José Reinan Ramos

Stapled hemorrhoidectomy: Initial experience of a Latin American group

The purpose of the present study was to determine the value of circular emorrhoidectomy (procedure for prolapse and hemorrhoids [PPH]) on the basis of data collected prospectively during the initial experience of a group of Latin American surgeons. Between 2000 and 2001, PPH was performed using a circular stapler in 177 patients who had third- and fourth-degree hemorrhoidal disease. The average age of the patients was 47.7 years (range 26 to 85 years). Anal bleeding was the most common preoperative complaint (93.2%) followed by anal pain (60.2 %), anal itching (43%), and constipation (41 %). Hemorrhoids were classified as third degree in 132 patients (74%) and fourth degree in 45 patients (25.4%). Skin tags were detected in 86 patients (48.8%) and rectocele in 14 patients (7.9%). Data collected included patient demographics, type of anesthesia, and specific details of the surgery such as duration of the operation, distance from the staple line to the dentate line, need for complementary hemostasis, and any unexpected occurrences. Postoperative data collected included the degree of pain, which was evaluated on the basis of the type and dosage of analgesics required, laxative consumption, and the presence of bleeding, fever, urinary retention, or hematomas. Each patient completed a written questionnaire addressing these events. Patients returned for follow-up visits on days 7, 15, 30, and 90. Responses to pain, bleeding, fever, anal continence, recurrence of hemorrhoids, and level of satisfaction were compiled. The duration of the procedure ranged from 6 minutes to 2 hours (average 2 3 minutes), and most operations lasted no more than 20 minutes, with the exception of one that lasted 2 hours because of intraoperative bleeding. Intraoperative problems were minor. An additional one or a few sutures were required in 58.7% of patients to achieve perfect hemostasis. In 128 patients (72.3%) the hospital stay was less than 24 hours. Same-day surgery was chosen for 37 patients (20.9%). Pain was controlled with analgesia only using one to six doses of oral dipirona in 126 patients. Five patients were readmitted to the hospital: four for control of bleeding and one for conventional hemorrhoidectomy due to an acute episode of external hemorrhoidal thrombosis. At day 30, patients rated the efficacy of the procedure in alleviating preoperative symptoms as follows: 77.5% excellent; 16% good; 5.3% average, and 1.2% poor. At 3 months postoperatively no patient had had a recurrence of hemorrhoidal prolapse, and there were no instances of stenosis or anal incontinence. Surgeons also rated the efficacy of the procedure as excellent in 75%, good in 19.8%, average in 4.7%, and poor in 0.6%. With proper selection of patients and adequate stapling technique, stapled hemorrhoidectomy may be considered safe; it is easily learned, has a satisfactory degree of pain, and is well accepted by both patients and surgeons.

Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

Ressecção anterior ultrabaixa e interesfinctérica do reto com anastomose coloanal por videolaparoscopia

The author present the laparoscopic coloanal anastomosis and intersphincteric resection technique to treat patients with very low rectal cancer. The operative steps are: 1 - Patient positioning; 2 - Instruments and equip positioning; 3 - Insertion of the ports; 4 - Preparation of the operative field; 5 - Difining and dividing the inferior mesenteric artery and vein by the medial approach; 6 - Mobilization of splenic flexure and sigmoid colon; 7 - rectal mobilization and total mesorectum excision by Rullier technique; 8 - Rectal division and coloanal anastomosis; 9 - intersphincteric resection and coloanal anastomosis by coloplasty, J pouch or latero-to-end techniques. The technique employed is safe and have presented low rate of complication and no mortality.

