para cobrir a região de ocorrência
herniária, o chamado orifício mio-pectíneo de Frouchaud. A recidiva estimada em grandes séries, para hérnias ínguino-femorais, situa-se entre 0,7% para TAPP
e 0,4% para TEP6.
A causa mais frequente para a recidiva é a dissecção
incompleta do espaço pré-peritoneal, sem adequada visualização das estruturas anatômicas2,11.
COMPLICAÇÕES RELACIONADAS DIRETAMENTE à ABORDAGEM LAPAROSCÓPICA
A
B
Figuras 11a e 11b – Hérnia de trocárter
Hérnias de trocárter
Podem ocorrer especialmente nos sítios de colocação
dos trocárteres de calibre maior (10-12mm), podendo
levar à obstrução intestinal e até mesmo peritonite por
hérnias estranguladas (Figuras 9, 10 e 11). Podem ser
evitadas com o adequado fechamento das brechas igual
ou maiores do que 10mm.
A
Figuras 9a e 9b – Hérnia de trocárter com obstrução
intestinal
B
A
Lesões viscerais e de vasos
B
v. 2 n. 4
Lesões viscerais podem ocorrer inadvertidamente devido a não visualização completa da parte ativa das pinças, quando da utilização do eletrocautério.7
De maneira mais incomum podem acontecer lesões da
bexiga urinária, intestinos e vasos ilíacos, as quais em
geral são fruto de manobras inadequadas, introdução
25
Artigo de Revisão
Skinovsky et al.
dos trocárteres secundários sem visualização direta ou
uso inadequado da energia térmica monopolar9.
Deve-se evitar sobremaneira a manipulação da região
denominada “Triângulo do Desastre”, local anatômico
onde estão os vasos ilíacos, também localizado abaixo
do trato íleo-púbico.
Lesões dos vasos epigástricos superficiais em geral são
de fácil resolução, com cauterização local, compressão pelo próprio trocárter ou utilização de clipes. Esta
complicação ocorre de maneira menos frequente quando realizada a transiluminação, no momento de introdução dos trocárteres secundários4,8.
A lesão de serosa intestinal que ocorre durante a dissecção deve ser tratada como qualquer outra lesão intestinal. Esta enterotomia pode ocorrer pela tração visceral
ou devido à lesão térmica durante o uso da fonte de
energia, geralmente na lise de aderências. Em alguns
casos a injúria pode não se manifestar nas horas iniciais após o procedimento. Se o lúmen não foi violado,
Quadro 2 – Complicações Intra-Operatórias
a lesão pode ser deixada intocada, ou o cirurgião pode
fechá-la com o uso de grampeador endoscópico. A incidência de reconhecimento da enterotomia varia de 6 a
14,3%23,24. Em qualquer caso, o pronto reconhecimento
destas injúrias é fundamental para se evitar complicações tardias.
FÍSTULA ENTEROCUTÂNEA
Esta é uma complicação não usual, especialmente dos
reparos laparoscópicos das hérnias ventrais e incisionais. A exata etiologia não é bem determinada, devido
à raridade do problema. Pelos menos 3 fístulas enterocutâneas foram relatadas na literatura25,29. Isto representa uma incidência de 0,3 e 1,4%, respectivamente,
nas séries relatadas. Foram relatadas ocorrências tanto de maneira precoce quanto tardia. Uma destas foi
manejada com sucesso de maneira não operatória. Os
outros dois casos requereram ressecção cirúrgica aberta ou simples sutura com drenagem. Foi identificada
a causa somente em um caso, uma enterotomia não
visualizada.
CONCLUSÕES
Fonte: Roll S, Cavazzola LT. In: Silva RS, De Carli LA. Videocirurgia. Porto Alegre: Artmed; 2007. p.183-4.
Quadro 3 – Complicações Pós-Operatórias
Fonte: Roll S, Cavazzola LT. In: Silva RS, De Carli LA. Videocirurgia. Porto Alegre: Artmed; 2007. p.183-4.
26
As complicações precoces, segurança e efetividade clínica das abordagens a céu aberto e laparoscópicas são
similares. A abordagem laparoscópica apresenta diversas vantagens-chave, incluindo menor risco de infecção e estada hospitalar mais curta, além de redução da
taxa de complicações, dor pós-operatória e íleo após o
procedimento.
Benefício adicional da abordagem laparoscópica é o
fato de que, através de um único procedimento, hérnias grandes ou múltiplas podem ser reparadas sem
extensão da incisão, permitindo igualmente encontrar
e reparar defeitos silenciosos clinicamente.
A cirurgia laparoscópica parece ser efetiva em pacientes complexos, especialmente os obesos e/ou aqueles
que apresentam recorrências.
Avanços no desenvolvimento de novos biomateriais
prostéticos, novos instrumentos, equipamentos e técnicas para colocação das próteses podem no futuro
reduzir a morbidade pós-operatória, minimizar recorrências e melhorar o cuidado aos pacientes.
Complicações são inerentes a qualquer procedimento
cirúrgico. Planejamento cirúrgico, familiaridade anatômica, técnica adequada e cuidadosa, material adequado
e experiência as diminuem a ponto de que sua ocor-
v. 2 n. 4
rência passa a ser uma simples fatalidade, um acidente
de percurso.
Complicações ocorrem, o importante é saber identificá-las e tratá-las de maneira precoce e efetiva.
REFERÊNCIAS
1. Roll S, Cavazzola LT. In: Silva RS, De Carli LA. Videocirurgia.
Porto Alegra: Artmed; 2007. p.183-4.
2. Davis CH, Arregui ME. Laparoscopic repair for groin hérnias.
Surg Clin North Am. 2003;83:141-61.
3. Cihan A, Ozdemir H, Uçan BH, Acun Z, Comert M, Tascilar O,
Cesur A, Cakmak GK, Gundogdu S. Fade or fate: seroma in laparoscopic inguinal hernia repair. Surg Endosc. 2006 Feb;20(2):325-8.
4. Cohen RV, Schiavon CA, Roll S, Pinheiro Filho JC. Complications and their management. In: Leblanc KA. Laparoscopic hernia
surgery: an operative guide. London: Arnold; 2003, p. 89-96.
5. Fitzgibbons RJ Jr, Camps J, Cornet DA, Nguyen NX, Litke BS,
Annibali R, Salerno GM. Laparoscopic inguinal herniorrhaphy: results of a multicenter trial.Ann Surg. 1995 Jan;221(1):3-13.
6. Awad SS, Fagan SP. Current approaches to inguinal hernia repair.
Am J Surg. 2004 Dec;188(6A Suppl):9S-16S.
7. Roll S, Campos FG. Cirurgia laparoscópica. In: Silva AL. Hérnias
da parede abdominal. São Paulo: Atheneu; 1997. p 279-89.
8. Schultz C, Baca I, Gotzen V. Laparoscopic inguinal hérnia repair:
a review of 2500 cases. Surg Endosc. 2001 Jun;15(6):582-4.
