Pedro Ferraina

Natural orifice surgery: initial clinical experience

BackgroundNatural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience.MethodsUnder an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance.ResultsNine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred.ConclusionThe limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.

Robotic-assisted heller myotomy versus laparoscopic heller myotomy for the treatment of esophageal achalasia: multicenter study

Laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups.

Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy

IntroductionThere have been attempts to minimize the invasiveness of laparoscopic cholecystectomy by reducing the size and/or the number of the operating ports and instruments. These attempts create technical challenges related principally to retraction and triangulation necessary to expose the surgical field for a safe surgery. A new technique based on retraction and triangulation with magnetic instruments for single port laparoscopic surgery is presented.MethodsBetween March 2007 and December 2008, 40 laparoscopic cholecystectomies were performed with single-port laparoscopic surgery with the assistance of magnetic forceps (IMANLAP™ project). The surgical technique is described, and the intraoperative and postoperative course of the patients is assessed.ResultsThere were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. Depending on the patient’s anatomy, a 1-mm needle was added in some cases. There were no interactions observed between the magnetic devices and the anesthetic monitoring and the rest of the devices of the operation room.ConclusionsThis new procedure is feasible and safe. The main goal is control of the magnetic field, allowing enough controlled strength for retraction and sufficient triangulation for adequate exposure of the surgical field. This allows for the use of a single port through which an optic device with a working channel can perform the operation with safety. Finally, the procedure can be performed in a manner similar to the traditional laparoscopic cholecystectomy, and it also appears to be simple to learn.

Relation between postoperative infections and gallbladder bile leakage during laparoscopic cholecystectomies

AbstractBackground: In 1,577 laparoscopic cholecystectomies, 111 due to acute and 1,466 due to chronic cholecystitis, the incidence of intraoperative gallbladder rupture and its relationship with abdominal wound infections were evaluated. Methods: A sampling test for binomial proportions and a binomial approximation test for discrete data were employed for statistical analysis. Gallbladder accidental opening took place in 250 (19%) out of the 1,466 chronic and in 44 (40%) out of the 111 acute cholecystitis, disclosing a statistically significant difference (p<0.01). Postoperatively, there were 32 (2%) surgical wound infections, 17 (1.3%) in the absence of gallbladder injury and 15 (5%) when gallbladder injury was observed, likewise showing a statistically significant difference (p<0.05). Results: It should be pointed out that all 32 wound infections involved the umbilical incision, of which 3 with chronic suppuration required reintervention where remnants of stones were found in the parietal route. The seven with symptomatic abdominal fluid resolved without specific treatment. As regards the seven intraabdominal infections, two remitted with antibiotics and five required percutaneous drainage. There was no significant correlation between the presence of cavity fluid abdominal collections or infections and bile spillage. Conclusion: Gallbladder injury proved more frequent in laparoscopic cholecystectomies performed due to acute cholecystitis, while bile spillage increased the incidence of umbilical wound infection, particularly in the presence of remnants of stones, but there was no correlative increase in the incidence of intraabdominal collections or infections.

Primary segmental infarction of the greater omentum: a rare cause of RLQ syndrome: laparoscopic resection.

The authors report a rare case of a patient with a primary segmental infarction of the greater omentum who reported acute abdominal pain. Despite preoperative clinical studies and imaging evaluation, an etiologic diagnosis could not be determined. The diagnosis of this uncommon disease was determined after initial laparoscopic exploration. A laparoscopic resection was performed. The patient had an uneventful recovery and was discharged within 12 hours. The differential diagnosis of the right lower quadrant syndrome includes several disorders, of which the primary segmental infarction of the greater omentum is not frequent. The authors emphasize the usefulness of routine laparoscopic exploration in patients with RLQ syndrome because it adds the possibility of mini-invasive treatment to the initial diagnosis.

Fluorescence Cholangiography in Laparoscopic Cholecystectomy Experience in Argentina

The frequency of laparoscopic cholecystectomies in Argentina has increased in the last few years. The use of intraoperative methods for the detection of bile ducts such as intraoperative cholangiography (IOC) varies within the country although it is a routine procedure in our workplace. Surgical injuries in bile ducts remain a constant, amounting to about 0.4%. This is the reason why we have been looking for an easy alternative to IOC, with the aim to reduce those numbers. Sponsored by the company Karl Storz, in 2011 we started performing fluorescence cholangiography in our laparoscopic cholecystectomies; we have kept those records prospectively and now have a total of 65 cases. The use of this method seems promising with some clear advantages such as its low cost, real-time performance and the possibility to visualize structures before they are sectioned. We have been able to visualize the main bile duct without dissection in 89.5% of the cases. Areas that still need improvement include some technical issues such as the depth for visualization in obese patients or in those with severe or substantially chronic inflammatory stages where the light cannot penetrate tissues appropriately.

