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v. 3 n. 8
AWRJ - Abdominal Wall Repair Journal
1
O que você
espera em um
reparo de
Hérnia Ventral
Videolaparoscópica?
Acesso com mínimo trauma.
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Endopatch XCEL®
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Ethicon® Securestrap
Visite nosso site: Ethicon.com
Referências: 1. Yap, H. & Cardinale, M. Tack comparison surface area CAD, Ethicon internal document, CAD drawings ORN-50-3090 The Lineup, Rev 13. 2. Cardinale, M. et al.
Comparison of acute holding strength of an absorbable strap fixation device in porcine flank at various implantation angles, Ethicon Internal Document. 3. Shnoda, P.
28-day mesh fixation study of the Orion device to evaluate mesh migration and tissue response using a swine model, Ethicon internal document, Study Report PSE accession
Nº. 09-0132.
2
© Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda., 2015. Johnson & Johnson Medical Brasil, uma divisão de Johnson & Johnson do Brasil
Indústria e Comércio de Produtos para Saúde Ltda. - Rua Gerivatiba, 207 - São Paulo, SP • CEP 05501-900 - Responsável técnico: Nancy Mesas do Rio - CRF-SP nº 10.965
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v. 3 n. 8
Impresso em Março/2015 - Válido de Março/15 a Março/17 - BRMRETH5462.
Volume 3 Número 8
Abril 2015 / Julho 2015
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:
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)
v. 3 n. 8
1
Copyright© 2015 by LapSurg
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LapSurg International Institute of Endoscopic Surgery
Produção: Primax Edições
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Editoração Eletrônica: Erik Ferreira
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DadosInternacionais
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Dados
naPublicação
Publicação(CIP)
(CIP)
AWRJ –– Abdominal Wall Repair Journal [recurso eletrônico] /
AWRJ
LapSurg International
International Institute
Institute of
of Endoscopic
Endoscopic Surgery.
Surgery. –– Ano 1,
3, n.1
n.8
LapSurg
(abr. 2015/jul.
Curitiba
: Lap
Surg International
Institute
(dez.
2012/mar.2015)2013)- .―.―
Curitiba
: LapSurg
International
of Endoscopic
Surgery,Surgery,
2015- 2013.
Institute
of Endoscopic
.
Quadrimestral.
Quadrimestral.
Modo
Modo de
de acesso:
acesso: <http://www.lapsurg.com.br/front/awrj/index>
<http://www.lapsurg.com.br/front/awrj/index>
ISSN 2317-5982
1. Hérnia – Periódicos. 2. Hérnia – Cirurgia. 3. Hérnia –
Tratamento.
I. Título.
1. Hérnia
– Periódicos. 2. Hérnia – Cirurgia. 3. Hérnia –
Tratamento. I. Título.
CDD 617.557
CDU 616.34-007.43
CDD 617.557
CDU 616.34-007.43
2
v. 3 n. 8
sumário • Summary
Conselho Editorial ........................................................................................................... 01
Editorial ............................................................................................................................. 04
Artigos Originais - Original Articles
• Impact of Smoking on Ventral Hernia Repair: Analysis of Nsqip.......................... 07
Impacto do tabagismo sobre correção de hérnia ventral: Análise da NSQIP
Ciara R. Huntington, Samuel W. Ross, Laurel Blair, Tanushree Prasad, Amy E. Lincourt,
Ronald F. Sing, B. Todd Heniford, Vedra A. Augenstein
• Extraperitoneal Space: Right Access For Endoscopic Hérnia Repair?..................... 17
Espaço extraperitoneal: Acesso correto para o reparo herniário endoscópico?
Leandro Totti Cavazzola, Miguel Prestes Nácul, José Gustavo Olijnyk, João Vicente Machado Grossi
Relatos de Casos - Cases Reports
• Garangeot’s Hernia: A Case Report .............................................................................. 27
Hérnia Garangeot’s: Relato de caso
James Skinovsky, Flávio Panegalli Filho, Fernanda Keiko Tsumanuma,
Rômulo Augusto Andrade de Almeida, Alinne Vandramin
Anexo High Tech Surgery - Appendix High Tech Surgery
• Incidence of Gallbladder Stones after Bariatric Surgery............................................... 31
Incidência de cálculos da Vesícula Biliar após Cirurgia Bariátrica
Ibarra Eliana, Pascowsky Maria, Souza Juan Manuel, Vega Emiliano, Pilar Quevedo,
Marianela Aguirre Ackerman, Guillermo Duza, Edgardo Serra, Mariano Palermo
• Eventos Tromboembólicos em Pacientes Submetidos à Cirurgia Abdominal
a Céu Aberto e Cirurgias Videolaparoscópicas.............................................................. 35
Thromboembolic events in patients submitted open abdominal
surgery and laparoscopic abdominal surgery
James Skinovsky, Cristina Okamoto, Joseph Chenisz, Daniel Lacerda,
Augusto Mozzaquatro, Stephan Saab, João Paulo Bacarin
Artigo de Revisão High Tech Surgery - Review Article High Tech Surgery
• Videocirurgia: De Onde Viemos e Para Onde Vamos?.............................................. 41
Videosurgery: Where we come and where are we going?
James Skinovsky, Sérgio Roll
v. 3 n. 8
3
EDITORIAL
CIRUGÍA LAPAROSCÓPICA POR PUERTO ÚNICA Y MINI-LAPAROSCOPÍA
Desde el advenimiento de la cirugía laparoscópica, tanto los avances
técnicos como de la industria han permitido que esta sea cada vez menos invasiva. En la búsqueda de menor trauma parietal se desarrollaron
ciertas técnicas como la cirugía acuscópica, NOTES y cirugía laparoscópica por puerto único. La cirugía acuscópica desarrollada en los años
noventa, siendo Michel Gagner quien la ha descripto, a caído en desuso dado que el instrumental utilizado no presentaba la rigidez suficiente
para poder realizar los procedimientos resectivos con adecuada tensión
en forma segura, siendo la tensión y triangulación la clave en la cirugía
laparoscópica. La cirugía por orificios naturales (NOTES) desarrollada
por Kaloo tuvo su auge alrededor del año 2006 para luego caer en desuso
por sus dificultades técnicas y baja aceptación de los pacientes, no pudiéndose convertir en una técnica standart. Esta ultima técnica a quedado
restringida para pacientes muy seleccionados dando paso al desarrollo
de la cirugía laparoscópica por puerto único. Por lo tanto si hay alguna
virtud que nos ha dejado el NOTES, es favorecer el desarrollo del puerto
único. La cirugía por puerto único utiliza el ombligo como cicatriz natural para el acceso a la cavidad abdominal. Esta permite la realización de
diversos procedimientos no dejando prácticamente cicatriz, con lo cual la
agresión a la pared abdominal es mínima siendo sus potenciales beneficios un mejor resultado cosmético, menor dolor postoperatorio y mayor
confort general del paciente. Para estas dos ultimas variables se siguen
aguardando ensayos clínicos controlados aleatorizados. Las desventajas
de esta técnica serian la disminución de la triangulación. También ofrece
dificultades para la retracción de órganos y choque de instrumentos dado
que los mismos ingresan muy próximos entre sí. Numerosas alternativas
surgen para sortear estas dificultades como ser, la utilización de diferentes plataformas de acceso, instrumental curvo y/o articulado, y también
la colocación de puntos externos para lograra una adecuada retracción
de los órganos. Es así como se ha logrado desarrollar instrumental mini-laparoscópico fabricado con la misma rigidez que los instrumentos laparoscópicos convencionales lo cual permite la realización de diferentes
procedimientos resectivos abdominales con mínima invasión parietal utilizando puertos de 2,7 a 2,9 mm. Esto permite la misma maniobrabilidad
y triangulación de la laparoscopía convencional con la ventaja de menores
incisiones y menor trauma parietal.
Patologías pasibles de ser realizadas por estas técnicas son: apendicitis, litiasis vesicular y colecistitis, patología de pared abdominal, cirugía
colónica, bariátrica y de otros órganos solidos.
Por lo tanto creo que tanto la cirugía laparoscópica por puerto único como la mini-laparoscopia son dos opciones mini-invasivas, que presentan similares resultados en cuanto a las complicaciones cuando se la
compara con la cirugía laparoscópica multi-puerto, pero con un plus muy
4
v. 3 n. 8
EDITORIAL
grande como ser un mejor resultado cosmético por un menor trauma
parietal, llevando esto a tener un grado de satisfacción muy elevado de
los pacientes
Dr. Mariano Palermo
MAAC, FACS, (Hon)SCGP, (Hon)SBC, (Hon)SPCE
Doctor en medicina (UBA).
Docente Autorizado de Cirugía de la Universidad de Buenos Aires.
Cirujano de Centro Cien – DIAGNOMED y Fundación DAICIM,
Buenos Aires, Argentina.
Presidente de ICYLS (International Club of Young Laparoscopic
Surgeons).
Vicepresidente de AIICE (Asociación Iberoamericana de
Innovación en Cirugía Endoscópica)
v. 3 n. 8
5
Artigos Originais
Original Articles
6
v. 3 n. 8
IMPACT OF SMOKING ON VENTRAL HERNIA REPAIR:
ANALYSIS OF NSQIP
Impacto do tabagismo sobre correção de hérnia ventral:
Análise da NSQIP
Ciara R. Huntington, MD, Samuel W. Ross, MD, MPH, Laurel Blair, MD,
Tanushree Prasad MA, Amy E. Lincourt, PhD, MBA, Ronald F. Sing, DO, FACS,
B. Todd Heniford, MD, FACS, Vedra A. Augenstein, MD, FACS*
Carolinas Medical Center
Department of General Surgery
Division of Gastrointestinal and Minimally Invasive Surgery
Carolinas Medical Center
Charlotte, North Carolina
Author Contributions
Study design: Huntington, Ross, Sing, Heniford, Augenstein
Data Acquisition/Analysis: Ross, Huntington, Lincourt, Prasad, Sing, Heniford, Augenstein
Manuscript draft: Huntington, Ross, Blair, Sing, Heniford, Augenstein
Critical review: All authors
Disclosure statement
Dr. Heniford holds a patent for CeDARTM, a free mobile application designed to predict the rate and cost of
wound complications after ventral hernia repair; he does not receive financial gain from this app.
Drs. Heniford and Augenstein have previously been awarded surgical research and education grants from W.L.
Gore and Associates, Ethicon, Novadaq, Bard/Davol, and LifeCell Inc. All other authors confirm
they have no financial and personal relationships with other people or organizations that could
potentially and inappropriately influence this work and its conclusions.
*Corresponding Author: Vedra A. Augenstein, MD, FACS, Carolinas Medical Center, 1025
Morehead Medical Drive, Suite 300, Charlotte, North Carolina 28204
Office: (704) 355-8787, Fax: (704) 355-4117, [email protected]
Accepted for oral presentation at the Academic Surgical Congress, Las Vegas, NV, February 2015
and presented at the North Carolina Chapter of American College Surgeons Meeting July 2014.
Abstract
Introduction: Although smoking is known to increase complications following surgery, elective operations
on smokers are common, and there is no consensus
among surgeons regarding preoperative smoking cessation. This study quantifies the effect of smoking on
ventral hernia repair (VHR) using national outcomes
data. Methods: The NSQIP database was queried for
all elective laparoscopic VHR (LVHR) and open VHR
(OVHR) from 2005-2013. Standard statistical tests,
v. 3 n. 8
including multivariate regression (MVR) controlling
for age, sex, BMI, diabetes, Charlson Comorbidity
Index(CCI), recurrent and incarcerated hernia, were
performed. Results: There were 162,037, VHRs identified: 30,110 LVHR and 131,927 OVHR. In LVHR,
smokers were similar to nonsmokers by rates of recurrent hernia, gender, and mean CCI(p>0.05) but had
decreased age, BMI, and diabetes rates and increased
rate of incarceration(p<0.05). In OVHR, smokers
were more often female with increased rates of recurrent and incarcerated hernias(p<0.05) while non-smokers had increased mean age, BMI, and decreased
7
Augenstein et al.
Artigo Original
CCI(p<0.05). Results of MVR found higher odds for
all postoperative complications examined in smokers
undergoing OVHR, including wound and other morbidity, reoperation, readmission, and mortality(p<0.05).
Likelihood of major complication was increased in
smokers undergoing LVHR(p<0.05), but wound complication and mortality were similar(p>0.05). Conclusions: Smoking increases morbidity in LVHR and
OVHR, but also carries increased risk of death after
OVHR. Preoperative smoking cessation should be
goal for all repairs, but if repair must be performed,
LVHR is associated with fewer complications than
OVHR in a smoker.
Keywords: Hernia, Impact of Smoking, Surgery.
INTRODUction
Smoking is the leading cause of preventable death in
the United States with over 480,000 deaths from tobacco-related illnesses annually1. Currently, over 42.1
million Americans smoke cigarettes (18% of the US
population). While the smoking rate has decreased
slightly in the United States over the past decade, it
remains one of the preeminent public health concerns
both in this country and across the globe1.
Smokers have increased perioperative risks compared to non-smokers. In a recent meta-analysis of 107
studies, smokers had 52% increased rate of overall
morbidity2. Specifically, their relative risk of wound
complications doubled, with a 54% increase in postoperative infections, and a 73% increase in pulmonary
complications2. In another study comparing matched
groups of smokers and non-smokers undergoing surgery from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP),
smokers had increased rates of unplanned intubation,
respiratory failure, pneumonia, and were 1.38 times
more likely to die in the month following surgery compared to nonsmokers3.
Despite increased risks to their health and cost to the
healthcare system, 10 million smokers undergo surgery each year. Ventral hernia repair (VHR) is one of
the most common operations performed by surgeons
in the United States, with over 350,000 operations
performed annually; the majority of which are elective4. Previous studies have confirmed the detrimental effects of current tobacco use in ventral hernia
patients; Bencini et al found an association between
smoking and increased rate of recurrence in 146 pa-
8
tients undergoing laparoscopic VHR (LVHR). They
noted a 58% smoking rate in recurrent hernia group
compared to 23% smokers in the non-recurrent hernia
cohort, p=0.015. In a study of 1505 patients undergoing VHR at twelve Veteran’s Affairs (VA) hospitals,
smoking was associated with 1.5 times greater chance
of wound infections compared to non-smokers; it was
the only modifiable risk factor for wound complications after VHR identified by the study6. Smokers are
much more likely to develop surgical site infections
than non-smokers after ventral hernia repair, and
smoking remains a predictor of readmission in VHR7.
We have previously demonstrated that wound complications in OVHR cost an additional $27,000 in the
hospital and an additional $20,000 over a year as an
outpatient; mesh infections cost more than $80,0008.
Though smoking has persistently been associated
with postoperative complications, there has not been
a quantification of the effect of smoking on VHR on
a national level nor the cumulative effect of years of
smoking on outcomes in VHR. Furthermore, studies
have examined laparoscopic and open approaches, but
the risks that tobacco use might lend to each approach
has not been delineated.