9. Bobrzynski A, Budzynski A, Biesiada Z, Kowalsczyk M,
Lubikowski J, Sienko J. Experience: the key factor in successful laparoscopic total extraperitoneal and transabdominal preperitoneal
hernia repair. Hernia. 2001Jul; 5(2)80-3.
10. Lucas SW, Arregui ME. Minimally invasive surgery for inguinal
hernia. World J Surg. 1999 Apr;23(4):350-5.
11. Speranzini M, Deutsch CR. Tratamento cirúrgico das hérnias
das regiões inguinal e crural: estado atual. Rio de Janeiro: Atheneu;2001.
12. Bittner R. Teaching laparoscopic hérnia repair (TAPP): learning courve of young trainees in a high volume center. Proceedings
from the American Hernia Society Annual Meeting. 2007; 144.
13. Reuben B, Neumayer L. surgical management of inguinal hernias. Adv Surg. 2006; 40:299-317.
14. Voyles CR. Impacto of randomized trials regarding endoscopic
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inguinal hérnia repair in the Netherlands. Surg Endosc. 2002 Mar;
16(3):547.
15. Cassar K, Munro A. surgical treatment of incisional hernia. Br J
Surg. 2002 May;89(5)534-45.
16. Millikan KW. Incisional hérnia repair. Surg Clin North Am.
2003 Oct;83(5):1223-34.
17. Yahchouchy-Chouillard E, Aura T, Picone O, Etienne JC, Fingerhut A. Incisional hernias. Related risk factors. Dig Surg. 2003;
20(1):3-9.
18. Bay-Nielsen M, Kehlet H, Strand L et al. Quality assessment
of 26304 herniorrhaphies in Denmark: a prospective nationwide
study. Lancet. 2001 Oct 6;358(9288):1124-8.
19. Kulah B, Duzgun AP, Moran M, Kulacoglu IH, Ozmen MM,
Coskun F. Emergency hernia repairs in elderly patients. Am J Surg.
2001 Nov; 182(5):455-9.
20. Sowula A, Groele H. [Treatment of incarcerated abdominal
hernia]. Wiad Lek 2003;56(1-2):40-4.
21. Berger D, Bientzle M, Müller A. Postoperative complications
after laparoscopic incisional hernia repair. Surg Endosc. 2002
Dec;16(12):1720-3.
22. Heniford BT, Park A, Ramshaw BJ, Voeller, G. Laparoscopic
repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg. 2003 Set; 238(3):391-400.
23. Koehler RH, Voeller G. Recurrences in laparoscopic incisional
hernia repairs: a personal series and review of the literature. JSLS.
1999 Oct-Dec;3(4):293-304.
24. Chari R, Chari V, Eisenstat M, Chung R. A case controlled
study of laparoscopic incisional hernia repair. Surg Endosc. 2000
Feb;14(2):117-9.
25. Carbajo MA, Martp del Olmo JC, Blanco JI, Toledano M, de la
Cuesta C, Ferreras C, Vaquero C. Laparoscopic approach to incisional hernia. Surg Endosc. 2003 Jan; 17(1):118-22.
26. Stoppa RE. The treatment of complicated groin and incisional
hernias. World J Surg. 1989 Set-Out;13(5):545-54.
27. White TJ, Santos MC, Thompson JS. Factors affecting wound
complications in repair of ventral hernias. Am Surg. 1998 Mar;
64(3):276-80.
28. McLanahan D, King LT, Weems C, Novotney M, Gibson K.
Retrorectus prosthetic mesh repair of midline abdominal hernia.
Am J Surg. 1997 May;173(5):445-9.
29. Bageacu S, Blanc P, Breton C, Gonzales M, Porcheron J, Chabert
M, Balique JG. Laparoscopic repair of incisional hernia: a retrospective study of 159 patients. Surg Endosc. 2002 Feb;16(2):345-8.
27
NOVA SESSÃO – ENTREVISTA COM O EXPERT
NEW SECTION – INTERVIEW WITH THE EXPERT
28
v. 2 n. 4
PROPHYLACTIC USE OF MESHES – STATE OF ART
USO PROFILÁTICO DAS TELAS – ESTADO ATUAL
Prof ‘. Jan Kukleta
Zurich University – Switzerland
1. One of the headlights nowadays in the hernia
field is the possibility to use preventive meshes in
particular patients in order to prevent future hernia defects. What do you think about it?
The idea of using a prophylactic mesh in order to
prevent a development of incisional hernia of a prophylactic mesh is quite an old one. The occurrence of
incisional hernias after an uncomplicated laparotomy
closure is a fact (5-20%). The incidence of incisional
hernia development in groups of patients “at risk” is
much higher (50% in e.g. morbidly obese). The strategy to decrease the occurrence comprises improvements in technical aspects of primary closure (running
vs. interrupted, absorbable vs. slow absorbable vs.
non-absorbable, 1:4 vs. 1:7, etc.) or in reinforcement
of the closure with a mesh. There is enough data today, which demonstrates the superiority of mesh reinforcement in patients with higher risk for incisional
hernia in terms of reduction of hernia occurrence.
The necessity of reinforcement is recognized, but there are still some doubts about the indication and fear
of overtreatment. The mesh related complications
(stiffness, foreign body feeling, infection, seroma-formation, chronic pain) and the effectiveness of mesh
reinforcement (additional operating time and cost) are
not sufficiently assessed to allow general recommendation of prophylactic mesh use in unselected patients.
(Not every patient at risk develops a hernia, not every
hernia requires an operation).
2. Which kind of patients have the best indications for this kind of treatment?
The risk factors are known, but not exactly validated.
Therefore the groups of patients at risk are not well
determined yet. Chronic lung disease, obesity, diabetes mellitus, collagen deficiency (like in patients with
AAA), or creation of an end- standing colostomy
are clear predispositions for an incisional or parastomal hernia. Patients with very thin abdominal wall,
smokers, anemia, chemotherapy, etc. suffer from development of an incisional hernia more often than a
comparable population.
Although there is not enough consensus about, who
v. 2 n. 4
are the patients at risk, there is a general understanding
in the surgical community that risk groups should be
determined and their laparatomy-closures should be
reinforced with a prophylactic mesh.
The ethical considerations (Primum nihil nocere) of
increased risk of infectious complications are justifiable, but not proven. Several randomized and some
comparative studies demonstrated significantly reduced incidence of incisional hernia without any significant differences in wound complication rates.
Based on published experience with mesh reinforcement in non-selected patients undergoing definitive
colostomy there is an evidence level 1 that prophylactic mesh has to be used (despite the relatively low number of randomized patients).
3. Which kind of mesh is the best indications and it
must to be located in which position in the abdominal
wall layers?
The meshes that show the least mesh-related complications today are macroporous structures made of polypropylene or monofilament polyester. Their shrinkage
rate is limited (dislocation, chronic pain), tendency to
bridging is very low (foreign body feeling, stiffness).
