Marcelo de Paula Loureiro

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).

Simpatectomia lombar retroperitoneal endoscópica

In the last few years, there has been an increase in the indication of lumbar sympathectomy for plantar hyperhidroses. There are few reports of the laparoscopic access for this operation, even when it seems to be a very apropriate method. A case of a left lumbar sympathectomy through the retroperitoneal endoscopic approach is presented. The total control of left plantar hiperhidroses was achieved, showing the effectiveness of this operation, completely feasible through extraperitoneal endoscopic route.

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.

Impact of continuous training through distributed practice for acquisition of minimally invasive surgical skills

BackgroundMinimally invasive surgery (MIS) requires the mastery of manual skills and a specific training is required. Apart from residencies and fellowships in MIS, other learning opportunities utilize massive training, mainly with use of simulators in short courses. A long-term postgraduate course represents an opportunity to learn through training using distributed practice.ObjectiveThe objective of this study is to assess the use of distributed practice for acquisition of basic minimally invasive skills in surgeons who participated in a long-term MIS postgraduate course.MethodsA prospective, longitudinal and quantitative study was conducted among surgeons who attended a 1-year postgraduate course of MIS in Brazil, from 2012 to 2014. They were tested through five different exercises in box trainers (peg-transfer, passing, cutting, intracorporeal knot, and suture) in the first (t0), fourth (t1) and last, eighth, (t2) meetings of this course. The time and penalties of each exercise were collected for each participant. Participant skills were assessed based on time and accuracy on a previously tested score.ResultsFifty-seven surgeons (participants) from three consecutive groups participated in this study. There was a significant improvement in scores in all exercises. The average increase in scores between t0 and t2 was 88% for peg-transfer, 174% for passing, 149% for cutting, 130% for intracorporeal knot, and 120% for suture (p < 0.001 for all exercises).ConclusionLearning through distributed practice is effective and should be integrated into a MIS postgraduate course curriculum for acquisition of core skills.

THE ROLE OF THE SLEEVE GASTRECTOMY AND THE MANAGEMENT OF TYPE 2 DIABETES

ABSTRACT Background : Currently, bariatric surgery has promoted weight loss and improved glycemic control in obese patients through different techniques, including vertical sleeve gastrectomy. Aim : Present and update the different vertical sleeve gastrectomy ways of action, both in the treatment of obesity and diabetes, approaching its potential effect on gastrointestinal physiology, as well as the benefits achieved by this manipulation. Methods : Pubmed database search was used crossing the headings: obesity, type 2 diabetes and sleeve gastrectomy. Results : Published data have shown that short-term weight loss tends to be higher in patients undergoing vertical sleeve gastrectomy compared to Roux-en-Y gastric bypass. In relation to glycemic control, the procedure demonstrated remission of diabetes in up to 60% after one year of surgery. After three years, however, differences in remission rate between surgical and clinical group was not observed, questioning the durability of the technical in a long-term. Conclusion : Despite showing good results, both in the weight loss and co-morbidities, conflicting results reinforce the need for more studies to prove the efficiency of the vertical sleeve gastrectomy as well as to understand its action about the molecular mechanisms involved in the disease.

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.