Therefore, the purpose of this study was to examine
national outcomes in VHR in smokers and to quantify
the effect of smoking on patient outcomes. The authors hypothesized that, similar to previous literature,
smoking would independently be associated with adverse outcomes. Additionally, a secondary goal was to
determine the difference in outcomes between LVHR
and OVHR in an active smoker.
methods
DATA SOURCE
This is a retrospective cohort study examining
smoking impact on patients following VHR utilizing
data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
database. Demographic information, comorbidities,
procedural data, and postoperative complications within 30 days are collected by trained data abstractors,
supplemented as necessary with additional questions
addressed to treating physicians and follow up calls to
patients. Over 400 centers currently participate in this
program9.
NSQIP VARIABLES AND OUTCOMES
NSQIP records over 30 patient comorbidities but does
v. 3 n. 8
Impact of Smoking on Ventral Hernia Repair: Analysis of NSQIP
not include a global comorbidity scale on which to
rate patients such as the Charlson Comorbidity Index
(CCI)10. The CCI is one such scoring system that has
been extensively validated in surgery patients11-13. Age
group and major comorbidities are ranked from one
to six points. Points are then summated to provide a
total patient score that correlates with ten year survival rate14. The authors used available NSQIP data to
create a NSQIP Charlson Comorbidity Index which
has previously published15, where comorbidities are
scored as points according to the original CCI. Previous studies have verified that CCI adapted to large
administrative databases have had similar sensitivity in
stratifying mortality16,17, and this strategy has been used
in NSQIP in previous studies18,19.
Primary outcomes of interest for this study were death, and wound-related, major, and minor complications. Additional outcomes of interest were operative
time and hospital length of stay (LOS). NSQIP has
over 25 complications variables. To facilitate multivariate analysis and comparison between groups, the authors classified complications into wound complications wound disruption, superficial and deep surgical
site infections (SSI), minor complications superficial
SSI, wound disruption, renal insufficiency, urinary
tract infection, bleeding requiring transfusion, and
deep vein thrombosis (DVT)/thrombophlebitis, and
major complications deep SSI, graft or flap failure,
pneumonia, unplanned intubation, respiratory failure,
pulmonary embolism, acute renal failure (ARF), cerebrovascular accident (CVA), myocardial infarction,
sepsis and septic shock, similar to previously published work15
STUDY DESIGN
The NSQIP database was queried for all elective
LVHR from 2009-2013 and OVHR from 2005-2013
as determined by current procedural terminology
(CPT) codes; CPT codes for laparoscopy were introduced in 2009. The following CPT codes were utilized for LVHR: 49652, 49653, 49654, 49655, 49656,
and 49657. The following CPT codes were used for
OVHR: 49560, 49561, 49565, 49566, 49570, 49572,
49585, and 49587. Patients under age 18 and cases coded as “emergent” were excluded for primary analysis.
Variables are clearly described in the ACS NSQIP data
dictionary; smokers are defined as patients who have
smoked cigarettes in the year prior to admission for
surgery (NSQIP Data Dictionary, acsnsqip.org). Patients who smoke cigars or pipes or use chewing tobacco were excluded.
v. 3 n. 8
STATISTICAL ANALYSIS
Descriptive statistics were reported as means with
corresponding standard deviations for continuous variables and percentages for categorical variables. Bivariate analyses were performed to evaluate patient
demographics, comorbidities, operative details, and
outcomes with respect to effects of smoking status
within each operative approach strata (OVHR and
LVHR). Categorical variables were evaluated using
Pearson’s Chi-squared and Fisher’s exact test where
appropriate. Continuous and ordinal variables were
evaluated using two-sample t-tests for normally distributed data or Wilcoxon two-samples test for non-normally distributed data. Multivariate logistic regression
(MVR) and Analysis of Covariance (ANCOVA) for
adverse patient outcomes were then performed within
surgical approach strata controlling for age, sex, BMI,
diabetes, CCI, recurrent and incarcerated hernia. Odds
ratios with corresponding 95% confidence intervals
and ANCOVA adjusted means were used to report the
results of the multivariate regression models.
Statistical significance was set at p≤0.05, and all reported p values are two-tailed. All data were analyzed
using Statistical Analysis Software, version 9.4 (SAS
Institute, Inc., Cary, NC).
RESULTS
PATIENT CHARACTERISTICS
There were 162,037 VHRs in the study period: 30,110
LVHR and 131,927 OVHR. General patient characteristics by operative approach are displayed in Table
1. Notably, there were 5,603 smokers in the LVHR
strata (18.6%) and 26,310 smokers underwent OVHR
(19.9%).
Operative details were collected for LVHR and OVHR
(Table 2): inpatient admission (41.3% vs. 48.6%), recurrent hernias (14.7% vs. 17.5%), incarcerated hernias
(30.0% vs. 24.7%), with most operative fields classified
as “clean” (85.3% vs. 79.0%). The average operative
times were 97.0 ± 63.6 minutes in LVHR and 100.8 ±
90.9 minutes in OVHR. The mean size of the hernia
defect or mesh used is not recorded in this data set.
9
Artigo Original
Augenstein et al.
Table 1 – Patient characteristics
10
v. 3 n. 8
Table 2 – Operative details
PATIENT CHARACTERISTICS BY SMOKING
STATUS
The patient characteristics for LVHR and OVHR
groups stratified by smoking status are displayed in Table 3. In LVHR, smokers were similar to nonsmokers
by rates of recurrent hernia, gender and mean CCI
(p>0.05); however, they had decreased age, BMI, and
rates of diabetes, and increased rate of incarcerated
hernias (p<0.05). When compared to non-smokers,
smokers who underwent OVHR were younger with
decreased rates of diabetes, lower mean BMI, and increased average CCI (p<0.05). They were more often
female with increased rates of recurrent and incarcerated hernias compared to non-smokers (p<0.05).
Table 3 – Patient characteristics by smoking status
v. 3 n. 8
11
Augenstein et al.
Artigo Original
PATIENT OUTCOMES BY SMOKING STATUS
Comparisons for each operative approach stratified by
smoking status are displayed in Table 4. Analysis of
smokers versus nonsmokers in LVHR found no significant difference (p>0.05) for wound complications, minor complications, length of stay (LOS), readmission,
reoperation, and mortality, but had increased rates of
major complications compared to non-smokers, 2.6%
vs. 2.0% (p=0.005).
In OVHR, smokers had higher rates of wound complications, minor complications, major complications,
mean LOS, reoperation, and readmission (p<0.05).
Thirty-day mortality rate was similar in smokers and
nonsmokers (p>0.05).
Table 4 – Postoperative Outcomes by Smoking Status
MULTIVARIATE ANALYSIS BY SMOKING
STATUS
To control for confounding factors between smokers
and nonsmokers, multivariate regression analysis was
performed; results are displayed in the Table 5. In
OVHR, smokers had a higher odds ratio for all complications examined including 60% increased odds
of wound complications (OR 1.6, 95% CI 1.4-1.7,
p<0.0001), 30% increased odds of major complications (OR 1.3, 95% CI 1.2-1.4, p<0.0001), and nearly
12
twice the likelihood of 30-day mortality (OR 1.9, 95%
CI 1.5-2.5, p<0.0001).
In multivariate analysis of LVHR patients, major complications were increased by 70% in smokers compared
to non-smokers (OR 1.7, 95%CI 1.3-2.4, p<0.0006).
There was no difference in wound complications, minor complications, reoperation, readmission, or 30-day
mortality (p>0.05). Paradoxically, adjusted LOS was
shorter in the smokers undergoing LVHR compared to
non-smokers (mean 1.9 vs. 2.3 days, p<0.0064).
v. 3 n. 8
Table 5 – Operative details
Discussion
This study of over 162,000 elective ventral hernia repairs from a national surgical outcomes database demonstrates that smokers not only have an increased
risk of major complications and prolonged hospitalization after VHR, but that operative approach can
magnify or mitigate the risks of this elective operation.
Cigarette smoking was found to be a substantial independent risk factor for major complications following
LVHR and a multitude of postoperative complications
after OVHR including wound infection and disruption,
major complications, minor complications, reoperation, readmission, and increased risk of post-operative
death. While major complication rates are increased in
both open and laparoscopic approaches, OVHR carried higher rates of wound complications, reoperation,
readmission, and death, even after controlling for confounding factors.
Wound infections in VHR have been extensively studied, and reported rates in ventral hernia repair have
ranged from 8%-50%20,21. A study designed to find
predictive factors of increased wound infection or prolonged length of stay examined 25,172 VHRs using
national outcomes data and found that smokers had
1.46 times greater risk of wound infections compav. 3 n. 8
red to non-smokers (95% CI 1.13–1-84, p=0.003)22.
Wound healing in tobacco users is impaired at the molecular and cellular levels23,24. Nicotine in tobacco products is a vasoconstrictor which restricts flow to the
wound and interferes with angiogenesis25. Additionally,
nicotine inhibits proliferation of cells necessary for
wound-healing and blocks prostaglandin production,
which in turn increases platelet adhesiveness, leading to
microscopic thrombosis and tissue ischemia26. Wound
complications may lead to mesh infections, hernia recurrences and may progress to reoperation, administration of long term antibiotics, and, potentially, mesh explantation. Wound complications have been shown to
be directly-related to recurrence or predict recurrence
in several studies27-29. The current study demonstrates
that smokers are more likely to develop a wound-related problem in 6.9% of OVHR (compared to 4.7%
in non-smokers, p<0.0001) and 1.3% in LVHR (compared to 1.0%, p=0.051). Laparoscopy has previously been associated with fewer infections in VHR than
open repair6, and this study confirms that if an operation must be pursued, LVHR may be the safer choice
to avoid wound-related complications in smokers. Given the above information, it may also result in fewer
recurrences, but this has not been proven in this patient
category.
Surgical site infections and wound complications in-
13
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Augenstein et al.
crease the risk of hernia recurrence by at least 3-fold,
and management of these complications can cost from
$25,000 to $50,000 per occurrence30,31. A study presented at the American College of Surgeons in 2013 revealed the expansive cost of these infections; the average
cost of a wound complication was $40,000 and mesh
infection was $80,0008. Beyond financial consequences, wound infections directly impact patients’ quality
of life. Patients with wound complications have increased pain, mesh sensation, and movement limitation
at one month postoperatively; even when controlling
for confounding factors, VHR patients with wound
complications have a significantly poorer quality of life
at six months post-operatively compared to those without wound complications32. A predictive model for
the development of wound infection after OVHR and
its estimated costs was presented at the 2012 American
College of Surgeons; along with obesity and uncontrolled diabetes, smoking is one of the most important modifiable comorbidities in the algorithm8. A free
version of this algorithm for clinical use is now widely available as the downloadable CeDAR appTM for
mobile devices (http://www.carolinashealthcare.org/
download-the-app)8. This mobile app may be useful in
preoperative counseling of patients with preventable
comorbidities such as tobacco use33. The app is based
on 500 patients who underwent VHR at our institution and includes over a million data points. Patients are
able to see how smoking cessation among other significant data points changes their risk of wound infections
and hospital and follow up charges. Further studies are
on the way to validate the efficacy of this recently developed medical app.
In this study, more than 26,000 smokers underwent
elective OVHR across the US. Univariate analysis demonstrated no difference in the incidence of mortality, but when controlling for confounders, smoking
increased the incidence of death within 30 days of the
operation compared to non-smokers. While the overall incidence of post-operative mortality was quite low
(0.4%), this was a significant finding. Increased mortality in smokers after cardiac and non-cardiac surgery
has been demonstrated in some studies, including elective colorectal surgery34-36; however a recent Cochrane
analysis failed to demonstrate overall increased postoperative mortality in smokers2. The risk of death was
not increased in smokers versus non-smokers undergoing LVHR in univariate or multivariate analysis.
In an era where insurance company are tiering surgeons with a new push toward outcomes based reimbursement37-39, there has been considerable debate about
14
whether smokers should be refused elective surgery.
Given the increased risk to the patients, smoking cessation should be strongly encouraged40; permanent
abstinence from tobacco is possible but rare, but even
brief interventions for smoking cessation can be effective41-43. However, smoking cessation at least three weeks prior to surgery can reduce the risks of surgery
considerably41,42,44. In one randomized, controlled trial
of smoking cessation 6-8 weeks prior to surgery, complications decreased from 52% to 18% in the smoking
intervention group with significant improvement in
wound-related complications (5% vs. 31%, p=0.001),
cardiovascular complications (0% vs. 10%, p=0.08),
and reoperation (4% vs. 15%, p=0.07)41. Though 75%
of patients who smoke preoperatively endorse a desire
to quit, only 5% will be successful in permanent abstinence45. Though some patients are successful in short
term smoking cessation, 25% of patients continue to
smoke through the perioperative period46. A Cochrane
review of 13 trials on preoperative smoking cessation
reported that preoperative counseling and nicotine replacement therapy (such as nicotine patches or gum)
improved rates of short-term smoking cessation and in
some cases, improved postoperative morbidity47. From
multiple, albeit small trials, the best evidence to reduce
complications and achieve long-term abstinence supports intervention starting 4-8 weeks before surgery
including weekly counseling sessions and nicotine replacement47.
Active smokers are at increased risk of complications
if they undergo VHR. Preoperative optimization of
high risk patients should be achieved prior to elective
surgery for medical, ethical, and economic reasons8,45,48.
Patients with preventable comorbidities such as morbid obesity, uncontrolled diabetes, and active smoking,
will see postoperative benefit from targeted preoperative interventions prior to undergoing VHR8. A goal for
surgeons should be to counsel patients to make necessary medical and lifestyle changes such as smoking cessation. It is controversial as to whether to ensure adherence with recommendations in ways such as checking
cotinine levels prior to surgery (a breakdown product
of nicotine found in the urine and blood49). Given the
increased rates of morbidity and in some cases, small
but increased odds of death, all smokers should be encouraged to quit smoking. When smokers require ventral hernia repair, surgeons might consider LVHR as a
way to mitigate smoking-induced complications.
This study utilizes national data to provide important
insight into the care of ventral hernia in patients who
smoke, but it does have several limitations. As NSQIP
v. 3 n. 8
is not a hernia specific database, the study unfortunately does not have detailed information on the hernia
defect size, location for placement of mesh, type of
mesh, technique, or hernia recurrence rates. Thus the
multivariate model cannot account for additional technical factors such as surgical technique, use and location of mesh, or defect size. Smokers in NSQIP are
self-reported and broadly defined as active smokers if
they used cigarettes within the last year, and no other
tobacco products are counted40. Patients who stopped
smoking either permanently or temporarily in the weeks or months prior to surgery could affect the results
of this study. Despite these limitations inherent to the
data sources, over 162,000 VHRs are in the dataset, and
a considerable proportion of patients undergoing elective surgery across the country are represented.
conclusion
Smokers who undergo elective OVHR have increased
wound, minor, and major complications, increased rates of reoperation, and 30-day readmission. Despite a
low overall mortality rate for this operation, smokers
have increased odds of peri-operative death compared
to non-smokers in OVHR. LVHR performed in active
smokers is associated with increased major complications. Smoking cessation prior to surgery should be
encouraged, and if a repair is performed, a laparoscopic approach should be considered when appropriate.