Megaporous meshes (pore size ≥ 1500µ) cause less seromas. Meshes for intraperitoneal use must have an
absorbable or permanent protective barrier in order
to reduce the extent of adhesions and to prevent late
intestinal complications. Due to not calculable risk of
potential morbidity and substantial additional cost of
mesh and its fixation intraperitoneal mesh in my opinion not appropriate for prophylactic use.
All three possible anatomic mesh positions within the
abdominal wall (epifascial, retromuscular sublay or
preperitoneal) and the intraperitoneal mesh placement
were investigated. Because the extraperitonealy placed
meshes have similar prophylactic effect in all three
positions, it seems to be most practical to place the
mesh epifascially for following reasons: least additional
operative time, least additional surgical damage to the
abdominal wall, least fixating effort in term of cost
and last, but not least in case of wound morbidity the
easiest way of treatment (open drainage, VAC).
29
Entrevista com o Expert
Jan Kukleta
4. Do you think biological meshes has a place in
such a procedures? Why?
Biologic emeshes in prophylaxis? No!
For several reasons: Cost - too expensive for prophylaxis. Nature – non-cross-linked (too early loss
30
of mechanical security), cross-linked (long-standing
inflammatory process, behavior like prosthetics until
complete transformation). Handling. (difficult fixation). The overall experience with this extremely heterogenic group is much too short to be applied in a
prophylactic intention.
v. 2 n. 4
Artigo Original
Skinovsky et al.
ANEXO – HIGH TECH SURGERY JOURNAL
APPENDIX – HIGH TECH SURGERY JOURNAL
v. 2 n. 4
31
SINGLE PORT LAPAROSCOPIC APPENDECTOMY BY USING
STRAIGHT INSTRUMENTS: A SAMPLE BEFORE A MULTICENTER RANDOMIZED CONTROL TRIAL
Mariano Palermo MD PhD FACS1, Guillermo E. Duza MD1, Enrique Buela MD2,
Pablo A. Acquafesca MD1, Luis A. Blanco MD1, Constanza Abdenur MD2, Hernan Ges MD2,
Carlos A. Zorraquin MD1, Francisco J. Tarsitano MD1
1
Department of General and Gastrointestinal Surgery. Hospital Nacional Profesor A. Posadas.
University of Buenos Aires. Argentina
2Department of Pediatric Surgery. Hospital Nacional Profesor A. Posadas.
University of Buenos Aires. Argentina
ABSTRACT
INTRODUCTION
Introduction: Acute appendicitis is the most frequent acute surgical condition with approximately
250,000 new cases per year in the United States. Since Semm published, in 1983, the first Laparoscopic
Appendectomy, surgeons have been trying to expand
the benefits of minimally invasive surgery, with less
wall trauma and better esthetic results. Material and
Methods: Between April 2012 and June 2013, 43 patients underwent a single port trans-umbilical laparoscopic appendectomy. Out of 43 patients (26 adults
and 17 children). In adults the mean age was 20.07
years old. The average body mass index (BMI) was
24 (range 21 – 28). In pediatric patients the mean age
was 11.7 years old (4 – 14). The technique used to
perform the single port trans-umbilical laparoscopic
appendectomy using regular straight laparoscopic instruments. Results: The 43 patients were admitted due
to right lower quadrant abdominal pain, pain, fever,
nauseas and/or vomits. One patient showed congestive appendicitis, 20 phlegmonous, 3 gangrenous, 1
gangrenous with localized peritonitis and 1 patient
presented and appendicular inflammatory mass. Out
of the pediatric population, 15 patients showed phlegmonous appendicitis and 2 gangrenous.Length
of the surgery, in adults 53.16 (Range 25 – 75). In
children was 44.56 minutes (20 - 90). Average of
admittance in adults was 1.65 days. In the pediatric
patients 2 days. The satisfaction mean was 9.5 (8 and
10). Conclusions: The single port technique is safe,
effective, replicable and offers all the advantages of
laparoscopic surgery and the esthetic results are better
when compared to a multiport conventional laparoscopic surgery. Keywords: Gastronomy. Laparoscopy.
Novel techniques.
Acute appendicitis (AA) is the most frequent acute
surgical condition with approximately 250,000 new
cases per year in the United States. Even though
appendicitis may present at any age, it is most frequent in the second decade of life (mean age 22 years
old) with a lifetime risk of 8.6% in males and 6.7%
in women1. Since it was first described by Claudius
Amyand in 1735, who successfully excised the first inflamed appendix, up to Charles Heber McBurney who
was able to accurately describe the point of maximum
tenderness in 1889 and later in 1894 the adequate incision to expose and excise the inflamed appendix, there
were no major changes regarding the surgical technique for this condition2. Since the time Semm published, in 1983, the first Laparoscopic Appendectomy3,
creating a controversy in the medical community until
it was universally accepted, surgeons have been trying
to expand the benefits of minimally invasive surgery,
with less wall trauma and better esthetic results, thus
giving rise to the technique of single port laparoscopic
surgery (SPLS).
The aim of this article is to describe a new technical approach of laparoscopic appendectomy by single
incision utilizing reusable straight instruments, with
no need for access devices nor specific laparoscopic
instruments, thus, drastically reducing costs without
compromising the benefits of the technique. And
communicate our initial experience in adult and pediatric patients.
32
MATERIAL AND METHODS
Between April 2012 and June 2013, 43 patients un-
v. 2 n. 4
Single Port Laparoscopic Appendectomy By Using Straight Instruments:
A Sample Before A Multicenter Randomized Control Trial
derwent a single port trans-umbilical laparoscopic
appendectomy. Out of 43 patients, 26 were adults and
17 children. 14 adults were female and 12 male. The
mean age was 20.07 years old with a range between
15 and 27. As for the surgical records, 2 patients underwent cesarean section and one pyloroplasty. The
average body mass index (BMI) was 24, with a range
between 21 and 28.
Out of the pediatric patients 7 were male and 10 were
female. The mean age was 11.7 years old with a range
between 4 and 14. This population did not show any
surgical history.
The technique used to perform the single port trans-umbilical laparoscopic appendectomy was by means
of a single incision at the umbilicus, in which a 10 mm
trocar and another one of 5 mm were inserted. The
abdomen was insufflated up to 12 mmHg. The reusable material utilized was: a 10 mm endo-camera of
30 degrees, a 5 mm grasper, a 5 mm hook and when
needed a 5 mm clip applier.
exploration of the cavity is carried out. The second 5
mm trocar is placed with a cephalad incision, in parallel to the 10mm trocar in the supra aponeurotic space
previously created (Figure 2). The appendix is located
and grasped (Figure 3).
Figure 2 – Introduction of portals
SURGICAL TECHNIQUE
The patient must be placed in a dorsal decubitus position, and the left arm must be preferably close to the
body.
The navel is grasped by two Allis clamps and is reflected. A transumbilical incision is made with a scalpel.
Then, the aponeurosis is dissected with a scissors creating a supra aponeurotic space cephalad and a second
5mm trocar is placed through the same skin incision
(Figure 1).
