Eduardo Aimoré Bonin

Renaissance of Minilaparoscopy in the NOTES and single port era.

The authors suggest that minilaparoscopy should be considered as the most sophisticated evolution of laparoscopic surgery at the present time.

Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches.

A minilaparoscopic combined approach for inguinal hernia appears to be safe and feasible for a more simple endoscopic hernia repair.

Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

IntroductionEsophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique.MethodsBetween January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures.ResultsThe procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively.ConclusionsThoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Development of laparoscopic skills in Medical students naive to surgical training

Objective To assess the acquisition of basic laparoscopic skills of Medical students trained on a surgical simulator. Methods First- and second-year Medical students participated on a laparoscopic training program on simulators. None of the students had previous classes of surgical technique, exposure to surgical practice nor training prior to the enrollment in to the study. Students´ time were collected before and after the 150-minute training. Skill acquisition was measured comparing time and scores of students and senior instructors of laparoscopic surgery Results Sixty-eight students participated of the study, with a mean age of 20.4 years, with a predominance of first-year students (62%). All students improved performance in score and time, after training (p<0,001). Score improvement in the exercises ranged from 294.1 to 823%. Univariate and multivariate analyses identified that second-year Medical students have achieved higher performance after training. Conclusions Medical students who had never been exposed to surgical techniques can acquire basic laparoscopic skills after training in simulators. Second-year undergraduates had better performance than first-year students.

Apendicite aguda pós colonoscopia: desafio diagnóstico e tratamento minimamente invasivo - relato de caso

We present a case of a 54-year-old man with abdominal pain four hours after colonoscopy and upper endoscopy. Since he had had a polipectomy and an ulcer was seen in the terminal ileum, the diagnosis of appendicitis was even more difficult. The authors discuss the rarity of this situation and the minimally invasive approach to treat appendicitis.

Biópsia hepática e peritoneal por laparoscopia ou por notes em suínos: comparação de parâmetros operatórios e evolução pós-operatória

OBJECTIVE To evaluate the impact of NOTES compared to laparoscopic surgery, through the analysis of physiological parameters as well as surgical complications and postoperative outcome, for liver biopsy. METHODS 12 female pigs were divided into two groups: laparoscopy group (GLap) and NOTES group (GNote). The animals underwent liver biopsy by peritoneal laparoscopy or transvaginal endoscopy. The respiratory rate, heart rate, O2 saturation and expiratory concentrations of CO2 were recorded every 10 minutes. In the seventh postoperative day, the animals underwent laparotomy for evaluation of intra-abdominal complications. RESULTS Most of the animals showed weight loss after the procedure, however in no case more than 5%. There was no difference in percentage change in weight between the groups (p = 0.7535). Also, no differences were observed when comparing the averages of ETCO2 (p = 0.4762), and average heart rate (p = 0.6035). However, the GLap showed higher respiratory rate than the GNote (p = 0.0043), as well as the average O2 saturation (p = 0.0080). However, no animal showed SatO2 less than 87% and this difference was not considered clinically significant. Only one GNote animal presented with an operative complication. CONCLUSION NOTES is associated with physiological parameters similar to those found in operative laparoscopy. Performing transvaginal peritonioscopy is not associated with increased postoperative complications when compared to laparoscopy.

Balloon-assisted enteroscopy for suspected Meckel's diverticulum and indefinite diagnostic imaging workup.

Meckel’s diverticulum (MD) is estimated to affect 1%-2% of the general population, and it represents a clinically silent finding of a congenital anomaly in up to 85% of the cases. In adults, MD may cause symptoms, such as overt occult lower gastrointestinal bleeding. The diagnostic imaging workup includes computed tomography scan, magnetic resonance imaging enterography, technetium 99m scintigraphy (99mTc) using either labeled red blood cells or pertechnetate (known as the Meckel’s scan) and angiography. The preoperative detection rate of MD in adults is low, and many patients ultimately undergo exploratory laparoscopy. More recently, however, endoscopic identification of MD has been possible with the use of balloon-assisted enteroscopy via direct luminal access, which also provides visualization of the diverticular ostium. The aim of this study was to review the diagnosis by double-balloon enteroscopy of 4 adults with symptomatic MD but who had negative diagnostic imaging workups. These cases indicate that balloon-assisted enteroscopy is a valuable diagnostic method and should be considered in adult patients who have suspected MD and indefinite findings on diagnostic imaging workup, including negative Meckel’s scan.

Surgical Learning Application (app) for Smartphones and Tablets: A Potential Tool for Laparoscopic Surgery Teaching Courses.