Further analysis is necessary to stratify adequate length
of smoking cessation. Physicians of all specialties need
to recognize smoking as a significant risk in surgical
patients. Prospective trials are needed, similar to those
for perioperative antibiotics and deep venous thrombosis prophylaxis; these trials should focus on guidelines to help ensure smoking cessation pre-operatively
and post-operatively and measure improved surgical
outcomes.
ACKNOWLEDGEMENTS
The authors would like to thank Tiffany Cox, M.D.,
and Bindhu Oommen, M.D., M.P.H., for their assistance with this manuscript.
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v. 3 n. 8
EXTRAPERITONEAL SPACE:
RIGHT AcCESS FOR ENDOSCOPIC HÉRNIA REPAIR?
Espaço extraperitoneal: Acesso correto para o reparo herniário endoscópico?
Leandro Totti Cavazzola, 2Miguel Prestes Nácul,
3
José Gustavo Olijnyk, 4João Vicente Machado Grossi
1
Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa
de Pós-Graduação em Medicina - Ciências Cirúrgicas, Porto Alegre, Brasil
1-4
ABSTRACT
The correction of inguinal hernias is one of the most
performed surgeries in the world today. Although this
procedure is considered safe, simple and have satisfactory results, there is no consensus regarding the best
technique to use. Today, the inguinal hernia repair can
be accomplished by open or endoscopic video techniques. Although open techniques dispend am lower cost,
video-endoscopic techniques are considered more cost-effective in reducing the time of postoperative recovery
causing a positive socioeconomic impact. Currently the
transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) are the most widely used endoscopic
video. The TEP has lower cost per dispense with the
use of clamps and allow better postoperative recovery.
However, the TEP is more difficult to perform, because it has a lower visual field that may be partially offset
by performing a good dissection of the extraperitoneal
space. For this reason, the use of a balloon dissector
is critical. This review about the methods for accessing
the extraperitoneal space in video endoscopic inguinal
hernia repair by totally extraperitoneal technique includes the advantages and disadvantages of different techniques to access the extraperitoneal space such as closed
and open with finger dissection with optica (“telescóptica”) and balloon.
Keywords: TEP. Inguinal hernia. Balloon. Hérnia repair.
BACKGROUND
New technologies and innovations in surgical approaches need to demonstrate an improvement in patient
care especially in regard to their safety, satisfaction, ease
of use and cost-effectiveness1,2 relationship. The great
v. 3 n. 8
success of laparoscopic cholecystectomy encouraged
surgeons to seek other indications for the method, eg,
the treatment of hernias of the inguinal3 region.
Inguinal hernias of the region represent 75% of all
abdominal wall hernias, one of the most common ailments of adults and can lead to complaints such as
pain and discomfort4. The risk of a man developing
a hernia in the groin during your life is 27%, nine times higher than in women5. Surgical treatment of a
hernia in this region is the procedure most often performed abdominal surgery and the most commonly
performed by general surgeons in the United States.
In this country, approximately 700,000 surgeries are
performed each year, making up 15% of all surgeries
according to data from the National Center for Health
Statistics5. 20 million repairs are performed annually
worldwide6.
The data in Brazil are not as well known. According
to the Brazilian Institute of Geography and Statistics
(IBGE), approximately 5.4 million people suffer from
hernia in Brazil7 Abdominal wall hernias were responsible for about 500 000 surgeries performed between
1993 and 1996 by general surgeons SUS (Unified Health System), ranking second among the procedures hired, costing the state coffers about 100 million dollars
at the time8. Data from DATASUL regarding hospitalizations for the treatment of abdominal wall hernias
SUS express the reality of the public health system,
which in 2012 represented 74.9% of the population
who did not have additional9 health plan. These data
show that in Brazil the percentage of inguinal hernioplasty performed by video-endoscopy is very low.
From 2008 to 2012 162 008 cholecystectomies were
performed by laparoscopic inguinal hernioplasty but
only 3982 were made by this method in this period10.
From January to October 2013, 94150 and 11858 hernioplasty unilateral inguinal bilateral inguinal hernioplasty were performed by SUS. Only 657 of these were
made by endoscopic techniques10.
17
Artigo Original
Cavazzola et al.
The treatment of inguinal hernias region has been
an area of controversy in surgical practice from the
moment he was conceived. Although the procedure is
considered safe and relatively simple, with satisfactory
results, patients may experience a prolonged postoperative recovery, with a delay in returning to normal
work activities and recurrence. Thus, the inguinal hernia region not only affect the individual patient, but
also have great socioeconomic importance and significant impact on employment, disability and costs to
the health system with a recurrence rate of 5% to 10%
and a cost of over 28 billion dollars in the United States11. Throughout history, many techniques have been
proposed and innovations for their treatment. These
innovations were adopted through a combination of
subjective processes and application of scientific method12. During the past 25 years, the treatment of inguinal hernias region has undergone a dramatic change. Clearly, the force responsible for this change was
the desire to reduce the length of hospital stay, the
patient’s disability and recurrence rates13.
The advent of laparoscopy with successful laparoscopic cholecystectomy, the acceptance of the use of
prostheses and the effectiveness of extraperitoneal
repairs enabled the development of video-endoscopic
techniques for repair of inguinal hernias crus13,14. Many
of the early attempts use of laparoscopy for the treatment of inguinal hernia region of non-adherence to
technical principles learned with open surgery, probably due to technological deficiency. Subsequent technological advances have allowed a return to the principles established15 In 1992 Arregui and colleagues16 and
Dion and Morin17 reported a posterior preperitoneal
trans-abdominal laparoscopic approach, now known
as technical pre-trans-abdominal peritoneal (TAPP)
using a large prosthesis to completely cover the hole
miopectin Fruchaud of overlapping. The prosthesis
was fixed superiorly and inferiorly in the abdominal
transverse arch ligament of Cooper with a stapling
device. Inguinal hernia surgery endoscopic TAPP was
accompanied by several surgeons including Corbitt18.
In these early years of video-endoscopic era, TAPP
repair using a polypropylene mesh, expanded PTFE
or polyester was the predominant method for the treatment of inguinal hernias by laparoscopic15. However, both the TAPP repair as obviously required repair
IPOM entry into the peritoneal cavity. Dulucq19 was
the first surgeon to perform a direct extraperitoneal
approach without entering the abdominal cavity an inguinal hernia crural region to repair, Ferzli in 199220
and McKernan and Laws22 later popularized technique
18
Dulucq preferring the term “totally extraperitoneal”
(TEP). Using an open access, dissection was performed directly in the extraperitoneal space without any
access to the peritoneal cavity. In 1993 Phillips and colleagues23 Arregui et al24 reported a technique in which
separate the extraperitoneal space initial dissection was
performed under direct vision through a video endoscopic optical introduced into the peritoneal cavity. The
optics was later relocated to the extraperitoneal space
and the procedure completed as a endoscopic inguinal
hernia repair (TEP).
The first video endoscopic inguinal hernia surgery in
Brazil was held in October 1991 by the surgeon of São
Paulo Sergio Roll which published its first series of 58
patients in 199325.
Never interest in inguinal hernia repair was so intense
and this is due to the advent of video-endoscopic techniques that have evolved in parallel with the experience
and technology11. Currently, the two video endoscopic
techniques used for the treatment of inguinal hernias
crus are trans-abdominal preperitoneal (TAPP) and
totally extraperitoneal (TEP) using a polypropylene
mesh. The video-endoscopic repairs continue to develop its place in the surgical armamentarium for the
treatment of inguinal hernias crus.
Endoscopic techniques used today achieve excellent
long-term results with a low rate of recurrence, but
the prevention of chronic inguinal pain remains difficult4,25. The lack of consensus in the literature about
the best repair technique or how ideal to ensure a durable result in long-term prosthesis is also amazing4,25.
INGUINAL HERNIA REPAIR TECHNIQUE
FOR TOTALLY EXTRAPERITONEAL
ENDOSCOPIC (TEP)
CONCEPTS
The description of endoscopic TEP inguinal hernia
repair by Dulucq19 in the early 1990s in Europe can
be considered as a logical further development of the
TAPP technique26. The TEP technique has gained
popularity in recent years and has been considered by
some authors as the TAPP preferred because it is less
invasive and prevent entry into the peritoneal cavity4,27
The video endoscopic inguinal hernia repair TEP synergy advantages of minimal access to the a tension-free repair using prosthesis28. The video endoscopic
inguinal region of vision by the posterior approach
allows the surgeon a magnified panoramic exhibition
of three possible hernia defects (defect direct, indirect
and femoral besides the shutter) contributing to the
v. 3 n. 8
Extraperitoneal Space: Right Access for Endoscopic Hérnia Repair?
understanding of the occult hernias or recurrences.
The extraperitoneal space is logical for prosthesis implantation site. This anatomical space, the prosthesis
far from the subcutaneous tissue is relatively avascular,
and suffers the action of intra-abdominal keeps it in
place by pushing it against the anterior abdominal wall
pressure. This also allows non prosthesis fixation by
avoiding the use of staples which is costly and may
be associated with postoperative pain4,25. Clearly if the
surgical procedure is performed in the extraperitoneal
space, access it directly would be preferable. The video
endoscopic inguinal hernia repair TEP will involve a
peritoneal access, avoiding possible injury or visceral adhesions. In addition, it incorporates more easily
using instrumental 3 millimeters (mm) with the inherent advantages of minilaparoscopy as the expansion
of visual space and field of work, decreased incidence
of peritoneal injury and esthetical result29.
The TEP for inguinal hernia repair is a complex procedure mainly be held in a restricted virtual space, the
extraperitoneal space, which has to be accessed and
developed during surgery. Therefore, dissection of the
extraperitoneal space is fundamental step in the surgical procedure. Therefore, some concepts on anatomical spaces should be established.
ANATOMICAL SPACES
The advent of endoscopic surgery, several potential
anatomical spaces have attracted the interest of surgeons as true “secret passages”30,31. Anatomical space
can be defined as a cavity or compartment. Have potential space is one that is not apparent until distention
or created by dissection. In 1991, Haines32 defined a
space true potential as that to be created does not alter
the structural and functional integrity of tissue offers a
mesothelial lining which is covered with small amount
of serous fluid and can be repeatedly created and obliterated without causing tissue damage or require repair. With connective tissue planes a thin layer of loose
areolar tissue connects adjacent surfaces. The separation of these surfaces determines, even minimal tissue
damage. A surgical procedure in this kind of space
tends to injure areolar tissue and adhesions may form,
hindering or even preventing the repeated access to
this space. Most anatomical areas covered by video-endoscopic techniques, including the extraperitoneal
space, cannot be considered “true potential spaces”
because it does not meet the criteria of Haines30,31.
In a surgical procedure, spaces or anatomical planes
need to be opened by an active physical process such
as dissection in order to separate the adjacent tissues
v. 3 n. 8
previously in contact so that its shape and extension
can be configured and operated. The blunt dissection
can be, even with the use of hand or finger only. For
video endoscopic procedures, this pre-dissection prior
to the introduction of gas or liquid. It is necessary to
develop and refine methods to create, develop and explore anatomical spaces through natural or surgically
created pathways30,31.
EXTRAPERITONEAL SPACE
Using the concept of Haines32, the extraperitoneal
space is not a true “potential space”, even though its
surface can be easily separated. However, since dissected anatomic changes in the characteristics of the space depending on scar formation occurs, and may be
even more significant if a prosthesis or other biomedical material has been placed. The repetition of the
dissection in a second moment becomes complicated
and even contraindicated.
Despite the increased interest in the surgical community, only relatively few centers worldwide have adopted the extraperitoneal video-endoscopic access as
standard. Lack of space, difficulty in spatial orientation
and anatomical identification are the problems most
frequently encountered by the surgeon33,34. Either way,
video-endoscopic surgical procedures of the extraperitoneal space including the retroperitoneum, are
considered safe and feasible with various techniques
described in the literature35 However, it is essential to
understand these anatomical and surgical concepts in
inguinal hernia repair for video-endoscopic TEP, the
correct plan is accessed and dissected36.
The extraperitoneal space involves all portions of the
abdomen that are located outside the serous membrane known as the peritoneum that covers part or all of
abdominal organs37. The retroperitoneum is a part of
the abdominal cavity located between the posterior
parietal peritoneum and the posterior abdominal wall.
Its upper part extends to the peritoneal reflection liver
(with an upper limit diaphragm) and its bottom goes to
the extraperitoneal pelvic region, and bounded below
by the pelvic diaphragm38.
As Lange et al36, the pre-peritoneal space is located
between two components of the preperitoneal fascia
complex: a lap component known as posterior lamina of the dorsal fascia transversalis and component
known as preperitoneal fascia. It is difficult to look for
the correct line of cleavage in this space in the posterior layer of the transversalis fascia. Furthermore,
the position of the arcuate line is variable. The ventral (posterior layer of the transversalis fascia) would
19
Artigo Original
Cavazzola et al.
be suspended between the arcuate line and the pubis. This component serves as a cover of the actual
preperitoneal space and must be opened so that it is
accessed. Already dorsal component of preperitoneal
fascia is inserted in the bladder probably preventing
spontaneous cleavage of that structure together with
the peritoneum during dissection. Both components
originate in the posterior fascia of the rectus abdominis muscle.
Katkhouda and colleagues28 argued that access to the
preperitoneal space was performed at the level of the
arcuate line to this space really was not accessed and
the posterior fascia of the rectus abdominal inferior
epigastric vessels where they are. The correct dissection plane find themselves between the rectus abdominis muscle and the posterior lamina of the transversalis fascia. This fascia must be incised so that it is
in the correct space. If this fascia is left intact dorsally,
the lower epigastric vessels tend to stand out from
the rectus abdominis muscle without the support of
the ventral component, getting in a “clothesline”,
obstructing the view and sometimes needing to be
connected.
Lange and colleagues36 reinforced this concept that an
inguinal hernia surgery video-endoscopic technique
for TEP, the floor of the procedure should be made
by the peritoneum covered by the dorsal component
of the pre-peritoneal fascia and preperitoneal fat. The
anatomical adequate workspace can only be accessed
after the cleavage of the ventral component of the two
layers preperitoneal fascia, also known as the posterior
layer of the transversalis fascia complex.