Figure 3 – Initial transumbilical incision
Figure 1 – Isolation of appendix
A 10 mm trocar is placed with the Hasson technique
and the abdomen is insuflated with CO2 (12 mmHg),
a 30 degree 10 mm endocamera is placed. Concentric
v. 2 n. 4
After this, a 16 or 14G catheter over needle (Abocath®) is placed in the right iliac fossa, and a suture
passed in order to create proper tension on the
appendix. The catheter over needle sheath (Abocath®) inserted in the cavity under direct visualization (Figure 4).
33
Anexo
Palermo et al.
Figure 4 – Closure of the base of the appendix
Figure 6 – Outside view
A 0 Prolene® suture is passed creating a snare
through the catheter. The appendix is passed inside and pulled towards the abdominal wall, thus
creating the tension and straightening necessary
for an adequate triangulation. A tip: during this
step change the placement of the catheter over
needle and Prolene® in order to always have proper
tension and visualization of the caecal and mesoappendix.
The meso-appendix is coagulated with a Hook
device, utilizing monopolar electrocautery. Also a
harmonic scalpel can be used. During this step it is
necessary to always have a 5mm clip applier available in case any bleeding may present during the
coagulation of the meso-appendix (Figure 5).
Figure 5 – Ressection of appendix
A sectioning of the appendix with scissors between ligations (Figure 7).
Figure 7 – Post-operative result
If necessary, irrigation and aspiration of the abdominal cavity. A specimen bag is placed through
a 10 mm trocar and the amputated caecal appendix
is grasped and inserted in the bag for its extraction.
The 10 mm trocar is removed. The aponeurosis
between both trocars is sectioned with an electronic scalpel. Removal of the surgical specimen
inside the bag (Figures 8a and 8b).
Figures 8a e 8b – Section and extraction of the apêndix
Ligation of the appendicular base and distal ligation with Vicryl® or Prolene® 0 external sutures/
knots positioned and descended with a Maryland
dissector (Figure 6).
34
A
v. 2 n. 4
B
Posterior closure of the aponeurosis and skin, reconstruction of the navel. Skin is closed with separated 3-0 Nylon sutures. The surgical scar
after surgery is observed once the umbilicus is closed.
RESULTS
The 43 patients (26 adult and 17 children) operated by
single port transumbilical laparoscopic appendectomy
were admitted due to right lower quadrant abdominal pain with 24 to 72 hours of symptoms, including
pain, fever, nauseas and or vomits. And appendicitis
was diagnosed. A single port transumbilical laparoscopic appendectomy was performed in all the cases. As
regards the intraoperative and anatomopathological
findings in the adult population was: 1 patient showed
congestive appendicitis, 20 phlegmonous, 3 gangrenous, 1 gangrenous with localized peritonitis and 1 patient presented and appendicular inflammatory mass.
Out of the pediatric population, 15 patients showed
phlegmonous appendicitis and 2 gangrenous without
peritonitis.
As for the length of the surgery, in adults the stated
mean in minutes was 53.16 with a range between 25
and 75 minutes. In children the average was 44.56 minutes, with a range between 20 and 90 minutes.
In reference to postoperative complications, 1 patient
presented fever at the first postoperative day relinquishing spontaneously on postoperative day number
3. One patient presented fever and abdominal distention during the first 3 postoperative days. An ultrasound showed fluid in the abdominal cavity, requiring
a re-laparoscopy with 3 ports, in which a cavity washing was needed.
The pediatric population did not present any outstanding complications.
For the pain assessment an analog scale was used (1
means no pain and 10 maximum pain). At 12 hour
time the average was 3.67 with a range between 3 and
v. 2 n. 4
8. Such scale was assessed once again at 24 hour time
and presented an average of 2.42 with a range between
1 and 8.
The average of admittance in adults was 1.65 days, excluding the re-operated patient by multiport laparoscopy and it was 1.85 days including that patient. 16
patients were discharged home on postoperative day
number 1, 6 patients on day number 2, 2 patients on
day number 3, 1 patient on day number 4 and the re-operated patient was discharged on day number 6. All
the pediatric patients were discharged on second postoperative day.
As regards the cosmesis satisfaction degree in adults,
scale from 1 to 10 was used, where 1 is non-satisfactory and 10 is very satisfactory. This variable was assessed a month after surgery. The satisfaction mean was
9.5 with a range between 8 and 10.
Results are equivalent to those of a conventional laparoscopic appendectomy with a much better esthetic
result. It should be noted that this technique is not applicable to complicated appendicitis with massive peritonitis or abscess. As seen in Figures 16 and 17 there
are practically no visible scars one month after surgery.
Nevertheless, more cases need to be reported internationally in order to draw conclusions regarding post-operative pain and costs. Therefore, it is still necessary to carry out RCTs (Randomized Controlled Trials)
comparing different minimally invasive appendectomies. Currently our group is carring out a multicenter
RCT comparing single port versus regular laparoscopic appendectomy.
DISCUSSION
The caecal appendix is a blind-ended intestinal loop
attached to the caecum, 3 to 4cm under the ileocecal valve4. It presents a mucosa, a continuum of the
colon epithelium, a submucosal layer with abundant
lymphoid follicles, a circular internal muscle layer,
the continuum of the muscular layer of the caecum
and a longitudinal external muscle layer formed by
the coalescence of the three teniae coli. The base of
the appendix is relatively fixed, the end usually moves
freely. Therefore, the position of the appendix varies.
In a traditional anatomical study of 10,000 patients,
the most frequent position was paracolic/retrocolic
with the appendix extending upwards (65% of cases)5.
Other positions of the appendix are: iliac fossa (31%),
35
Anexo
Palermo et al.
retrocecal fossa (2.5%) and in the peri-cecal and peri-ileal regions (1.5%)6,7. The meso-appendix is a continuum of the inferior layer of the small intestine and
passes behind the terminal ileum. The appendicular
artery, terminal branch of the superior mesenteric artery, runs near the free margin of the meso-appendix.
Luminal obstruction is the most widely accepted triggering factor for acute appendicitis. Causes may be
luminal, related to the wall or extraluminal. Among
the luminal causes we have fecalites, parasites, foreign
bodies and thickened barium6,8,9. Among the causes
involving the wall, hyperplasia of lymphoid follicles
and appendicular tumors. Finally, among the unusual
extraluminal causes are tumors and metastases.
The main factors in the development of acute appendicitis are endoluminal hypertension due to an increase
of mucus secretion, lack of elasticity of the appendiceal wall and exacerbated virulence of the microorganisms generally in the lumen9.
When the lumen is obstructed, the continuous secretion of the appendiceal mucosa produces the accumulation of mucus in the lumen. This, together with
the lack of elasticity of the appendiceal wall, increases
intraluminal pressure and the subsequent blockade of
the lymphatic drainage. The accumulation of mucus
and stasis of the appendiceal contents favors bacterial
proliferation. At this stage, the appendix presents mucosal ulcers and considerable wall edema (congestive
appendicitis).