Dear Editor: We present herein our experience in developing a medical application software for smartphone and tablets to be used in laparoscopic surgery teaching courses, such as the one at Jacques Perissat Institute, Brazil. The use of software programs, called medical applications (apps), has increased over recent years among medical students, residents, and surgeons. Although medical apps have become popular as reference for disease diagnosis and medical calculators, many of such programs have been devoted to medical education. In fact, medical apps for medical learning purposes took a step forward regarding app software use, as they rank second in number in 2014 with an estimated 800 apps. In the field of surgery, the number of available apps is relatively small compared with other medical areas, such as anesthesiology and radiology. For instance, for hernia surgery, one of the most common surgical procedures performed worldwide, a review in 2014 mentioned only 6 apps related to learning of anatomy and surgical techniques. Two of them were produced by pharmaceutical and devices companies, concerning their products. As software-learning platforms became part of medical curriculum over the years, the use of apps for medical learning seems natural, since smartphones and tablets are portable and facilitate on-demand access to medical contents. However, doctors’ general perception of medical app quality is low, and most of them agree that there is a need for quality assessment. In a survey of 115 urologists, data showed that they believe peer review (78%) and validation (78%) would be beneficial, and 48% supported regulatory oversight for medical app quality. Despite medical apps seen as a promising surgical learning tool, they lack quality assessment, and there are doubts if they are an effective educational tool. Content quality of medical education is always a concern, especially when electronic information is delivered. Governance and legal framework have been proposed for apps designed to have a direct impact on clinical decisionmaking, including medication dose calculation, adjustment of therapy, and for diagnostic purposes. Despite these efforts, currently there are no formal requirements for quality control for surgical learning apps contents. Boulos et al have listed some requirements for online medical/healthrelated information resources, such as providing authorship information, list of all references or sources of contents, full disclosure of any app sponsorship or potential conflicts of interest, and finally ensuring a balanced and nonbiased coverage of facts. Accuracy of information can be evaluated through peer review, a process in which a panel of experts elaborate a critical analysis of content in which it can be either approved or not. Although it has been considered a “gold standard” method for evaluating scientific merit, one limitation of peer review is low interrater reliability. The number and allocation of reviewers is not well established; a minimum of 3 to 5 reviewers randomly selected from a pool of reviewers seems appropriate. Reviewer analysis may be obtained by a survey, with participants answering a Likert-type questionnaire based on accuracy, quality, and relevance of information. In October 2014, we at the Jacques Perissat Institute, Brazil, conceived a surgical learning app for tablet computer concerning abdominal wall (hernia) surgery (iPad, Apple, Cupertino, CA) including 3 basic elements—text, illustrations, and videos (available at https://itunes.apple. 595322 SRIXXX10.1177/1553350615595322Surgical InnovationPaiz et al research-article2015

Long-term professional performance of minimally invasive surgery post-graduates

OBJECTIVE to evaluate the contribution of a post-graduation program in surgeons professional careers. METHODS participants were asked to answer a questionnaire with questions related to possible changes in their professional performance after the end of the course. RESULTS forty-three (76.7%) of the 56 participants eligible for the study responded to the questionnaires. Most participants, 32 (74.4%), had previous contact with laparoscopic surgery; however, only 14 (32.5%) reported the experience as primary surgeon. The expectations on the course were reached or exceeded for 36 (83.7%) participants. Thirty-seven (86%) incorporated minimally invasive procedures in their daily surgical practice, 37 (86%) reported improvements in their income above 10% and 12% reported income increase of over 100%, directly related to their increase of laparoscopic activity. CONCLUSION the program in minimally invasive surgery provides a high level of satisfaction to its participants, enables them to perform more complex technical procedures, such as sutures, and improves their professional economic performance.

Effectiveness of a reusable low-cost balloon trocar dissection device in the creation of preperitoneal space during endoscopic surgery. An experimental study in swine

PURPOSE To evaluate a new, low-cost, reusable balloon trocar device for dissection of the preperitoneal space during endoscopic surgery. METHODS Twenty swine (weight: 15-37 kg) were randomized to two groups, according to whether the preperitoneal space was created with a new balloon device manufactured by Bhio-Supply (group B) or with the commercially available OMSPDB 1000® balloon device manufactured by Covidien (group C). Quality and size of the created preperitoneal space, identification of anatomic structures, balloon dissection time, total procedure time, balloon resistance and internal pressure after insufflation with 300 mL of ambient air, balloon-related complications, and procedure cost were assessed. RESULTS No significant differences in dissection time, total procedure time, or size of the created preperitoneal space were found between the groups. Balloons in group B had a significantly higher internal pressure compared to balloons in group C. None of the balloons ruptured during the experiment. Three animals in group C had balloon-related peritoneal lacerations. Despite a higher individual device cost, group B had a lower procedure cost over the entire experiment. CONCLUSION The new balloon device is not inferior to the commercially available device in terms of the safety and effectiveness for creating a preperitoneal space in swine.