Moreno-Egea et al39 have discussed the term “pre-peritoneal space,” suggesting that if using only the
term “extraperitoneal space.” Also suggested that this
concept also applies to the retroperitoneal space. For
the authors, the term pre-peritoneal fascia should be
common to all its regional meanings (urogenital fascia, umbilical-prevesical fascia, lumbar fascia, sacrum-genital-rectal fascia, etc.). The authors description the
fascia transversalis separately, even if folded back to
hold the inferior epigastric vessels, with the call back
layer is considered the pre-peritoneal fascia. In 1858,
Retzius described the homonymous lateral to the bladder (bladder pre-space), separated by prevesical umbilical fascia space, anterior and situated. The space of
Retzius is also displayed on a video endoscopic inguinal hernioplasty PET, but should avoid any operation
on this medial zone (Cooper ligament below) to not
cause injury to the bladder or venous plexus40. Bogros
(1786-1825) described a triangular space in the iliac re-
20
gion between the iliac fascia, transversalis fascia and
parietal peritoneum. The space Bogros lies between
the peritoneum and the posterior lamina of the transversalis fascia separated by internal spermatic fascia41
and is correct to be accessed and developed in a video endoscopic inguinal hernia repair TEP space. Like
Lange, Moreno-Egea and colleagues39 found that the
variety of terms used to describe the fascial elements
involved in a video endoscopic inguinal hernia repair
TEP make complex understanding of the workspace
this technique to surgeons unaccustomed to this approach, hindering spreading technique. Conclude that
it is necessary to create a consensus on the terminology for the wider dissemination of the TEP repair.
Understanding this knowledge should encourage the
spread of this video-endoscopic repair.
EXTRAPERITONEAL SPACE ACCESS
Endoscopic access to the extraperitoneal space began
with a focus on addressing the retroperitoneal organs,
mainly for urological procedures. In 1969, well before
the blossoming of laparoscopy, Bartel42 performed the
first endoscopic visualization of the retroperitoneal
space with a mediastinoscopy, using an open access technique without gas. In 1978, Wickham was the first to
perform an air insufflation of the retroperitoneal space for the realization of a ureterolithotomy33. In 1980,
Hald and Rasmussen43 described the first dissection
video-endoscopic retroperitoneal also with the help of
a mediastinoscopy. The authors, however, found very
limited due to the use of only a gas for performing
dissection. The historical description of Clayman laparoscopic nephrectomy for a transperitoneal approach
in 199144 created a worldwide interest in video endoscopic surgery of the retroperitoneal organs. A year
later, Clayman described the first nephrectomy using
a retroperitoneal approach. However, discouraged by
inadequate workspace and retroperitoneal air suboptimal due to the limitation of the initial dissection of the
retroperitoneal space, the authors chose the transperitoneal approach in its subsequent cases-.
The retroperitoneal organs are usually addressed by
extraperitoneal route in open procedures. Thus, the
video-endoscopic surgery, the retroperitoneal route
would be the logical choice technique for exploration
of the retroperitoneum. However, the presence of
dense fibrous trabeculae and retroperitoneal adipose
tissue do not allow the creation of a satisfactory air
retroperitoneum without the use of disruptive force.
The shortage of space for surgical manipulation due
to unsatisfactory retroperitoneal air was mainly res-
v. 3 n. 8
ponsible for the poor results of this method in the
past and its limited dissemination46 the revival of retroperitonealscopy reason was due to the pioneering
work of Indian urologist Mumbai, Durga Gaur that
opened the retroperitoneal and extraperitoneal routes
for surgeons. In 1992, Gaur published their experience with the use of a handmade balloon dissection to
develop the extraperitoneal space47. The balloon dissector allowed rapid dissection of fibro-fatty tissue
of the retroperitoneum, creating adequate space for
performing endoscopic surgical procedures. Through
this seminal article considered, all retroperitonealscopy
evolved (Figure 1).
Figure 1 – Balloon original of Durga Gaur 1992
The first publications in the early 1990s describing inguinal hernia surgery video-endoscopic TEP did not
use any type of balloon dissector in accessing the extraperitoneal space, but direct dissection with the help
of finger48 or optical video-endoscopic, call for “telescoping dissection”49. Later, the use of a dissector,
or processed artisan flask was proposed. The introduction of the balloon dissector has made access to the
extraperitoneal space to be simplified.
THE TECHNIQUES OF ACCESS EXTRAPERITONEAL SPACE
The most important step in conducting an endoscopy surgical procedure in the extraperitoneal space is
to obtain satisfactory access. The video extraperitoneal
laparoscopic approach provides secure and minimally
invasive procedures to a variety of approach. This technique has a learning curve and requires a thorough knowledge of the anatomy of the extraperitoneal
space49. Wickmam33 and Clayman45 published the first
v. 3 n. 8
descriptions of access techniques for urological retroperitoneal endoscopic video. Wickmam described an
open technique in which plans for after opening the
abdominal wall to access the retroperitoneal space, an
initial digital dissection followed by dissection with optical video-endoscopic (telescopic dissection) and carbon dioxide gas itself (CO2) was performed. Clayman
already described a closed technique in which one needle puncture was performed in Veres extraperitoneal
space. After insufflation to about 10 to 15 millimeters
of mercury (mmHg) was positioned one trocar puncture “blind” in the retroperitoneum. As the pre-space
achieved with this technique was still limited, was also
required additional telescopic dissection with the use
of gas (CO2). The problem with these techniques is
not determined that an initial air in retroperitoneum
satisfactory. Dissection in this way can be difficult,
time consuming and even frustrating, because the initial view does not permit the identification of anatomical landmarks and even simple endoscopic spatial
orientation50. These access techniques to the retroperitoneum were reproduced for access to the extraperitoneal space for the realization of a video endoscopic
inguinal hernia repair TEP. The basic principle is to
create an anatomical space through which the miopectin hole can be visualized49.
THE CLOSED TECHNIQUE
Dulucq27 first published a technique of closed access
to the extraperitoneal space for the realization of a video endoscopic inguinal hernia repair TEP. A Veres
needle was positioned in the space of Retzius through
a puncture in the suprapubic region. Then proceeded
with CO2 insufflation and placement of a trocar directly “blindly” into the extraperitoneal space. In this
method, it is difficult to accurately place a Veres needle in the correct anatomical space. Furthermore, the
workspace is initially narrow4.
Access via the transperitoneal visualization is an alternative (Grade D - MBE)4. This technique starts with
the creation of a pneumoperitoneum and placement
of a trocar into the peritoneal cavity. The initial dissection of the extraperitoneal space is held with forceps
endoscopic video of 3 or 5 mm into the extraperitoneal
space positioned under transperitoneal view with the
aid of CO2. Although relatively simple and cost-effective not to use any material single use, this technique may
present some potential complications inherent to the
peritoneal access as visceral injury or herniated portal.
Furthermore, the presence of pneumoperitoneum can
compromise the extraperitoneal space29.
21
Artigo Original
Cavazzola et al.
Another way of achieving access to the extraperitoneal
space enclosed by technique described in Patent US
5271380 of 1993 Siegfried Riek et al51 US 5334150 and
Steven Kaali 199452 who invented the “optical trocar.”
Unlike a conventional trocar in the tissue penetration
is performed blindly optical display trocars to allow
tissue penetration when the trocar is advanced through the abdominal wall. An optical trocar consists of a
rigid tube with a transparent window in the distal portion of acute penetrating format. A rigid optic endoscopic video miniature camera and coupled to a light
source positioned within the optical trocar allows the
visualization of the tissues at the tip of the tube through the transparent penetrating window. These patents
have generated two products to market: the Visiport®
produced by ©Covidien (Mansfield, USA) and the Xcel
Endopath Bladeless® Company © Johnson & Johnson
(Cincinnati, USA). In 2008, Tai and co-workers53 describe a technique for access to the closed space for
an extraperitoneal endoscopic video inguinal hernia
repair with the use of PET Visiport® (©Covidien). The
goal would be to simplify and accelerate the installation of extraperitoneal working space. The use of the
optical trocar caused a decrease in access time and less
loss of gas during the procedure. One of the problems of the technique was the extra cost of the optical
trocar. The use of an optical trocar for developing the
extraperitoneal space has not spread. This type of trocar is currently used primarily to access to the cavity,
the peritoneal cavity especially in situations involving
risk of puncture accident, especially in patients with
previous surgery.
THE OPEN TECHNIQUE
Initially described by Ferzli et al20 and McKernan and
Laws21, the open space for access to the extraperitoneal endoscopic video inguinal hernioplasty TEP technique, is carried out in most cases with a trocar type Hasson. Through a umbilical skin incision for median-(the
side of the hernia) transverse 1-2cm long, the anterior
fascia of the rectus abdominis muscle is addressed.
Originally, the fascia was incised was made longitudinally on the midline. However, cross the midline increases the risk of peritoneal opening. Therefore, the
technique was modified to a transverse incision along
the anterior sheath of the rectus abdominis muscle49.
After opening the fascia, the muscle is retracted laterally (or trans-rectal access done) and the space between the rectus abdominis muscle and its posterior
sheath is accessed under direct vision. More recently,
Daes54 described a variation of the open technique.
22
Access was obtained in a well-lateralized position in
cranial and abdominal wall on the side of the hernia.
After reaching the extraperitoneal space, Daes used a
balloon dissector and held the section of the semilunar line with video-endoscopic visualization. A modification of the technique aimed to facilitate anatomical
understanding, working in an area with more space,
allowing the TEP repair even the most complex cases
and in large hernias, prior prostatectomy, incarcerated
hernias, patients who have a small distance between
the navel and the pubis and obese.
The skin incision open technique should be larger than
the size of the trocar around 12-15mm to allow adequate visualization of the anatomical planes and allow
the insertion of a finger, the trocar device or a balloon
dissector43. The dissection of the anatomic structures
through a small incision is especially difficult in obese
patients. If you choose to extend this incision, access
is facilitated, but increases the chance of gas leakage
around the trocar, which interferes with the maintenance of an adequate air pre-peritoneum55.
When an open access is performed to dissect the extraperitoneal space can be initiated using one of the
following techniques49:
a) The digital dissection
In this technique, one uses the blunt tip of a finger.
A gentle sweeping motion across the midline of the
pubic symphysis is first employed. This dissection with
the finger should be tangential to the rectus muscle.
Once this is done, the Linea Alba is hooked with your
finger and pulled the cephalic direction, causing it to
rupture. With experience, the digital dissection offers
a fast, effective, safe and less costly alternative technique49. However, this approach requires an incision
large enough to accept the surgeon’s finger size. Depending on the size of the incision, higher gas leak can
occur, making it difficult to maintain the extraperitoneal space. In addition, an extended scar is not desired56.
b)Dissection with optical (“Telescopic”)
The telescopic blunt dissection under direct vision
with an optical endoscopic was described by Ferzli and
colleagues20 using a 10mm trocar with a working channel of 5mm, and McKernan and Laws21 is a method
often used in many centers around the world25. It is
initiated by placing a 10mm trocar into the extraperitoneal space. Using the very perspective of 10mm
(preferably zero degrees in order to have a front view),
the dissection is carried medially until first the retropubic space of Retzius and then continues laterally into
v. 3 n. 8
the space Bogros and fascia ileos-psoas. The dissection
remains in the midline in a plane parallel to the rectus
abdominis muscle to stop any bleeding or peritoneal
injury and should be carried out later through the posterior lamina of the inner portion of the transversalis
fascia as described by Cooper49.
The anatomical delineation and development of the
extraperitoneal working space in a video endoscopic
inguinal hernia repair TEP is also satisfactory with
both the digital dissection how to telescopic. However,
both techniques are more time consuming, may cause
more bleeding and the initial anatomical identification
is more complex25. Because of the limitations of the
techniques described above, the use of a balloon dissector has been proposed.
c) The Balloon Dissector
After the initial access to the extraperitoneal space in
open surgery, the balloon dissector is introduced along
the posterior part of the abdominal rectus muscle toward the pubis and positioned in the extraperitoneal
space. The balloon is inflated with liquid or gas separating adjacent tissue layers and create the desired
space49. After the completion of the initial creation of
anatomical space, the balloon must be kept inflated for
approximately 5 to 7 minutes for hemostasis56. After
the balloon is removed, the primary and secondary
portal are established and the video endoscopic inguinal hernia repair performed TEP. When the introduction of optical endoscopic should first assess the
quality of dissection with the balloon, trying to detect
any peritoneal injury, vascular or visceral and whether
there are any fragments of the balloon. If the initial
dissection balloon is not satisfactory for either its quality or its extension, additional fascial barriers can be
broken with the finger or the tip of the optical or even
repeated with the dissection balloon57.
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74. Moll FH, Gresl Jr C, Chin A, Hopper PK inventores; Origin
Medsystems Inc., cessionário. Retraction Methods using endoscopic inflatable retraction devices. United States patent US 5309896.
1994 May 10.
75. Moll FH, Chin AK. Balloon Assisted Extraperitoneal Laparoscopic Approaches. J Am Assoc Gynecol Laparosc. 1994 Aug;1(4,
Part 2):S23.
76. Hirsch IH, Moreno JG, Lotfi MA, Gomella LG. Controlled balloon dilatation of the extraperitoneal space for laparoscopic urologic surgery. J Laparoendosc Surg. 1994 Aug;4(4):247-51.
77. Sierocuk TJ, Garrison WA, Michetti AR, inventores; Ethicon
Endo Surgery Inc., cessionário. Surgical Dissector. United States
patent US 5607441. 1997 Mar 4.
78. Echevery JM, Fernandez LM, Jervis JE, Robinson JC, Tanaka
S, Voss LK, inventors; General Surgical Innovations Inc., assignee.
Apparatus and method for developing na anatomic space for laparoscopic procedures. United States patent US 6015421. 2000 Jan 18.
79. Peartree KA, Palermo TJ, Tanaka S, Powell FT, inventors; General Surgical Innovations Inc., assignee. Balloon dissector appara-
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tus. United States patent US 6592602. 2003 Jul 15.
80. Criscuolo C, Creston B, Aranyi E, Geiste R, inventors; Tyco
Healthcare Group Inc., assignee. Balloon dissector with cannula.
United States patent US 7300448. 2007 Nov 27.
81. Heikkinen TJ, Haukipuro K, Koivukangas P, Hulkko A. A
prospective randomized outcome and cost comparison of totally
extraperitoneal endoscopic hernioplasty versus Lichtenstein hernia
operation among employed patients. Surg Laparosc Endosc. 1998
Oct;8(5):338-44.
82. Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C,
Whitehead A, Singh R, Spiegelhalter D. Randomised controlled
trial of laparoscopic versus open mesh repair for inguinal hernia:
outcome and cost. BMJ. 1998 Jul 11;317(7151):103-10. Erratum in:
BMJ 1998 Sep 5;317(7159):631.
83. Ferzli G, Sayad P, Huie F, Hallak A, Usal H. Endoscopic extraperitoneal herniorrhaphy. A 5-year experience. Surg Endosc. 1998
Nov;12(11):1311-3.