If the process continues, the intraluminal pressure blocks venous drainage which produces more wall edema
and ischemia of the appendix (Phlegmonous appendicitis). On the other hand, bacterial invasion expands to
other layers.
Inflammatory progression leads to venous thrombosis
and involvement of the arterial flow. The antimesenteric border of the appendix, the area least irrigated,
produces an infraction (Gangrenous appendicitis). Finally, permanent secretion to viable portions of the
appendiceal mucosa increase intraluminal pressure
even further, perforating those infarcted areas (Perforated appendicitis).
Cultures of acute appendicitis are polymicrobial, with
a highly diverse mixture of colonic bacteria and prevalence of anaerobic bacteria over aerobic bacteria. An
average of 10 different microorganisms can be isolated per sample.
Clinical Presentation and Complementary Tests
Initially, patients present with sudden onset and diffu-
36
se abdominal pain, more pronounced in the epigastrium or periumbilical area. In general, pain presents as
colicky or continuous but of moderate intensity. Pain
is caused by appendiceal tenderness extending through
the solar plexus as genuine visceral pain. Frequently,
this initial painful condition is accompanied by nausea
which may, but not always, lead to vomiting. After a
variable period of time, generally three or four hours,
pain migrates to the iliac fossa as intense pain, caused
by irritation of the anterior wall of the peritoneum.
This sequence is known as Murphy´s sequence and is
reported in only 50 to 60% of patients with appendicitis.
Typical signs of acute appendicitis are pain upon palpation and decompression and tensing of the muscles
over the right iliac fossa. Upon palpation, the maximum tenderness point is located at 3.5-5cm of the anterosuperior iliac spine, over an imaginary line to the
navel (Mc Burney sign). Pain upon decompression is
caused when releasing the hand suddenly, after a deep
and sustained palpation at the McBurney point (Blumberg sign).
Vital signs practically do not change in an acute non-complicated appendicitis. Body temperature may increase by 1 or 2 degrees; nevertheless fever above 38°C
is uncommon. On the other hand, even in an advanced
appendicitis, temperature may be normal. Heart rate
is normal or may be slightly elevated. Approximately
70% of patients with appendicitis present leukocytosis
above 10,000/mm3 and a slight left shift.
Doria et al. carried out a metanalysis of the studies
published between 1986 and 2004 to assess the accuracy of CT scan and Ultrasound. CT scan presented
an accrued sensitivity and specificity of 94 and 95%,
respectively, in children, 94 and 94%, respectively, in
adults. Ultrasound presented an accrued sensitivity and
specificity of 88 and 94%, respectively in children and
83 and 93%, respectively in adults.
The swollen appendix is seen in a CT scan as an enlarged tubular structure of the caecal end sometimes
accompanied by inflammatory trabeculations in the
surrounding fatty tissue. Most of the modern CT units
identify the appendix. It is necessary to examine the
entire appendix, from its attachment to the caecum up
to the tip and report its maximum transversal diameter.
Traditionally, a maximum diameter of 6 mm has been
established for the diagnosis of appendicitis10,11.
The appendix appears in an ultrasound as an enlarged
blind-ended structure with intestinal layers. Contrary
v. 2 n. 4
to the normal intestine, the swollen appendix is fixed,
incompressible with a round morphology in the cross
sectional view. Measurements of the appendix are carried out with full compression. Traditionally, the diagnosis of appendicitis is made when the diameter of the
compressed appendix exceeds 6 mm12,13.
Complications are similar to those reported in conventional appendectomies even though there are no series
to confirm this. Following, there is a list of the most
frequent post-laparoscopic appendectomy complications. Bleeding, abdominal collection, infection of the
surgical scar, wall hematoma (as with this technique
the approach is through the aponeurotic area without
muscle, this complication is not frequent), herniation
at the trocar entry site, lesion at trocar entry site (as
with this technique the entry to the abdominal cavity
is systematically open this problem decreases considerably). In case any of these complications should arise,
a minimally invasive approach must be the first choice14,16,17.
Single port laparoscopic surgery has been successfully
applied to conditions such as appendectomy, cholecystectomy, splenectomy, antireflux operations, bariatric
surgery, spleen surgery and adrenalectomy in the adult
and pediatric population15,18.
Most of the reported series are still small, single-surgeon experiences, and long-term results are yet to be validated. One important benefit of single port transumbilical laparoscopic surgery is the superior cosmesis
with no visible scarring15,19,20. In the current era where
a high premium is placed on cosmesis, it is likely that
this technology will see an increased demand.
The single port technique, while having a steep learning curve, can be performed with adequate mentoring and preparation on the part of the trainee. Surgical training programs should take the lead in ensuring
that new technology is safely and effectively taught to
the new generation of trainees15.
In our series, residents and fellows helped by young
laparoscopic surgeons, proficient in multiport laparoscopic appendectomy had a short learning curve
to perform a single port transumbilical laparoscopic
appendectomy without usign any device and by using
regular straight laparoscopic instruments. The 30°
cameras, energy source (monopolar electrocautery),
meso-appendix dissection technique, and endoloop
ligation of the appendix stump were exactly the same
as the technique used in the conventional multiport laparoscopic appendectomy procedures15.
v. 2 n. 4
The electrocautery dissection of the meso-appendix
and endoloop ligation of the stump increases the duration of the single port appendectomy as compared
to studies that use endoscopic staplers, but when using
staplers the costs increases.
Some studies have noted a higher incidence of umbilical wound infections with this procedure, not in our
initial experience15.
This is presumed to be secondary to the radial pressure
on the surrounding tissues from manipulation of the
instruments through a narrow working channel. We
avoid this complication by using specimen bags to remove the appendix in all the cases15,21.
Novel teaching methods need to be developed to facilitate resident learning in this era where great importance is accorded to work-hour restriction, ethics,
patient safety concerns, and surgical department economics15,22,23. Imparting single port laparoscopic surgery skills may require the development of simulation
technology to reinforce such skills.
In our initial experience, single port laparoscopic surgery appears to be promising for the treatment of acute appendicitis. The technique can be imparted satisfactorily to general surgery residents without advanced
laparoscopic skills.
CONCLUSIONS
Considering the aforementioned, this technique is safe,
effective, replicable and offers all the advantages of any
laparoscopic surgery. But, the esthetic results are better
when compared to a multiport conventional laparoscopic surgery. Besides it has similar complication rates to
standard laparoscopic surgery.
Therefore, we believe it is very important that all general
surgeons, especially residents and young surgeons fully
acquire all the knowledge referred to these new minimally invasive techniques.
With the future results of the multicenter RCT that our
group is leading , we will be able to have stronger level 1
evidence in order to compare this new techniques with
the conventional ones.
REFERENCES
1. Addiss DG, Shaffer N, Fowler BS, et al. Epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol.
1990 Nov;132(5):910-25.
2. McBurney C. The incision made in the abdominal wall in cases
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of appendicitis, with a description of a new method of operating.
Ann Surg. 1894:20(1):38-43.