Tratamento cirúrgico do câncer da porção distal do têrço inferior do reto pela ressecção anterior ultrabaixa e interesfinctérica com anastomose coloanal por videolaparoscopia

PURPOSES: The main purpose of this study was to evaluate the postoperative complications, the length of the hospital stay, the clinic functional results, and the oncological outcome at 2,5 years follow-up of patients with very low rectal cancer treated by laparoscopic coloanal anastomosis and intersphincteric resection. PATIENTS AND METHODS: 491 patients were treated by laparoscopic colorectal surgery, 13 of 172 with rectal cancer were selected and prospectively evaluated. All with very low rectal cancer, 9 female. No patient T4 or with complete response to quimioirradiation was selected. Quimioirradiation was used in 8 patients. RESULTS: The postoperative complication rate was 23,1% and the anastomotic fistulas rate was 7,7%. No patients died postoperatively. 61,5% of the patients were discharged before 7 days of hospital stay. The median number of harvested lymphnodes was 13. Mean distal tumor-free margin was 1,5 cm. Circumferential margin was positive in 1 case (7,7%). Fecal incontinence was related in 41% of the patients and fracionned evacuations in 91%. Eleven patients (84%) have related good quality of life. One patient is with definitive stoma (7,7%). With median follow-up of 30 months, there were one local recurrence (7,7%) and two cases of lung metastases (15,4 %). All, the three patients died of the diseases. Ten patients are survived (77%) without disease. CONCLUSIONS: Analysis of results led to the following conclusions: a) The technique employed is safe and have presented low rate of complication and no mortality; b) The use of this technique have permited short length of the hospital stay; c) Functional results were regular , but colostomy was avoid in 92,3% of the patients; d) The use of this technique does not compromise the oncological outcome at a median follow-up of 30 months.

Modelo de programa de treinamento em cirurgia robótica e resultados iniciais

Objective: to describe the implementation of a training program in robotic surgery and to point the General Surgery procedures that can be performed with advantages using the robotic platform. Methods: we conducted a retrospective analysis of data collected prospectively from the robotic surgery group in General and Colo-Retal Surgery at the Samaritan Hospital (Rio de Janeiro, Brazil), from October 2012 to December 2015. We describe the training stages and particularities. Results: two hundred and ninety three robotic operations were performed in general surgery: 108 procedures for morbid obesity, 59 colorectal surgeries, 55 procedures in the esophago-gastric transition area, 16 cholecystectomies, 27 abdominal wall hernioplasties, 13 inguinal hernioplasties, two gastrectomies with D2 lymphadenectomy, one vagotomy, two diaphragmatic hernioplasties, four liver surgeries, two adrenalectomies, two splenectomies, one pancreatectomy and one bilio-digestive anastomosis. The complication rate was 2.4%, with no major complications. Conclusion: the robotic surgery program of the Samaritan Hospital was safely implemented and with initial results better than the ones described in the current literature. There seems to be benefits in using the robotic platform in super-obese patients, re-operations of obesity surgery and hiatus hernias, giant and paraesophageal hiatus hernias, ventral hernias with multiple defects and rectal resections.Objective: to describe the implementation of a training program in robotic surgery and to point the General Surgery procedures that can be performed with advantages using the robotic platform. Methods: we conducted a retrospective analysis of data collected prospectively from the robotic surgery group in General and Colo-Retal Surgery at the Samaritan Hospital (Rio de Janeiro, Brazil), from October 2012 to December 2015. We describe the training stages and particularities. Results: two hundred and ninety three robotic operations were performed in general surgery: 108 procedures for morbid obesity, 59 colorectal surgeries, 55 procedures in the esophago-gastric transition area, 16 cholecystectomies, 27 abdominal wall hernioplasties, 13 inguinal hernioplasties, two gastrectomies with D2 lymphadenectomy, one vagotomy, two diaphragmatic hernioplasties, four liver surgeries, two adrenalectomies, two splenectomies, one pancreatectomy and one bilio-digestive anastomosis. The complication rate was 2.4%, with no major complications. Conclusion: the robotic surgery program of the Samaritan Hospital was safely implemented and with initial results better than the ones described in the current literature. There seems to be benefits in using the robotic platform in super-obese patients, re-operations of obesity surgery and hiatus hernias, giant and paraesophageal hiatus hernias, ventral hernias with multiple defects and rectal resections.