84. Spitz JD, Arregui ME. Sutureless laparoscopic extraperitoneal
inguinal herniorrhaphy using reusable instruments: two hundred
three repairs without recurrence. Surg Laparosc Endosc Percutan
Tech. 2000 Feb;10(1):24-9.
85. Schurz JW, Arregui ME, Hammond JC. Open vs laparoscopic
hernia repair. Analysis of costs, charges, and outcomes. Surg Endosc. 1995 Dec;9(12):1311-7.
86. Farinas LP, Griffen FD. Cost containment and totally extraperitoneal laparoscopic herniorrhaphy. Surg Endosc. 2000 Jan;14(1):3740.
87. Bringman S, Ek A, Haglind E, Heikkinen TJ, Kald A, Kylberg F, et al.Is a dissection balloon beneficial in bilateral, totally
extraperitoneal,endoscopic hernioplasty? A randomized, prospective, multicenter study. Surg Laparosc Endosc Percutan Tech. 2001
Oct;11(5):322-6.
88. Basu S, Chandran S, Somers SS, Toh SK. Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth technique. Hernia. 2005 Dec;9(4):363-7.
89. Kuthe A. Invited comment to the paper of S. Basu: Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth
Technique. Hernia. 2006 Mar;10(1):102.
90. Loureiro MP. hernioplastia endoscópica extraperitoneal: custos,
alternativas e benefícios. Rev bras videocir 2006;4(3):135-138.
91. Chiang DT-W, Bohmer R. Cutting the cost: Laparoscopic inguinal hernia repair by totally extraperitoneal approach without
disposable instruments. Surg PractInternet. 2006 Nov ;10(4):154-8.
25
Relato de Caso
Case Report
26
v. 3 n. 8
GARANGEOT’S HERNIA:
A CASE REPORT
Hérnia Garangeot’s: Relato de caso
James Skinovsky1, Flávio Panegalli Filho2, Fernanda Keiko Tsumanuma3,
Rômulo Augusto Andrade de Almeida4, Alinne Vandramin4
PhD – Chairman Surgery Department, Positivo University, Red Cross University Hospital – Curitiba-Brazil
2
MD – Surgery Staff – Red Cross University Hospital – Curitiba-Brazil
3
MD – Assistant Professor – Positivo University, Red Cross University Hospital – Curitiba-Brazil
4
Academic Medicine Course – Positivo University – Curitiba-Brazil
1
BACKGROUND
Femoral hernias occur below the inguinal ligament when
the abdominal contents passes through the inguinal canal1. In about 0.8-1% of femoral hernias, the appendix
is included within the hernia sac2,3,4. The average age of
presentation is 554. The presence of appendicitis is even
more unusual1. This was first described by the French
surgeon Rene Jacques Croissant de Garengeot in 17315.6.
To date, few cases have been reported in the literature5.
It affects more women than men at a ratio of 13:16.
Many times diagnosis is incidental during hernia repair surgery7,8. Garengeot`s hernia can remain for
years without presenting imprisonment or inflammatory symptoms. There is a report of a case where the
patient remained with this type of hernia for 30 years
until symptoms such as increasing the size and touch
increased sensitivity appeared7. Among the reported
symptoms, there is: local inflammatory signs, abdominal distension, nausea and vomiting, periumbilical
pain, fever1,6,7. The abnormal anatomical position of
the appendix in the pelvis and a large mobile cecum
are factors attributed appendix entry into the inguinal
canal6. In cases of appendicitis, confuse the diagnosis
with femoral hernia incarcerated9. In addition, the presence of pus, from extra-hernia ruptured appendix, the
hernia sac can also lead to similar symptoms9.
One of the articles found reports a Richter hernia case
associated with herniated Garengeot6.
The gold standard for diagnosis is computed tomography, however, the use of ultrasound can also provide
an accurate diagnosis, being cheap and affordable and
without ionizing radiation1. MRI can also be used in
cases where CT is contraindicated as in cases of allergy
to contrast4. laparoscopy, and therapy can also be used
as a diagnostic method10.
v. 3 n. 8
It is important to know the anatomy of the femoral
triangle to accurately diagnose this hernia on imaging
studies. The triangle is formed medially by the adductor
longus muscle, laterally by the sartorius and superiorly by the inguinal ligament, while the iliopsoas, adductor longus pectineus and form your floor. The femoral
channel is the medial femoral vein. This channel is relatively narrow, which causes more chences to choke than
in inguinal hernias. The goal of imaging is to find a dead
end pipe in the right iliac fossa. The resonance characteristics suggesting a normal appendix is detecting a high
signal on T2 within the lumen and the presence artifacts
that show the presence of air in the Appendix. In case of
appendicitis, an inflammatory fluid around the appendix
appear in T2 hyper-radiation. Appendix size calculation
can also help in the diagnosis of appendicitis. There is a
need in contrast radiography examination4. Abdominal
x-ray does not help in the diagnosis of hernia8.
Its treatment is appendectomy and hernia repair, however, there isn’t a standard procedure because of its rarity7. Some authors showed that appendectomy via the
hernia sac is appropriate, however, in cases of perforation and abscess formation, the transabdominal route is preferable11. It was suggested that in cases where
no appendicitis, it is not necessary appendectomy3.12.
Both open surgery and laparoscopic the via13 can be
used. Retrograde appendectomy is an option in cases
of appendicitis, in order to prevent peritoneal contamination12. The hernia repair is preferably to place a
mesh11 except in cases of infection, where the screen
contamination of chance makes it preferable to use the
Cooper’s ligament for herniária correction7. The most
common complication of Garengeot De hernia repair
is a wound infection at a rate reaching 29%. Some cases
of necrotizing fasciitis and even death have been reported, probably related to delay in diagnosis and older
age of patients8.
27
Artigo Original
Skinovsky et al.
CASE REPORT
A 62-year-old male paciente was admitted in the emergency room with pain in the right inguinal region in
the last 3 days and progressive worsening. Denied bowel habit changes, denied nausea and vomiting, fever
or any other symptoms. The patient reported that he
had never noticed any changes in the groin before the
onset of pain. He denied any co-morbidity in treatment or previous surgeries.
On physical examination, it was noticed not reducible
bulging in the inguinal region, with intense pain on palpation, but no local inflammatory signs without pain
and signs of peritoneal irritation.
Laboratory tests were performed, the result of which showed no changes: blood count, coagulation tests,
renal function, blood glucose and normal electrolytes.
It was chosen by the non-operation of imaging due to
intense pain of the patient and clinical diagnosis already performed examining the patient.
It was performed a right inguinotomy of about 10 to
12 centimeters, with the patient under general anesthesia, but anesthetic block of ilioinguinal nerve. When
performing the opening of the abdominal wall plans
and dissection of the area was observable the cecal
apêndix with no inflammation insinuating themselves
imprisoned by the inguinal canal, indirectly, requiring
local dissection with partial opening of the channel to
release the appendix and part of cecum (Figure 1).
Appendectomy via sac and reduction of remaining
content, correction of inguinal canal with 3.0 Prolene
yarn was made. The correction occurred by technique
without tension, using heavyweight polypropylene
mesh, attached to the cooper ligament inferiorly and
Figure 1 – Hernia content after release of the inguinal canal – Garangeot’s Hernia
superiorly to the joint area with nonabsorbable sutures.
The patient had good postoperative evolution, reporting only little local nuisance, which resolved with the
use of simple analgesics. The patient was discharged
on postoperative second and returned with 1 week, 3
weeks, 1 month and 6 months postoperatively, without
evidence of any surgical complication or hérnia recurrence.
DISCUSSION
The history and physical examination of the patient
have proven completely sufficient for the diagnosis
of incarcerated hernia, but the diagnosis of Garangeot Hernia only appeared in the perioperative period.
This diagnosis could have been made preoperatively
by a CT scan, but it was decided to perform surgery
without it because the intensity of the patient’s pain.
Because of the rarity of cases like this there is not an
established surgical technique in the literature.
In this case appendectomy was performed via hernia
sac, but according to the literature presented in the
introduction, there would be conversion to transabdominal technique if there were cecal appendix with
signs of inflammation or other difficulties. The hernia
defect repair was carried out without tension polypropylene mesh, which determines a lower rate of post-operative complications and especially recurrence.
FINAL CONSIDERATIONS
The case presented is shown of great importance to
reporting because of their rarity, not only by the presence appendix of the inguinal canal, but also because
it occurred in a man (more commonly occurs in women).
Compared to cases such as this must be done a surgical precise, excluding the possibility of bottlenecks or
acute appendicitis inside the hernia and the treatment
should be conducted according to the case, where possible without performing the tension-free correction
of the hernia as recommended nowadays
REFERENCES
1. Shah A, Janardhan HS. De Garengeot hernia: a case report
and review of literature. Indian J Surg. 2013 Jun; 75(Suppl 1):
439–441.
2. Ahmed, K. et al. Appendicitis in De Garengeot’s hernia presenting as a nontender inguinal mass: case report and review of the
literature. Case Rep Surg. 2014; 2014: p.1-3. .
3. Brown N, Moesbergen T, Steinke K. The French and their her-
28
v. 3 n. 8
Garangeot’s Hernia: A Case Report
nias: prospective radiological differentiation of the Garengeot from
other groin hernias. J Radiol Case Rep. 2013 Apr; 7(4):16-21.
4. Halpenny D, Barrett R, O’Callaghan K, Eltayeb O, Torreggiani
WC. The MRI findings of a de Garengeot hernia. Br J Radiol. 2012
Mar;85(1011):e59-61.
5. Talini C, Oliveira LO, Araújo AC, Netto FA, Westphalen AP.
De Garengeot hernia: case report and review. Int J Surg Case Rep.
2015;8C:35-7.
6. Le HD, Odom SR, Hsu A, Gupta A, Hauser CJ. A combined
Richter’s and De Garengeot’s hernia. Int J Surg Case Rep. 2014;
5(10): 662–664.
7. Schäfer HM, Holzen U, Nebiker C. Swelling of the right thigh for
over 30 years: the rare finding of a De Garengeot hernia. Int J Surg
Case Rep. 2014;5(12):1120-2.
8. Piperos T, Kalles V, Al Ahwal Y, Konstantinou E, Skarpas G,
Mariolis-Sapsakos T. Clinical significance of de Garengeot’s hernia: A case of acute appendicitis and review of the literature. International Journal of Surgery Case Reports. 2012;3(3):116-117.
v. 3 n. 8
doi:10.1016/j.ijscr.2011.12.003.
9. Hsiao T, Chou, Y. Appendiceal pus in hernia sac simulating strangulated femoral hernia: a case report. Int J Gen Med. 2011 Mar
23;4:235-7.
10. Thomas B, Thomas M, McVay B, Chivate J. De Garengeot Hernia. JSLS : Journal of the Society of Laparoendoscopic Surgeons.
2009;13(3):455-457.
11. Ebisawa K, Yamazaki S, Kimura Y, et al. Acute Appendicitis in
an Incarcerated Femoral Hernia: A Case of De Garengeot Hernia.
Case Reports in Gastroenterology. 2009;3(3):313-317.
12. Hussain A, Slesser AAP, Monib S, Maalo J, Soskin M, Arbuckle J. A De Garengeot Hernia masquerading as a strangulated
femoral hernia. International Journal of Surgery Case Reports.
2014;5(10):656-658.
13. Comman A, Gaetzschmann P, Hanner T, Behrend M. DeGarengeot Hernia: Transabdominal Preperitoneal Hernia Repair
and Appendectomy. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2007;11(4):496-501.
29
Anexo High Tech Surgery
Appendix High Tech Surgery
30
v. 3 n. 8
INCIDENCE OF GALLBLADDER STONES
AFTER BARIATRIC SURGERY
Incidência de cálculos da Vesícula Biliar após Cirurgia Bariátrica
Ibarra Eliana, Pascowsky Maria, Souza Juan Manuel, Vega Emiliano, Pilar Quevedo,
Marianela Aguirre Ackerman, Guillermo Duza MAAC, Edgardo Serra MAAC,
Mariano Palermo MD PhD MAAC FACS
Bariatric and Metabolic Surgery Division. Centro Cien-DIAGNOMED
Afiliated Institution to the University of Buenos Aires
ABSTRACT
Objectives: To compare the incidence of gallstones
formation post bariatric surgery according to techniques, Roux en Y Gastric bypass ans gastric sleeve.
Material y methods: We made a literature search
through Medline database of prospective and retrospective work type. The search criteria focused on
obese patients referred for bariatric surgery that were
included in treatment protocols using surgical techniques Roux en-Y gastric bypass and gastric sleeve, and
monitoring plans designed to detect the development
of gallblader disease. Results: During the follow up,
134 patients (37%) developed gallbladder disease after
Roux en Y gastric bypass. In detail, 66 (49,25%) cases
of cholelithiasis occurred in the first year post surgery,
38 (57,5%) of which were developed specifically in the
first 6 months; 23 patients ( 17.16% ) during the second year of follow-up, while only 5 patients ( 3.73 %
) made it beyond the second year.On the other hand,
during the follow-up 21 patients (10%) developed gallbladder disease after gastric sleeve. In this case, only
one of the works included in this revision clarifies the
periods development of disease patients, specifying a
time interval of 18.4 +/- 10.7 months. Conclusion:
Our results are showing that the incidence of cholelithiasis is higher after Roux en Y gastric bypass than
after gastric sleeve. We understand that this result is
conditioned because of the poor number of patients
that underwent gastric sleeve, and also because two
of the works about gastric sleeve were aimed only to
detect cases of symptomatic or complicated illness ,
leaving out the diagnosis of asymptomatic patients. So
we could said that in reality, the incidence of galldblader diseade would be similar if we could compare
all patients , both symptomatic and asymptomatic. All
v. 3 n. 8
of the works make it clear that the only predictor of
gallbladder disease post- bariatric surgery is the rapid
weight loss , especially in the first six months, which
is when most cases of stone disease develops. So, the
choice of technique would not impact on the incidence of post bariatric gallbladder disease , although the
small number of studies about gastric sleeve require
new items to make a conclusion based on a more significant sample.
Keywords: Gallbladder, Obesity, Bariatric Surgery.
INTRODUCTION
Morbid obesity is a chronic multifactorial disease associated with significant physical and psychological
complications that contribute to worsen the quality of
patients life and reduce their life expectancy. The treatment of this disease with lifestyle modifications and
drug, fails, in most cases, to loose sufficient weight to
appropiate control of the comorbidities. So far, bariatric surgery is the only treatment that is able to reach
these long-term expectations.
Bariatric surgery is a therapeutic tool that requiring for
indications an strict selection criteria that refer to the
magnitude of obesity, the existence of complications
and failure of conventional treatments previously applied . Obese patients becomes in candidates for bariatric surgery when they have a BMI ≥ 40 kg/m2 or ≥
35 kg/m2 with 2 or more comorbidities that requiring
weight loss treatment, including Miellitus Diabetes, arterial hypertension, dyslipidemia, heart coronary.