3. Semm K. Endoscopic appendectomy. Endoscopy. 1983
Mar;15(2):59-64.
4. Jaffe BM, Berger DH. The appendix. In: Brunicardi FCB, Andersen DK, Billiar TR, et al, editors. Schwartz’s principles of surgery. 8th edition. New York: McGraw-Hill; 2005. p. 1119-37.
5. Korner H, Sondenna K, Soreide JA, Andersen E, Nysted A,
Lende TH, Kjellevold KH: Incidence of acute nonperforated
and perforated appendicitis: age-specific and sex-specific analysis.
World J Surg. 1997 Mar-Apr;21(3):313-7.
6. York D, Smith A, Phillips JD, et al. The influence of advanced
radiographic imaging on the treatment of pediatric appendicitis. J
Pediatr Surg. 2005 Dec;40(12):1908-11.
7. Wakeley CPG. Position of the vermiform appendix as ascertained by analysis of 10,000 cases. J Anat. Jan 1933; 67(pt 2): 277-283.
8. Ferraina P, Oría A. Cirugía de Michans. 5ta ed. Buenos Aires: El
Ateneo; 2003; 806-815.
9. Bennion RS, Baron EJ, Thompson JE Jr, Downes J, Summanen
P, Talan DA, Finegold SM. The bacteriology of gangrenous and
perforated appendicitis: revisited. Ann Surg. 1990 Feb;211(2):16571.
10. Silen W. Acute appendicitis and peritonitis. In: Kasper DL,
Braunwald E, Fauci AS, et al, editors. Harrison’s principles of internal medicine. 16th edition. New York: McGraw-Hill; 2005. p.
1805-8.
11. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for
diagnosis of appendicitis in children and adults? A meta-analysis.
Radiology. 2006 Oct;241(1):83-94.
12. Ege G, Akman H, Sahin A, et al. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis.
Br J Radiol. 2002 Sep;75(897):721-5.
13. Jeffrey RB, Laing FC, Townsend MD. Acute appendicitis: sonographic criteria based on 250 cases. Radiology. 1988
May;167(2):327-9.
14. Palermo Mariano, Giménez Mariano, Gagner Michel. Laparoscopic gastrointestinal surgery: novel techniques, extending the
limits. AMOLCA Editorial. In Press.
15. Sathyaprasad C. Burjonrappa, Hrishikesh Nerkar, Teaching
Single-Incision Laparoscopic Appendectomy in Pediatric Patients.
JSLS. 2012 Oct-Dec; 16(4): 619-622.
38
16. Dapri G, Casali L, Bruyns J, Himpens J, Cadiere GB. Single-access laparoscopic surgery using new curved reusable instruments:
initial hundred patients. Surg Technol Int. 2010 Oct;20:21-35.
17. Gao J, Li P, Li Q, Tang D, Wang DR. Comparison between
single-incision and conventional three-port laparoscopic appendectomy: a meta-analysis from eight RCTs. Int J Colorectal Dis.
2013 Oct;28(10):1319-27.
18. Uday SK, Bhargav PR. SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases. J Minim Access Surg. 2013 Apr;9(2):76-9.
19. Pisanu A, Porceddu G, Reccia I, Saba A, Uccheddu A. Meta-analysis of studies comparing single-incision laparoscopic appendectomy and conventional multiport laparoscopic appendectomy.
J Surg Res. 2013 Aug;183(2):e49-59.
20. Frutos MD, Abrisqueta J, Lujan J, Abellan I, Parrilla P. Randomized prospective study to compare laparoscopic appendectomy
versus umbilical single-incision appendectomy. Ann Surg. 2013
Mar;257(3):413-8.
21. Perez EA, Piper H, Burkhalter LS, Fischer AC. Single-incision
laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surg Endosc. 2013 Apr;27(4):1367-71.
22. Rehman H, Mathews T, Ahmed I. A review of minimally invasive single-port/incision laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012 Sep;22(7):641-6.
23. Gill RS, Shi X, Al-Adra DP, Birch DW, Karmali S. Single-incision appendectomy is comparable to conventional laparoscopic
appendectomy: a systematic review and pooled analysis. Surg Laparosc Endosc Percutan Tech. 2012 Aug;22(4):319-27.
B
“Drs. Mariano Palermo, Mario Luis Domínguez, Pablo
Acquafresca, Guillermo Duza and Mariano Gimenez have no
conflicts of interest or financial ties to disclose.”
C
Correspondence:
Dr. Mariano Palermo.
Av. Pte. Perón 10298 Ituzaingo (CP 1714),
Buenos Aires, Argentina.
Tel: 5411-44819995. e-mail: [email protected]
v. 2 n. 4
Single Port Laparoscopic Gastrostomy
A new minimally invasive approach for enteral feeding
Authors: Mariano Palermo, Mario Luis Domínguez, Pablo Acquafresca, Guillermo Duza, Mariano Giménez.
Department of Gastrointestinal Surgery.
Hospital de Clinicas “Jose de San Martin” University of Buenos Aires. Argentina.
Abstract
Introduction: Since the first classic descriptions of
surgical gastrostomies for feeding by supraumbilical
medial incisions, patients were operated under general
anesthesia, with prolonged time of surgery, these were
patients in poor health status, undernourished due to
inadequate intake or to neurological or tumor involvement, with prolonged hospitalization, both for the recovery of the intestinal motility as well as for the recovery of post-surgical wounds. Material and Methods:
Between July 2012 and December 2012, 5 patients underwent a single port laparoscopic gastrostomy. Three
were females and 2 males. The range of age was from
53 to 87 y/o with a mean age of 74. Results: The mean
time of the procedure was 50 minutes. Four patients
underwent glucose intake tolerance test after 12 hours
and one 24 hours later. Enteral feeding was indicated
after the glucose intake tolerance. No complications related with the procedure were observed. Discussion:
Nowadays, the gold standard technique to perform a
gastrostomy is the percutaneous approach. In patients
with head and neck disorders when is not possible to insert a nasogastric tube to insuflate the stomach, a laparoscopic gastrostomy would be indicated. We describe
a new technique, step by step, to perform less invasive
laparoscopic surgery by a single port laparoscopic gastrostomy. Conclusion: The lumen created is the same
than with open techniques but with a minimally invasive
approach, that allows to start feeding earlier providing
high quality feeding. Keywords: Gastrostomy. laparoscopy. Novel techniques.
Introduction
In the XVIII century, John Hunter described for the
first time the use of a gastric feeding tube, later, Physick used to carry out a gastric lavage, later on, Sedillot
in France, during the middle of the XIX century, desv. 2 n. 4
cribed the first surgical gastrostomy.
The first description of a technique to minimize the
transparietal access for gastrostomies was by Harry
Fenwick on the September 18th 1884 and published
in the Annals of Surgery. (1, 14).
The gold standard technique to perform a gastrostomy is the percutaneous approach (9,4,5). In patients
with head and neck disorders when is not possible to
insert a nasogastric tube to insuflate the stomach, a
single port laparoscopic gastrostomy would be indicated (17).
Material and Methods
Between July 2012 and December 2012, 5 patients underwent a single port laparoscopic gastrostomy. Three
were females and 2 males. The range of age was from
53 to 87 y/o with a mean age of 74. All the patients
had head and neck tumors with no posibility to get
access to the stomach through a nasogastric tube. Reason why a percutaneous or endoscopic gastrostomy
couldn’t be performed.
In patients with head and neck tumors, head and neck
trauma or any other disorder which don’t allows the
surgeon to pass through the esophagus and reach the
stomach to insulate it and perform a percutaneous gastrostomy (gold standard).
Necessary Material
A laparoscopic scope with working cannel, a 10 or 12
mm trocar, light source, optic fiber, pneumoperitoneum insuflator and a grasper.
Surgical Technique
The patient is placed in dorsal decubitus.
Asepsis and antisepsis are carried out from the inter
mamillary line to the pubis. It is necessary to have the
possibility of doing the case both laparoscopically or
open. Sterile drapes are placed.
An incision is made, two finger´s breadth under the
39
Palermo et al.
Anexo
costal border (9th rib), from the left transrectus and as
close as possible to Spiegel´s semilunar line (external
attachment of rectus sheath). It must be sufficient for
a 10 mm trocar. (Figures1,2).
Figure 3 – Carbon dioxide insufflation
Figure 1 – Incision made two finger´s breadth under the costal border
Figure 2 – Incision made two finger´s breadth under the costal border
A 30 degree scope is inserted (Figure 4).
Figure 4 – A 30 degree scope is inserted
The abdominal cavity in entered with open technique,
opening the anterior rectus aponeurotic sheath, blunt
dissection of the rectus abdominus, avoiding injury of
the anterior intercostal nerves, opening the posterior
aspect of the rectus sheath , dissecting the pre-peritoneal fat and opening the peritoneum .
Then the instruments are inserted in parallel to the 10
mm trocar (Figure 5).
Figure 5 – The instruments are inserted in parallel to the 10 mm trocar
Placement of a 10 mm trocar, carbon dioxide insufflation at 12 mm hg pressure or less and 20 ml flow.
(Figure 3).
40
v. 2 n. 4
The left quadrant is inspected visualizing the left liver
lobe, the distal esophagus, stomach and left colon under the subphrenic space.
A “grasper” is placed through the optics working cannel, mobilizing the anterior aspect of the stomach, by
checking its mobility we choose the segment with the
necessary mobility to avoid injury to the gastric vasculature by tension when pulling towards the abdominal
wall. (Figure 6).
the area where the foramen of the future ostomy will
be created. The stomach is incised, plane by plane,
checking its lumen, a Pezzer -type probe is placed under the lumen of the stomach, the mucosal layer is closed with pursestring sutures and the seromuscular wall
excess of the stomach is fixated to the cutaneous layer
(Figure 8).
Figure 8 – The seromuscular layer of the stomach is fixated with landmark sutures to the aponeurosis of the rectus abdominus
Figure 6 – Checking the mobility of the anterior stomach wall - external view
When exteriorizing the gastric segment, the pneumoperitoneum is lost and mobility and lack of tension are
verified with a Foerster clamp. (Figure 7).
Figure 7 – When exteriorizing the gastric segment, the pneumoperitoneum is lost
and mobility and lack of tension are verified with a Foerster clamp
Dextrose is instilled in a Boneau syringe, through a Pezzer tube and “clamped” to check passage of the fluid
to the duodenum, absence of leaks and reflux when
unclamping.
A Pezzer tube is fixated to the skin and cutaneous closure with non-continuous sutures, according to the
orifice needed for the probe diameter (Figure 9).
Figure 9 – A Pezzer tube is fixated to the skin
The seromuscular layer of the stomach is fixated with
landmark sutures to the aponeurosis of the rectus abdominus then, pursestring sutures are applied around
v. 2 n. 4
A glucose intake tolerance test is carried out after 12
hours, and enteral feeding is checked.
41
Anexo
Palermo et al.
Results
The procedure was performed in all the patients with
no technical complications. The mean time of the procedure was 50 minutes. In 4 patients glucose intake tolerance test was carried out after 12 hours and in one
24 hours later. Enteral feeding was indicated in all the
cases immediately after the glucose intake tolerance.
No complications related with the procedure were observed.
A high quality of feeding was significantly faster when
comparing when others techniques, because the thickness of the tube is bigger in the single port laparoscopic gastrostomy.
Discussion
Since, many variants have been described to place a
tube in the lumen of the digestive tract for decompressing or feeding purposes (2).
They can be classified as follows in table 1:
TABLE 1: Gastrostomies classification.
Since the first classic descriptions of surgical gastrostomies for feeding or decompression purposes by supraumbilical medial incisions, patients were operated
under general anesthesia, with prolonged time of surgery, these were patients in poor health status, undernourished due to inadequate intake or to neurological
or tumor involvement, with prolonged hospitalization,
both for the recovery of the intestinal motility as well
as for the recovery of post-surgical wounds (15, 16).
The issues of total recovery time to allow the patient
an earlier return to normal activities, of the complications due to the procedure and the economic cost have
urged to find a better surgical option to create new
techniques to maintain feeding continuity in this group
of patients, with unmet basic caloric requirements and
no parenteral alternative.
The technique to introduce a tube orally, to insuflate
the stomach and exteriorize it to construct a definite ostomy, as described by Hendrick, has evolved in
time: radiology contributed with a new device with the
introduction of the Seldinger technique for percutaneous gastrostomies improving surgery time, type of
anesthesia, less invasion of the abdominal wall and abdominal organs, improving hospitalization stay and recovery, both inside and outside the hospital, reducing
costs and constituting a simpler approach to be learnt
and practiced by the community of surgeons (7,8, 10,
42
11). The new techniques are not exempt of morbidity
and mortality, but are significantly reduced.
The introduction of laparoscopy as a new technique
was a turning point, as it allowed to explore the abdomen and operate with trocars, with the same advantages of minimally invasive techniques: it allowed to
insuflate the stomach and displace it from the surgical field away from the abdominal wall to the colon,
for this has been the cause of some complications in
radiologically-guided percutaneous procedures. In this
way, with the use of five trocars, which eventually became three, and of pneumoperitoneum and optic fiber, the surgical technique improved (3,6). The advantage of the technique is that there is no need to pass
through the aerodigestive tract to reach the stomach,
since it is approached from the abdomen with direct
visualization of the intra-abdominal organs.
An endoscopic gastrostomy is another possibility to
reduce the number of incisions and use of pneumoperitoneum. (12, 13, 16). As this procedure requires patent passage to the stomach and uncontrolled gastrostomy fixation to the abdominal wall with no possibility
to visualize interposing structures, it was necessary to
devise hybrid laparoscopic endoscopies to minimize
the number of ports utilized.