The different surgical techniques can be classified into
restrictive, malabsorptive and mixed. Within which, at
present, the Gold Standard is the gastric bypass.
In Latin America it reported that between 5 and 15 %
31
Anexo – High Tech Surgery
Palermo et al.
of people have gallstones, and there are populations
and ethnic groups with the highest prevalence, such as
Caucasian, Hispanic or Native Americans. Countries
like the United States, Chile, Bolivia are among the highest number of people affected by this disease1.
Following bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), the frequency of gallstone formation increases as compared to the normal population
due to rapid weight loss3,4. Hepatic supersaturation of
bile with cholesterol, gallbladder stasis, and increased
concentration of mucin within bile are possible causes5
The management of gallstone disease in these patients
is still controversial. Protocols coexist of conventional
prophylactic surgery (cholecystectomy simultaneously
with gastric bypass to all patients, whether or not gallstones), elective (cholecystectomy simultaneously with
gastric bypass to asymptomatic carriers of gallstones)
and conventional (cholecystectomy only in the presence of gallstones and symptoms).
MATERIALS AND METHODS
We made a literature search through Medline database
of prospective and retrospective work type. The search criteria focused on obese patients referred for bariatric surgery that were included in treatment protocols
using surgical techniques Roux en-Y gastric bypass and
gastric sleeve, and monitoring plans designed to detect
the development of gallblader disease. The terms used
for the search were “morbid obesity” “gastric bypass”
“sleeve gastrectomy” “gallbladder disease” “gallstones
“ “ Roux en-Y gastric bypass “ “ prospective” “ cholectystectomy”.
They were included for this review a total of 7 works,
governed by the aforementioned criteria. Of these, 2
are such prospective jobs while the rest are retrospective. Only two of these items the study population is
subject only to the surgical technique of gastric sleeve, and in turn these two items have the distinction
of being evaluated in monitoring the development of
symptomatic cholelithiasis and not of those who develop asymptomatically. Moreover of the 5 remaining
works, 4 refer to the use of gastric bypass with Roux-Y reconstruction and the only remaining, meanwhile,
compared both techniques.
In all the items patients were included in protocols
for monitoring including a preoperative abdominal ultrasound to rule out pre vesicular disease. Thus, were
excluded from the final sample all those patients with
previous cholecystectomy, gallstones preoperative
32
including both the finding of gallstones and biliary
sludge, and those patients that could not be followed
strictly. Those in which vesicular disease identified preoperatively underwent concomitant cholecystectomy
with bariatric surgery.
The post- surgical follow-up of all patients was performed at diferents periods of time at, between 6 months
and 2 years. This included clinical evaluation (weight,
BMI, percentage calculation weight loss, development
of symptoms compatible with vesicular disease) and
laboratory analysis, fundamentally, total cholesterol,
and triglyceride fractions.
We had a sample of 845 patients, of which 536
(63.4%) underwent Roux-Y gastric bypass, while the
remaining 309 (36.5%) underwent gastric sleeve.
From 536 patients undergoing Roux-Y-gastric bypas,
176 (32.8%) were excluded. In detail exclusions
were due to previous cholecystectomy in 78 patients
(13.61%); gallbladder disease preoperatively detected
in 89 patients (16.6%); lost to follow up in 9 (1.67%)
and doubtful ultrasound 5 (0.93%) . Having been excluded those already named , a cohort of 360 (67.16%)
patients without gallbladder disease patients was finally
obtained.
Moreover, of the 309 patients undergoing gastric sleeve , the excluded were 99 patients (32.03%). The reasons for these exclusions were prior cholecystectomy
in 40 patients (12.94%) ; previous disease in 38 patients (12.29%) and lost to follow up in 21 patients
(6.79%). Thus, we obtained a final sample of 210 patients (67,9%) without gallbladder disease.
RESULTS
From data collected from the different items we had
a sample of patients without gallbladder disease and
strictly monitored of 360 patients who underwent
Roux-en Y- gastric bypass was obtained , and 210 patients underwent gastric sleeve surgery
During the follow up, 134 patients (37%) developed
gallbladder disease after Roux en Y gastric bypass. In
detail, 66 (49,25%) cases of cholelithiasis occurred in
the first year post surgery, 38 (57,5%) of which were
developed specifically in the first 6 months; 23 patients (17.16%) during the second year of follow-up,
while only 5 patients (3.73 %) made it beyond the second year.
On the other hand, during the follow-up 21 patients
(10%) developed gallbladder disease after gastric sleeve. In this case, only one of the works included in this
v. 3 n. 8
Incidence of Gallbladder Stones after Bariatric Surgery
revision clarifies the periods development of disease
patients, specifying a time interval of 18.4 +/- 10.7
months.
DISCUSSION
While in this review, are presents results that include
two techniques of bariatric surgery, it should be noted
that while the literature that include the cases treated
with the technique of Bypass is abundant, the available regarding the incidence of gallstones post- Manga
gastric is scarce. This difference is explained by the BY
PASS is generally the most used technique.
Compared with the general population, obesity is associated with high serum cholesterol levels, determining
a higher incidence of lithiasis, which further increases
in the population of patients undergoing different techniques of bariatric surgery.
The latter is linked to several factors, including the
severe weight loss (especially in the first six months
post surgery), which in turn favors a significant mobilization of cholesterol from adipose tissue stores and
lower production of bile salts and phospholipids into
the gallbladder lumen.
Furthermore, after bariatric surgery, the motility vesicular decreased, and an increase in mucin secretion to
the bladder favoring that nucleation occurs .This predominant component of cholesterol on phospholipids
and bile salts in bile promotes the formation of gallstones in post-bariatric patients. Other factors stimulated the formation of gallstones post-surgery, as the
decrease in motility by altering the vagal nerve derived
from the surgical process are present in some cases
but are not constant in the different series. However,
rapid weight loss (more than 25% of initial weight in
6 months), is the only predictor of vesicular disease
present in all the series.
Adding the total of the studies analyzed, the sample
of patients undergoing bariatric surgery free of vesicular disease reached 494 cases, of which 360 correspond to surgical technique of Gastric Bypass and 210
to Gastric Sleeve. It should be noted that all patients
treated with the latter technique, only in 43 patients the
follow up post-surgical included clinical features and
ultrasound, while the remaining 167 only the appearance of symptoms was evaluated, both gallstones and
complicated stones
With respect to patients treated with Gastric Bypass,
of 360 undergoing this technique, 134 have developed
vesicular disease, that constitutes 37%. This percenv. 3 n. 8
tage is in line with others previous works, where they
obtained values of between 25% and 50 % : Amaral
and Thompson (28%), Schmidt et al. (40%), Shiffman
et al. (47%) , Surgeman (32%).
Regarding the series of cases treated with the technique of Sleeve Gastrectomy, if we consider the one of
Coupaye et. Al, which is the only one that have the
strictly follow-up raised in this review, 12 of the 43
cases developed vesicular disease, proven by clinical
signs and/or data obtained in the post-surgery scans.
This represents a 27.9% of vesicular disease after Sleeve Gastrectomy, with a value that is in tune with Gastric Bypass treated series.
This value drops significantly when we include the
other two sets of Sleeve Gastrectomy analyzed, but
this is based that in these work were aimed only to
detect cases of symptomatic or complicated illness,
leaving out the diagnosis of asymptomatic patients
detected by ultrasound, which are the most cases of
vesicular disease post- surgery.
CONCLUSION
Our results are showing that the incidence of cholelithiasis is higher after Roux en Y gastric bypass than
after gastric sleeve. We understand that this result is
conditioned because of the poor number of patients
that underwent gastric sleeve, and also because two of
the works about gastric sleeve were aimed only to detect cases of symptomatic or complicated illness, leaving out the diagnosis of symptomatic patients. So we
could said that in reality, the incidence of galldblader
diseade would be similar if we could compare all patients, both symptomatic and asymptomatic.
On the other hand, all of the works make it clear that
the only predictor of gallbladder disease post-bariatric
surgery is the rapid weight loss, especially in the first
six months, which is when most cases of stone disease
develops.
So, the choice of technique would not impact on the
incidence of post bariatric gallbladder disease, although the small number of studies about gastric sleeve
require new items to make a conclusion based on a
more significant sample.
REFERENCES
1. Li VK, Pulido N, Martinez-Suartez P, Fajnwaks P, Jin HY, Szomstein S, Rosenthal RJ. Symptomatic gallstones after sleeve gastrectomy. Surg Endosc. 2009 Nov;23(11):2488-92.
33
Palermo et al.
2. Taha MIA; Freitas Jr WR; Puglia CR; Lacombe A; Malheiros CA.
Fatores preditivos de colelitíase em obesos mórbidos após astroplastia em Y de Roux. Rev. Assoc. Med. Bras. Rev Assoc Med Bras
2006; 52(6): 430-4
3. Nagem RG, Lázaro AS, Oliveira RM, Morato VG. Gallstone-related complications after Roux-en-Y gastric bypass: a
prospective study. Hepatobiliary Pancreat Dis Int. 2012 Dec
15;11(6):630-5
4. Teivelis MP, Faintuch J, Ishida R, Sakai P, Bresser A, Gama-Rodrigues J. Endoscopic and ultrasonographic evaluation before and after roux-en-y gastric bypass for morbid obesity. Arq Gastroenterol.
2007 Jan-Mar;44(1):8-13.
5. Karadeniz M, Görgün M, Cemal K. The evaluation of gallstone
formation in patients undergoing Roux-en-Y gastric bypass due to
34
morbid obesity. Ulus Cerrahi Derg. 2014; 30(2): 76-79.
6. Sioka E, Zacharoulis D, Zachari E, Papamargaritis D, Pinaka O,
Katsogridaki G, Tzovaras G. Complicated Gallstones after Laparoscopic Sleeve Gastrectomy. J Obes. 2014; 2014.
7. Moon RC, Teixeira AF, DuCoin C, Varnadore S, Jawad MA.
Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Surg Obes Relat Dis.
2014 Jan-Feb;10(1):64-8.
8. Palermo M, Berkowski DE, Córdoba JP, Verde JM, Giménez
ME. Prevalence of cholelithiasis in Buenos Aires, Argentina. Acta
Gastroenterol Latinoam. 2013; 43(2):98-105.
9. Carbonell CLA, Prado YA, González TP, Ferro YP, Hernández
ZH. Clinical and epidemiological diagnosis of bladder stone. Rev.
Cienc Med Pinar Rio. 2012; 16(1): 200-214.
v. 3 n. 8
EVENTOS TROMBOEMBÓLICOS EM PACIENTES
SUBMETIDOS a CIRURGIA ABDOMINAL A CÉU ABERTO
E CIRURGIAS ViDEOLAPAROSCÓPICAS
Thromboembolic events in patients submitted open abdominal
surgery and laparoscopic abdominal surgery
James Skinovsky¹, Cristina Okamoto², Joseph Chenisz³, Daniel Lacerda³,
Augusto Mozzaquatro³, Stephan Saab³, João Paulo Bacarin³
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.
2
Doutora em Pediatria e Neonatologia, Especialização em Neonatologia na
Universidade Estadual de Osaka-Japão, Professora da Graduação do Curso de Medicina da Universidade Positivo.
3
Doutorandos do quinto ano de Medicina da Universidade Positivo.
1
resumo
Objetivo: Avaliar a presença de eventos tromboembólicos (tromboembolismo pulmonar e trombose venosa profunda) em pacientes submetidos a cirurgia abdominal a céu aberto, e cirurgias videolaparoscópicas,
assim como o perfil epidemiológico desses pacientes.
Método: Trata-se de uma análise observacional descritivo transversal, com coleta retrospectiva de pacientes
submetidos a cirurgia abdominal a céu aberto e videolaparoscópica no período de 1 ano (01/01/2013 31/12/2013) no Hospital da Cruz Vermelha. A amostra é composta por 498 pacientes, sendo 242 cirurgias a
céu aberto e 256 videolaparoscópicas. Foram pesquisados fatores clínicos, medicamentosos e cirúrgicos para
eventos tromboembólicos em todos os pacientes incluídos no estudo através de critérios previamente estabelecidos. Resultados: De toda amostra, 7 (1,4%) dos
pacientes apresentaram evento tromboembólico, sendo
4 trombose venosa profunda (TVP) e 4 tromboembolismo pulmonar (TEP). Assim, um mesmo paciente
apresentou tanto TVP como TEP. Considerando apenas cirurgias a céu aberto o evento tromboembólico foi
encontrado em 5 pacientes, sendo 2 casos de TVP e 3
TEP. A cirurgia de maior prevalência dentre as abertas
foi a apendicectomia, seguida da laparotomia exploratória. A taxa de incidência para cirurgia aberta foi de
2,1%, com intervalo de confiança de 95%, de 0,3% a
3,9%. Em cirurgias videolaparoscópicas, foram enconv. 3 n. 8
trados 2 casos de TVP e 1 TEP. A cirurgia de maior
prevalência entre as cirurgias por vídeo foi a colecistectomia, seguida da apendicectomia. A taxa de incidência
foi de 0,8%, com intervalo de confiança de 95%, de 0%
a 1,9%. Conclusão: O pós-operatório de cirurgia a céu
aberto representa um maior risco de desenvolvimento
para evento tromboembólico em relação ao pós-operatório de uma cirurgia videolaparascópica, isso se deve
também aos fatores que motivaram a via a céu aberto
serem determinantes de maior gravidade.
Palavras-chave: Cirurgia laparoscópica. Cirurgia abdominal. Eventos tromboembólicos.
Keywords: Laparoscopic surgery. Abdominal surgery.
Thromboembolic events.
INTRODUÇÃO
Os eventos tromboembólicos (ETE) estão entre as
principais causas de morbimortalidade no Brasil e no
mundo. Estima-se que cerca de 50 a 100 mil pessoas morram anualmente nos EUA por algum tipo de
ETE. Os ETE são caracterizados por Tromboembolismo Pulmonar (TEP) e Trombose Venosa Profunda
(TVP).
Diversos fatores de risco contribuem para essas entidades, dentre eles destacamos: estado de hipercoagulabilidade, estase venosa e lesão endotelial (Triade
35
Skinovsky et al.
de Virchow). Outros fatores de risco que devem ser
destacados são: diminuição da atividade fibrinolítica,
imobilização prolongada, pacientes submetidos a cirurgia, vítimas de trauma, presença de doenças malignas, idade avançada, falência cardíaca, episódio prévio
de TVP, obesidade, varizes, doenças intestinais inflamatórias, sepse, infarto agudo do miocárdio e reposição hormonal1,2.
O TEP isoladamente é responsável por cerca de 100
mil mortes por ano nos Estados Unidos e cerca de
10% deles ocorrem na primeira hora de sua evolução.
Além disso, segundo o Centers for Disease Control
and Prevention (CDC), o número de casos de Trombose Venosa Profunda gira em torno de 300.000 a
600.000 mil casos por ano. No Canadá, os números
giram em torno de 45.000 casos por ano2. Nos países
ocidentais, estima-se uma incidência de 48 casos de
TVP e de 23 casos de TEP por ano para cada 100.000
habitantes. Embora sejam apresentações distintas da
mesma doença, o risco de morte no TEP é de 5 a 17
vezes maior do que na TVP3.
Um estudo realizado em Worcester, Massachusetts,
verificou que mais da metade dos pacientes com a
doença não recebeu profilaxia correta para tromboembolismos venosos3. Estima-se que 10% dos óbitos
hospitalares ocorram devido a TEP, embora estudos
de autópsia revelem o TEP como fator contribuinte
ocorrendo em 29% a 37% dos casos de óbito4.
Este trabalho revisou retrospectivamente os prontuários de 498 pacientes selecionados aleatoriamente,
submetidos a cirurgia abdominal a céu aberto (242)
e a cirurgias videolaparoscópicas (256), no serviço de
cirurgia do Hospital da Cruz Vermelha no período de
01/01/2013 a 31/12/2013.
Abordaremos a seguir os métodos de coleta dos dados
com as variáveis analisadas. Posteriormente, com os
resultados obtidos da pesquisa, demonstraremos a relação do tipo de cirurgia e pós-operatório com eventos
tromboembólicos.
MÉTODOs
O estudo trata-se de uma análise observacional descritivo transversal, com coleta retrospectiva, tendo como
população paciente submetido à cirurgia abdominal a
céu aberto e por via videolaparoscópica.
A pesquisa revisou prontuários no período de
01/01/2013 a 31/12/2013 no Hospital da Cruz Vermelha.
O projeto foi conduzido com a aprovação do protoco-
36
lo pelo Comitê de Ética da Universidade Positivo, com
a permissão da direção do hospital e sem a assinatura
do termo de consentimento livre e esclarecido pelos
pacientes.
A amostra foi composta de 498 prontuários, sendo 242
de cirurgias abertas e outras 256 cirurgias videolaparoscópicas.
Os critérios de inclusão foram: todos os pacientes submetidos a cirurgia abdominal aberta ou via videolaparoscópica durante todo o ano de 2013.
Os critérios de exclusão foram: prontuários incompletos ou com informações inadequadas.
Os dados coletados foram organizados em planilha
Excel (Microsoft®) e a análise estatística foi feita com
o auxílio do programa Prism 4.0. Os testes de Fisher e
qui quadrado foram aplicados para o estudo de associação de variáveis nominais e os testes de Mann, Whitney e teste T para variáveis numéricas. A significância
adotada foi de 5%.
Foram pesquisados fatores clínicos, medicamentosos e
cirúrgicos para ETE em todos os pacientes incluídos no
estudo através de critérios previamente estabelecidos.
RESULTADOS
Foram coletados 498 prontuários de pacientes submetidos a cirurgia abdominal no ano de 2013. Desse
número, 242 realizaram cirurgia a céu aberto e 256 realizaram cirurgia videolaparoscópica.
Em relação ao gênero encontramos 278 (55,82%) pacientes do sexo feminino e 220 (44,18%) do sexo masculino. A média de idade encontrada foi 47,03 anos,
sendo que os extremos de idade foram 14 e 89 anos.
A cirurgia de maior prevalência foi a colecistectomia,
com 37,34%, seguida da apendicectomia e da laparotomia exploratória, com respectivamente 22,48%
e 11,04%. De toda amostra, 7 (1,4%) dos pacientes
apresentaram evento tromboembólico, sendo 4 TVP
e 4 TEP. Assim, um mesmo paciente apresentou tanto
Trombose Venosa Profunda como Tromboembolismo Pulmonar.
Do total da amostra, 84 (16,86%) pacientes apresentavam comorbidades, 210 (42,16%) doenças prévias e
apenas 35 (7,02%) foram submetidos a algum tipo de
profilaxia.
Considerando apenas cirurgias abertas encontramos 111 (45,86%) pacientes do sexo feminino e 131
(54,14%) do sexo masculino. A cirurgia de maior prevalência foi a apendicectomia, seguida da laparotomia exploratória e da herniorrafia inguinal unilateral
v. 3 n. 8
Eventos Tromboembólicos em Pacientes Submetidos
à Cirurgia Abdominal a Céu Aberto e Cirurgias Vídeolaparoscópicas
ou bilateral com, respectivamente, 36,36%, 21,48% e
6,61%. O evento tromboembólico foi encontrado em
5 pacientes, sendo 2 casos de TVP e 3 TEP. Dentre
todos os pacientes submetidos a cirurgia aberta, 42
(17,35%) apresentavam algum tipo de comorbidade,
105 (43,38) alguma doença prévia e apenas 17 (7,02%)
foram submetidos a algum tipo de profilaxia. A taxa
de incidência para cirurgia aberta foi de 2,1%, com intervalo de confiança de 95%, de 0,3% a 3,9%.
Entre os casos de TEP, em pacientes submetidos a cirurgias a céu aberto, 1 (33,33%) era do sexo feminino
e 2 (66,67%) eram do sexo masculino. Destes pacientes, 66,67% apresentavam algum tipo de comorbidade,
nenhum apresentava doença prévia e apenas um foi
submetido a um tipo de profilaxia. Os casos de TVP,
em cirurgias a céu aberto, foram observados em apenas 2 pacientes, sendo estes do sexo feminino. Destes
2 pacientes, 1 apresentava algum tipo de comorbidade,
todos tinham histórico de doença prévia e todos foram
submetidos a profilaxia.
Considerando, agora, apenas cirurgias videolaparoscópicas, encontramos 167 (65,23%) pacientes do sexo
feminino e 89 do sexo masculino (34,77%). A cirurgia de maior prevalência foi a colecistectomia, seguida
da apendicectomia e da gastrofundoplicatura a Nissen
com, respectivamente, 67,57%, 8,98% e 5,85%. O
evento tromboembólico foi encontrado em 2 pacientes sendo 2 casos de TVP e 1 de TEP.
Assim, um mesmo paciente apresentou tanto Trombose Venosa Profunda como Tromboembolismo Pulmonar. Dentre todos os pacientes submetidos a cirurgia
por vídeo, 39 (15,23%) apresentavam algum tipo de
comorbidade, 115 (44,92%) alguma doença prévia e
apenas 18 (7,03%) foram submetidos a algum tipo de
profilaxia. A taxa de incidência foi de 0,8%, com intervalo de confiança de 95%, de 0% a 1,9%.
Nesse trabalho, apenas um paciente submetido a cirurgia videolaparoscópica evoluiu para TEP. Esse paciente era do sexo feminino, não apresentava nenhuma
comorbidade, possuía doença prévia e não recebeu nenhuma profilaxia. A TVP, na cirurgia videolaparoscópica, foi observada em 2 pacientes, estes do sexo feminino. Esses não apresentavam nenhuma comorbidade,
um apresentava doença prévia e apenas um recebeu
algum tipo de profilaxia.
MÉTODOs
É fato que quando discorremos sobre complicações no
pós-operatório, os eventos tromboembólicos (TEP e
v. 3 n. 8
TVP) representam um importante fator com relação à
morbidade e mortalidade dos pacientes. Principalmente quando uma dessas complicações é o TEP, o qual é
responsável por 100 mil mortes anos nos EUA. Além
disso, 74% dos pacientes acometidos de Trombose Venosa Profunda não procuram auxílio médico, podendo
assim elevar os índices já citados, pois um terço dos
pacientes vítimas de TVP evoluem com TEP1,2,3.
Os eventos tromboembólicos podem evoluir para óbito, acredita-se que a embolia pulmonar, por exemplo,
seja a terceira causa de morte intra-hospitalar5. Ademais, segundo a União Europeia, no ano de 2007, o
número de óbitos após um evento tromboembólico,
foi em torno de 370 mil pacientes6.
Diversos fatores de risco podem levar ao desenvolvimento de ETE. O ato cirúrgico por si só pode levar a
um estado de hipercoagulabilidade, o qual culminará
com trombose. A imobilidade no período pós-cirúrgico contribui de forma importante para tais patologias, sendo fatores de risco: doenças malignas, idade
avançada, falência cardíaca, episódio prévio de TVP,
imobilização prolongada, obesidade, varizes, doenças
intestinais inflamatórias, sepses, infarto do miocárdio,
puerpério, uso de hormônios femininos e viagens longas1,2,3.
Outro estudo demostra que os 3 principais fatores de
risco são: idade acima de 70 anos, imobilização recente, historia prévia de trombose venosa profunda ou
embolia pulmonar e câncer7.
No que se refere ao fato etário, diversos estudos comprovam que a incidência de eventos tromboembólicos
aumenta exponencialmente com o aumento de idade,
sendo que a incidência aumenta de forma dramática
após os 60 anos.
Estudo publicado na Cleveland Clinic, coloca como
fator de risco idade maior que 75 anos. Outros estudos
colocam 70 anos associado com aumento de incidência, mostrando a associação positiva entre aumento da
idade com TEP e TVP5.
Nossos índices com relação à idade demonstraram que
dos sete pacientes acometidos de eventos tromboembólicos, dois estavam abaixo de 40 anos (28,58%), 2
entre 40 e 60 anos (28,58%), 3 estavam acima de 60
anos (42,84%)3,8.
Considerando o gênero, nas mulheres, mesmo que o
uso de contraceptivos e reposição hormonal predisponha a casos de eventos tromboembólicos, ocorre uma
disparidade quanto à prevalência entre os sexos. Contudo, alguns acreditam não haver disparidade significativa3. Estudo publicado na Arch Surg em Dezembro
de 2011 contou com a análise do prontuário de 2189
37
Skinovsky et al.
pacientes submetidos a cirurgia em um hospital universitário. Destes, 1,6% desenvolveram evento tromboembólico no pós-operatório, sendo 22 homens e
13 mulheres9. Porém nossos resultados demonstraram
o contrário, sendo que 5 dos 7 pacientes acometidos,
eram mulheres, como pode ser verificado em diversos
estudos mais atuais10.
Das comorbidades encontradas nos pacientes que desenvolveram ETE7, 3 pacientes eram obesos, sendo
que um deles também era tabagista. O tabagismo mostrou o aumento do risco relativo de trombose de 3,3
vezes para pacientes que fumavam mais de 35 cigarros/dia e de 1,9 vezes para os que fumavam entre 24 e
35 cigarros/dia, na Nurse Health Study, um estudo de
coorte realizado entre 1976 e 199211.
As doenças prévias encontradas nos pacientes que desenvolveram eventos tromboembólicos foram Câncer,
Hipertensão Arterial Sistêmica, Dislipidemia, Diabetes
Mellitus tipo 2, Insuficiência Cardíaca Congestiva, Bloqueio Atrioventricular e Trombose Venosa Profunda
prévia.
Na nossa amostra, dos 7 pacientes que apresentaram
evento tromboembólico, 3 possuíam alguma doença prévia. Um deles apresentava concomitantemente
Câncer de Sigmoide, Hipertensão Arterial Sistêmica,
Insuficiência Cardíaca Congestiva e Bloqueio Atrioventricular. Outro paciente apresentava Câncer de
Pâncreas, Hipertensão Arterial Sistêmica e Dislipidemia. Enquanto isso, o terceiro paciente apresentava
obesidade, Hipertensão Arterial Sistêmica e TVP prévia.
A incidência de evento tromboembólico é duas vezes
maior em pacientes acometidos por Câncer. Em relação ao tipo de Câncer, o mais envolvido com essa
complicação é o Carcinoma de Cabeça de Pâncreas,
encontrado em um de nossos pacientes12.
O tempo de internamento implica em aumento da incidência de TVP e TEP. Nesse estudo observou-se que
o tempo de internamento dos pacientes com evento
tromboembólico foi em média 12 dias, sendo que o
maior tempo de internamento foi de 32 dias e o menor
de 4 dias.
Apesar de diversos protocolos para a prevenção de
TVP já estarem disponíveis, encontramos um índice de
profilaxia de apenas 7,02% no número global da amostra. Assim como neste trabalho, a literatura demonstra que a adoção de medidas profiláticas em hospitais
gerais ainda é insatisfatória. Além disso, muitas vezes
quando realizada é de maneira ineficaz13,14,15.
O ponto principal desse estudo foi analisar o perfil dos
pacientes que evoluíram com um evento tromboem-
38
bólico em relação a cirurgias abdominais via videolaparoscópicas e a céu aberto. Como demonstrado nos
resultados, os pacientes submetidos a cirurgia aberta
tiveram um maior índice de eventos tromboembólicos (2,06%) em relação a pacientes submetidos por
cirurgia videolaparoscópica (0,78%). Notavelmente
os pacientes submetidos a cirurgia aberta tinham mais
comorbidades e fatores de risco, quando comparados
a pacientes submetidos a cirurgia videolaparoscópica.
Além disso, a profilaxia foi escassa em ambos os grupos, tanto cirurgias abertas quanto por vídeo. A profilaxia está muito relacionada à presença de eventos
tromboembólicos em pacientes cirúrgicos segundo diversos estudos. Os números parecem aumentar quanto
maior o índice de comorbidades e fatores de risco, tais
como: Câncer, idade maior que 40 anos, Evento Tromboembólico prévio. Os números indicam que pacientes cirúrgicos sem profilaxia, com essas características
tem o seguinte risco: 40 a 80% aumentado para TVP
distal, 10 a 20% para TVP proximal, e 0,2 a 5% para
embolia pulmonar fatal3,16.
Considerando outro estudo específico de cirurgias abdominais abertas verificou-se que 4 de 83 (5%) pacientes tiveram algum evento tromboembólico, no caso a
TVP, demonstrando um índice mais elevado do que o
encontrado neste devido estudo12.
Os índices apurados neste trabalho demonstram que
apesar do ETE ser uma complicação não tão prevalente, é a terceira maior causa de morte intra-hospitalar,
portanto, deve-se tomar as melhores medidas de prevenção com esses pacientes, dentre elas a profilaxia.
Por fim, fica claro que pacientes com fatores de risco, maior tempo de internamento, doenças malignas,
cirurgias de grande porte, principalmente por via céu
aberto, têm mais chance de desenvolver uma TVP ou
mesmo um TEP.
CONCLUSÃO
Após a análise do perfil epidemiológico de uma parcela de pacientes submetidos a cirurgia abdominal via
videolaparascópica e a céu aberto, observou-se que, de
fato, o pós-operatório de cirurgia a céu aberto representa um maior risco de desenvolvimento para evento
tromboembólico em relação ao pós-operatório de uma
cirurgia videolaparascópica.
Considerando o perfil dos pacientes que foram submetidos a cirurgia a céu aberto, fica evidente que as
doenças prévias que motivaram este procedimento detinham uma maior gravidade. Dessa forma, apresenta-
v. 3 n. 8
Eventos Tromboembólicos em Pacientes Submetidos
à Cirurgia Abdominal a Céu Aberto e Cirurgias Vídeolaparoscópicas
vam um maior tempo de internamento, corroborando
para o desenvolvimento tromboembólico.