Under these circumstances, it was necessary to be very
selective on the segment chosen for the ostomy which
would allow a faster recovery after the gastrostomy in
patients unable to progress through the upper digestive tract. Therefore, adhesions had to be minimized
considering future intra-abdominal procedures, with
the advantages of minimally invasive procedures such
as less post-operative pain and faster recovery, thus
enabling earlier feeding. Following all these parameters a single incision is done placing the trocar in a
single working channel, under laparoscopic standards, with direct visualization, minimum pneumoperitoneum and completing the technique with a gastric
fixation and ostomy from outside of the abdominal
wall.
In the surgical armamentarium there are open, endoscopic, laparoscopic, percutaneous and combined
procedures, but when considering minimally invasive
procedures for shorter surgeries, there are patients
who are unable to pass the esophagus and unable to
undergo endoscopic or percutaneous procedures, but
who need a rapid intervention with less abdominal
involvement, in them open procedures are ruled out.
The technique we herein introduce came about when
thinking on the need to have a laparoscopic technique,
v. 2 n. 4
with three trocars and shorter surgeries of approximately one hour and pneumoperitoneum.
Based on this information, we designed this procedure tailored to the patient´s needs according to the
pathology, with a single left pararectus incision and
placement of a single trocar and optics with working
channel, with full vision to explore the abdominal cavity and look for metastases and eventually take selected biopsies under direct visualization of the gastric
segment in which the gastrostomy shall be created. It
is necessary to control the pressure on the abdominal
wall by the final positioning and abdominal pneumoperitoneum time (approximately 15 minutes), gastric
control during wall fixation and confirming that only
one aspect of the stomach has been utilized for the
gastrostomy considering future surgeries. Costs are
low, specially hospitalization costs and rapid recovery
from mini-invasive procedures, with minimal procedure related functional digestive disruption.
Conclusions
The main advantage of this technique is that feeding
of the patient starts with the adequate lumen, something not achieved up front with other minimally invasive techniques. The lumen created is the same than
with open techniques but with a minimally invasive
approach. Therefore, the single incision laparoscopy
prevents injury to the abdominal wall, with all the advantages of laparoscopic surgery, but, allows to start
feeding earlier with a large lumen ostomy, providing
high quality feeding without waiting months to achieve
this lumen, as is the case with the other techniques.
REFERENCES
“Drs. Mariano Palermo, Mario Luis Domínguez, Pablo
Acquafresca, Guillermo Duza and Mariano Gimenez have no
conflicts of interest or financial ties to disclose.”
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2. ASPEN Board of Directors and the Clinical Guidelines Task
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8. Foutch PG, Talbert GA, Gaines JA, Sanowski RA. The gastrostomy button: A prospective assessment of safety, success, and spectrum of use. Gastrointest Endosc. 1989 Jan-Feb;35(1):41-4.
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Pedro A. Gastrostomía percutánea: variantes técnicas. Rev Argent
Cir. 1999 Mar;76(3/4):106-12.
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with the Seldinguer technique: review of 252 patients. Radiology
1989;171:359-362.
11. Lee MJ, Saini S, Brink JA, Morrison MC, Hahn PF, Mueller PR.
Malignant small bowel obstruction and ascites: not a contraindication to percutaneous gastrostomy. Clin Radiol. 1991 Nov;44(5):3324.
12. Russell T, Brotman M, Norris F. Percutaneous gastrostomy.
A new simplified and cost-effective technique. Am J Surg. 1984
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Moyers P, Casola G. CT guidance for percutaneous gastrostomy and
gastroenterostomy. Radiology. 1992 Jul;184(1):201-5.
14. Stamm M. Gastrostomy: a new method. Med News. 1894;65:324.
15. Vitcopp G, Fernández Marty AP. Vías de alimentación enteral
por cirugía mini-invasiva. Actualización en Nutrición. 2004;5(4):1723.
16. Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale
A. Radiologic, endoscopic and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology. 1995
Dec;197(3):699-704
17. Palermo M, Gimenez M, Gagner M. Laparoscopic Gastrointestinal Surgery. Novel techniques, extending the limits. AMOLCA
Editorial. In Press.
Correspondence:
Dr. Mariano Palermo.
Av. Pte. Perón 10298 Ituzaingo (CP 1714),
Buenos Aires, Argentina.
Tel: 5411-44819995. e-mail: [email protected]
43
44
v. 2 n. 4
Fixação Segura em Qualquer
FIXAÇÃO SEGURA EM QUALQUER ÂNGULO
Ângulo
para o Reparo
PARA O REPARO LAPAROSCÓPICO DA HÉRNIA
Laparoscópico da Hérnia
ângulos.
• Segurança nos disparos em diferentes
Dispositivo
de Fixação com Grampos Absorvíveis.
• Design diferenciado com 2 pontos de fixação.
• Segurança
nosproporcionando
disparos em diferentes
ângulos.
homogênea,
mais confiança.
• Grampos implantados com força
• Design diferenciado com 2 pontos de fixação.
• Indicador de carga.
• Grampos implantados com força homogênea,
visualização na cavidade abdominal.
• Grampos na cor violeta para adequada
proporcionando mais confiança.
material
• Perfil do grampo baixo, reduzindo
• Indicador deexposto
carga. as vísceras.
PHYSIOMESH®
e ULTRAPRO®.
• Combinação perfeita com ETHICON
• Grampos na cor violeta
para adequada visualização
Indicações: Reforço. Indicações: O dispositivo de ixação absorvível ETHICON SECURESTRAP® - destina-se à ixação de material protésico a
tecidos
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seu representante
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maiores. Tal inclui a colocação de fechos no diafragma na vizinhança do pericárdio, aorta ou veia cava inferior durante a reparação de
hérnias diafragmáticas. Se a distância total entre a superfície do tecido e a estrutura subjacente for inferior à espessura tecidular mínima
ou
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Indicações:
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Estetotal
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e otecidos
osso, vasos
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mm. Ler todas
as no
utilizado
que apresentem
uma relaçãodeve
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com estruturas
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Tal inclui
a colocação
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instruções,
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e advertências
antes
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diafragma na
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do pericárdio, aorta
ou veia cava
inferior
durante a reparação de hérnias diafragmáticas. Se a distância total entre a
superfície do tecido e a estrutura subjacente for inferior à espessura tecidular mínima ou se puder estar incluída numa distância total inferior
v. 2 n. 4
©
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e Comércio
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Saúde Ltda., 2014.
Johnson & Johnson
Medical Brasil,
uma divisão
de Johnson
à espessura
tecidulardomínima,
a utilização
do dispositivo
está
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Advertências:
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é fornecido
estéril
e destina-se
& Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda. Rua Gerivatiba, 207 - São Paulo, SP • CEP 05501-900 Responsável técnico:
exclusivamente a ser usado num único paciente. Descartar depois de utilizar. A reutilização ou reprocessamento deste dispositivo irá conduzir
Nancy Mesas do Rio - CRF-SP nº 10.965 - SECURESTRAP - Registro ANVISA nº 80145901386 - PHYSIOMESH - Registro ANVISA nº 80145901373 a um desempenho
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na cavidade abdominal.
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