REFERÊNCIAS
1. Orra HA. Trombose venosa profunda. Disponível em: <http://
www.clinicadrhussein.com.br/pdf/trombose.pdf>. Acesso em:
15/02/2015.
2. Engelhom AL, Garcia AC, et al.Profilaxia da trombose venosa
profunda: estudo epidemiológico em um hospital escola. J Vasc Br
2002;1(2):97-102.
3. White RH. The epidemiology of venous thromboembolism. Circulation. 2003 Jun 17;107(23 Suppl 1):I4-8.
4. Spencer FA1, Emery C, Lessard D, Anderson F, Emani S, Aragam J, Becker RC, Goldberg RJ. The Worcester Venous Thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med. 2006
Jul;21(7):722-7.
5. Ozaki A, Bartholomew JR. Venous Thromboembolism (Deep
Venous Thrombosis & Pulmonary Embolism). Cleveland Clinic,
December 2012.
6. Cohen AT, Agnelli G, et al. Venous thromboembolism (VTE) in
Europe: the number of VTE events and associated morbidity and
mortality. Thromb Haemost. 2007 Oct;98(4):756-64.
7. Motykie GD1, Caprini JA. Risk factor assessment in the management of patients with suspected deep venous thrombosis. Int
Angiol. 2000 Mar;19(1):47-51.
8. Scottish Intercollegiate Guidelines Network (SIGN). Prevention
and management of venous thromboembolism. A national clinical
v. 3 n. 8
guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines
Network (SIGN); 2010 dec. 101 p.
9. Smith BR, Dinis S, Stamos M,Nguyen NT. Deep venous thrombosis after general surgical operations at a university hospital: two-year
data from the ACS NSQIP. Arch Surg. 2011 Dec;146(12):1424-7.
10. Deitelzweig SB1, Johnson BH, Lin J, Schulman KL. Prevalence
of clinical venous thromboembolism in the USA: current trends
and future projections. Am J Hematol. 2011 Feb;86(2):217-20.
11. Goldhaber SZ, Grodstein F, Stampfer MJ et al. A prospective
study of risk factors for pulmonary embolism in women. JAMA.
1997; 277:642(5).
12. Stein PD, Beemath A, Meyers FA, Skaf E, Sanchez J, Olson
RE. Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med. 2006 Jan;119(1):60-8
13. Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of
thromboprophylaxis guidelines. Chest. 2001;120:1964-71.
14. Maffei FHA, Caiafa JS, Ramacciotti E, Castro. Normas de orientação clínica para prevenção, diagnóstico e tratamento da trombose venosa profunda (revisão 2005). Salvador: SBACV; 2005. Disponível em: http://www.sbacv-nac.org.br. Acesso em: 15/02/2015.
15. Caiafa JS, Bastos M. Programa de profilaxia do tromboembolismo venoso do Hospital Naval Marcílio Dias: um modelo de educação continuada. J Vasc Bras. 2002;1:103-12.
16. Sakon M, Maehara Y, Yoshikawa H, Akaza H. Incidence of
venous thromboembolism following major abdominal surgery: a
multi-center, prospective epidemiological study in Japan. J Thromb
Haemost. 2006 Mar;4(3):581-6.
17. Muleledhu AL, Galukande M et al. Deep venous thrombosis
after major abdominal surgery in a Ugandan hospital: a prospective
study. Int J Emerg Med. 2013 Nov 28;6(1):43.
39
ARTIGO de revisão High Tech Surgery
review Article High Tech Surgery
40
v. 3 n. 8
VIDEOCIRURGIA:
DE ONDE VIEMOS E PARA ONDE VAMOS?
Videosurgery: Where we come and where are we going?
James Skinovsky1, Sérgio Roll2
1
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.
2
Doutor em Cirurgia. Ex-Presidente da America’s Hernia Society.
“Surgery is the first and the highest division of the healing art,
pure in itself, perpetual in its applicability, a working product
of heaven and sure of fame on earth”
Sushruta (400 B.C.)
HISTÓRICO
Figura 1 – Em 1901, a cavidade abdominal de uma grávida foi examinada por
Dimitri von Ott, que empregou um espéculo introduzido via colpotomia
Fonte: http//eleboo.e-bookshelf.de/products/reading-epub/product
A primeira tentativa de visualização de um órgão humano interno foi efetivada por Philipp Bozzini, em
Frankfurt, no ano de 1806, quando inspecionou a
uretra com uma cânula de duplo lúmen; um lúmen
transmitia a luz emitida por uma vela e o outro servia
para observação. A cirurgia laparoscópica foi inicialmente introduzida, no início do século passado, por
Dimitri von Ott, Georg Kelling e Hans Christian Jacobaeus. Von Ott, ginecologista russo, inspecionou a
cavidade abdominal de uma grávida em 1901, usando
um espelho frontal como fonte luminosa e inserindo um espéculo vaginal através da parede abdominal,
para observação interna (Figura 1). No mesmo ano
Jacobaeus publicou seu primeiro relato da chamada “laparotoracoscopia” (Figura 2). Ainda em 1901
Kelling, cirurgião alemão de Dresden, descreveu a
celioscopia, técnica pela qual enchia o abdômen de
cão vivo com ar e inseria um cistoscópio de Nitze
para inspecionar as vísceras (Figura 3). Nos anos seguintes vários autores na Europa e Estados Unidos
realizaram laparoscopias para fins diagnósticos. Em
1910, Jacobaeus publicou estudo de laparoscopias realizadas em doentes, descrevendo lesões hepáticas e
peritonite tuberculosa. Foi somente com a introdução
dos sistemas ópticos e da iluminação por fibras de
luz fria que o procedimento tornou-se mais popular,
especialmente nos serviços ginecológicos1-10.
Figura 2 – Hans Christian Jacobaeus, sueco, creditado como tendo realizado a primeira toracoscopia, em
1901, utilizando um cistoscópio
Fonte: http://archsurg.jamanetwork.com/article.aspx?articleid=396242
Figura 3 – Georg Kelling, cirurgião alemão,
geralmente creditado como tendo realizado a primeira laparoscopia, em 1901
Fonte: http//eleboo.e-bookshelf.de/products/
reading-epub/product
v. 3 n. 8
41
Skinovsky et al.
Em 1929, a introdução de lentes de visão oblíqua por
Kalk tornou a laparoscopia amplamente aceita como
meio diagnóstico.
Em 1938, na Hungria, Janus Veress inventou uma agulha para induzir pneumotórax em tuberculosos, na área
pré-antibióticos.
Na década de 1950, na Inglaterra, Hopkins e Kapany
introduziram a tecnologia das fibras ópticas na endoscopia, ampliando ainda mais o uso da laparoscopia
diagnóstica.
A laparoscopia no campo da cirurgia geral era somente
utilizada, em geral, para diagnóstico de doenças hepáticas e trauma abdominal, até que Lukichev em 1983 e
Muhe em 1985 divulgaram suas técnicas para a realização de colecistectomia laparoscópica em humanos.
Suas técnicas, em certa forma rudimentares, não receberam atenção adequada na época.
Kurt Semm, ginecologista, foi o primeiro a realizar
apendicectomia laparoscópica em 1981(Figura 4). Este
cirurgião e engenheiro alemão desenvolveu um aparelho de insuflação automática, para monitorar a pressão
intra-abdominal e o fluxo de gás. Até hoje, diversos
instrumentos e técnicas inventadas por Semm são amplamente utilizadas, como a eletrocoagulação, tesouras
em gancho, morceladores, instrumental para irrigação
e aspiração, aplicadores de clipes e outros11-20.
em seguida realizou diversas destas cirurgias, porém
o principal responsável pela divulgação meteórica do
método nos Estados Unidos e mundo foi Jacques Perissat (Figura 6), de Bordeaux , que realizou a cirurgia
poucos dias após os primeiros e que publicou a primeira grande série de casos desta cirurgia. Perissat confidenciou que tentou, em vão, espaço para demonstrar a técnica no Congresso SAGES americano em
1989. Conseguiu então um videocassete emprestado,
acoplou-o a uma televisão e deixou o vídeo correndo
em um dos corredores da conferência; logo dezenas
de cirurgiões assistiam boquiabertos aquela espetacular demonstração.
Figura 5 – Philippe Mouret – realizador da primeira colecistectomia
videolaparoscópica
Fonte: http://www.huliq.com/32578/
honda-foundation
Figura 4 – Kurt Semm, cirurgião alemão pioneiro da videocirurgia
Figura 6 – Professor Jacques Perissat (centro) – pioneiro da videocirurgia, com
Professores James Skinovsky (à direita daquele) e Mauricio Chibata (à esquerda)
Fonte:
html
http://www.repromedizin.de/dgrm-informationen/geschichte.
Erich Muhe realizou colecistectomia laparoscópica em
1985, porém seu procedimento foi limitado ao acesso
à cavidade peritoneal através de um trocarte de grande
diâmetro.
No ano de 1987, mais precisamente no dia 17 de março daquele ano, em Lyon na França, Philippe Mouret
(Figura 5) realizou a primeira colecistectomia laparoscópica completada pelo método. Francois Dubois
42
Em poucas semanas a notícia de uma técnica que fez
o aforisma “grandes cirurgiões, grandes incisões” cair
inapelavelmente ao chão espalhou-se como rastilho de
pólvora aos principais centros cirúrgicos do mundo.
Logo formadores de opinião se deram conta que estavam diante de um método capaz de rivalizar com grandes revoluções médicas mundiais, como a antissepsia
de Sammelweiss, a anestesia de Horace Wells e Tho-
v. 3 n. 8
Videocirurgia: De onde viemos e para onde vamos?
mas Morton, a descoberta da microflora de Thomas
Cock, os antibióticos de Fleming e outros.
Em 4 de Outubro de 1990, a European Association
for Endoscopic Surgery (EAES) foi fundada em Paris. Noventa e quatro cirurgiões de 10 países estavam
presentes21-30.
Desde então, um consórcio informal formado por cirurgiões e a indústria desenvolveram, em velocidade
assustadora, novos e melhores equipamentos para a
realização das então chamadas videocirurgias, especialmente sistemas ópticos, monitores especializados,
fontes de luz fria e insufladores mais potentes. Novas
fontes de energia igualmente apareceram e se desenvolveram, como o bisturi ultrassônico, ao largo de
lançamentos de instrumentos e grampeadores especializados e inovadores. Devido a isto, novas e mais
complexas cirurgias foram sendo realizadas por esta
abordagem. Contraindicações iniciais como doenças
com processos inflamatórios importantes e cirurgias
oncológicas foram caindo uma a uma e hoje praticamente todas as cirurgias abdominais, respeitados os
limites patológicos individuais, podem ser realizadas
pelo método visualizado pelo pioneiros de 1901, mais
de um século atrás.
diminuindo a necessidade do aprendizado de ética
discutível em pacientes e animais de experimentação.
Agora podemos treinar o quanto quisermos, pelo tempo que tivermos disponível. Novas tecnologias estão
a nossa porta, como a surpreendente cirurgia guiada
por imagem, onde imagens escaneadas do corpo do
próprio paciente serão projetadas, guiando o cirurgião
pela anatomia real.
A telecirurgia promete cirurgias a distância, acessíveis
para aqueles que necessitarem nos locais mais ermos,
como em estações espaciais e marinheiros no vasto
oceano.
A nanotecnologia permitirá para breve que pequenos
robôs passeiem pelo nosso corpo, diagnosticando doenças, desobstruindo vasos, fazendo biópsias e cauterizando sangramentos.
Utopia? Possivelmente Bozzini, aquele que inspecionou a uretra em 1806, também achava.
Bem-vindos ao admirável mundo da Cirurgia Minimamente Invasiva!
NOVAS TECNOLOGIAS, ABORDAGENS E O
ENSINO DA VIDEOCIRURGIA
1. Utterback JM. Mastering the dynamics of innovation. Boston:
Harvard Business School Press; 1994.
2. Christensen CM. The innovator’s dilemma: the revolutionary
book that will change the way you do business. New York: HarperCollins; 1997:15-16.
3. Roberts EB. Innovation: driving product, process, and market
change. San Francisco: Jossey-Bass; 2002.
4. Cosgrove DM. The innovation imperative. J Thorac Cardiovasc
Surg. 2000 Nov;120(5):839-42.
5. The American Heritage Dictionary of the English Language, 4th
ed. Houghton Mifflin; 2004.
6. Jones JW, McCullough LB, Richman BW. Ethics of surgical innovation to treat rare diseases. J Vasc Surg. 2004 Apr;39(4):918-9.
7. History of Technology. Encyclopaedia Britannica; 2004.
8. Gorden A. The history and development of endoscopic surgery.
London: Saunders; 1993.
9. Gotz F, et al. The history of laparoscopy. In: Color atlas of laparoscopic Surgery. New York; 1993.
10. Modlin IM, Kidd M, Lye KD. From the lumen to the laparoscope. Arch Surg. 2004;139:1110-1126.
11. Lau WY, Leow CK, Li AK. History of endoscopic and laparoscopic surgery. World J Surg. 1997;21:444-453.
12. Litynski GS. Endoscopic surgery: the history, the pioneers.
World J Surg. 1999;23:745-753.
13. Rosin D. History. In: Minimal Access Medicine and Surgery.
Oxford: Radcliffe Medical; 1993:1-9.
14. Desormeaux A.J. De l’endoscopie, instrument proper a éclairer
certaines cavités intérieures de l’économie. In: Compte rendu des
séances de l’academie des sciences. Paris: Bachelier; 1855.
15. Desormeaux AJ. De l’endoscope et de ses applications au diagnostic et au traitement des affections de l’urèthre et de la vessie.
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Paralelamente ao desenvolvimento da videocirurgia,
novas tecnologias e abordagens surgiram e vêm despontando como a Minilaparoscopia, NOTES – Natural Orifices Translumenal Endoscopic Surgery, LESS
- Laparoendoscopic Single-Site Surgery e a Cirurgia
Robótica31-43.
A capacidade de registro em vídeo de todas as cirurgias
facilitou enormemente a difusão e o ensino da abordagem videocirúrgica. Cirurgiões são agora capazes
de revisar suas próprias cirurgias, aprender com seus
erros e ensinar de maneira didática seus pares em desenvolvimento técnico.
A internet rápida facilita a comunicação em tempo real,
a transmissão de cirurgias ao vivo, a troca de experiências em sites especializados e chats, bem como cursos didáticos pela web e transmissões de eventos científicos,
permitindo acesso ao conhecimento fácil e barato, sem
limite de distância. Em breve aplicativos para dispositivos móveis como telefones celulares e tablets incrementarão o desenvolvimento científico na área.
A realidade virtual deixou de ser exclusivamente utilizada no treinamento de pilotos na área da aviação
e invadiu o campo do treinamento da videocirurgia,
v. 3 n. 8
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