Fluorescein Detection of Myocardial Ischemia in an Experimental Model of Acute Coronary Occlusion

The objective was to evaluate the feasibility and sensitivity of fluorescein to determine and delineate an ischemic area in an experimental model of acute coronary occlusion. The studies were performed at the center for experimental Surgery at Hospital de Clinicas “Jose de San Martin.” All animal protocols were approved by the Institutional Animal Care and Use Committee (IACUC) at University of Buenos Aires. All animals were maintained in a pathogen-free environment throughout the experiments. We used ten New Zeeland rabbits. They served as their own control model. All the experiments were performed under general anesthesia with tracheostomy. Median sternotomy was performed and the second diagonal artery was ligated. The infracted area was evaluated under xenon and UV (530 nm) light after the administration of 0.01 mg/kg fluorescein Fluorescein 10 % was intravenously administrated. Electrocardiogram (EKG), pulse oximetry, heart rate (HR), Troponin, CPK, CPK-MB, and LDH were determined postoperatively. All the animals were euthanized at the end of the experiment and the heart was harvested for histopathologic examination. Biochemical (enzymatic) and electrocardiography analyses were performed at baseline and at 90 min after complete occlusion of the second diagonal artery: Baseline (BL) and post-ischemic (PI) measurements were performed for LDH, CPK, CPK-MB, and Troponin. ST segment elevation of 1.8 ± 0.65 mm was detected in every case after coronary artery occlusion. Oxygen saturation and heart rate were 97 ± 2 % and 145 ± 5 % respectively. Enzymes results are: LDH (BL) 159.7 ± 112.2 (U/L) vs LDH (PI) 1,012 ± 359.9 (U/L) (p < 0.001). CPK (BL) 1,072 ± 121.7 (U/L) vs. CPK (PI) vs. 359.5 ± 95.7 (U/L) (p < 0.001), CPK-MB (BL) 0.89 ± 0.42 (ng/ml) vs CPK-MB (PI) vs. 3.89 ± 1.9 (ng/ml) (p < 0.001), Troponin (BL) 0.06 ± 0.06 (ng/ml) vs. Troponin (PI) 19.6 ± 5.9 (ng/ml) (p < 0.001). The xenon light failed to demonstrate any changes in the ischemic area. However, when evaluated under the UV (530 nm wave length) light, a clearly demarcated area lacking fluorescence can be appreciated. The area represented 0.7225 ± 0.39 cm2 in the anterior aspect of the myocardium distal to the ligated vessel. This was correlated and confirmed by microscopic evaluation. This study serves as a proof of principle that fluorescein detection of myocardial ischemia in an experimental model of acute coronary occlusion is feasible, sensitive, and reproducible. However, further clinical studies are required to understand if the findings of our study could be extrapolated into human studies.

Past, Present, and Future of Fluorescence

It is important to define fluorescence. There are several ways to describe this term: (1) the emission of electromagnetic radiation, especially of visible light, stimulated in a substance by the absorption of incident radiation and persisting only as long as the stimulating radiation is continued. (2) Emitting light during exposure to radiation from an external source. (3) Luminescence that is caused by the absorption of radiation at one wavelength followed by nearly immediate reradiation usually at a different wavelength and that ceases almost at once when the incident radiation stops. The common denominators for this term are a source of radiation, the absorption of this radiation, and the emission of a modified radiation that ends immediately as the source stops emitting radiation. Chemically speaking, fluorescence is brought about by absorption of photons in the singlet ground state promoted to a singlet excited state. The spin of the electron is still paired with the ground state electron. As the excited molecule returns to ground state, it involves the emission of a photon of lower energy, which corresponds to a longer wavelength, than the absorbed photon and therefore lower energy, than the absorbed radiation.

Elegir a la cirugía como especialidad: Opiniones de los estudiantes de la Universidad de Buenos Aires sobre la cirugía y los cirujanos

INTRODUCTION Since the number of applicants to residencies in general surgery in Argentina seems to be decreasing, we designed this work with the objective of studying the factors considered undesirable by students when choosing surgery as a specialty. MATERIAL AND METHODS Between March and April 2012, one-hundred students were surveyed with a structured questionnaire with true/false binary answers in an observational case-control design. The survey contained 26 statements that made reference to characteristics of surgery as a specialty, or about the personality and lifestyle of surgeons, as they could be perceived by students. As a control group the same survey was applied to 20 surgeons who were in contact with the students and that could represent a role model for them during their rotation in surgery. RESULTS Comparison between students and surgeons showed no difference in most answers, except in «surgery has poor reimbursement» (OR: 8,9; P=.0001), «there is not enough job demand» (OR: 8,1; P=.015), «surgery restrains intellectual development» (OR: 17,5; P=.014), «surgeons have too many non-scheduled activities» (OR: 9,36; P=.024), «they have a limited patient-physician relationship» (OR: 3,61; P=.009), «they have little time for family» (OR: 4,27; P=.036) and «they are exposed to infectious diseases» (OR: 5,90; P=.007). CONCLUSIONS Women would be as interested as men in working as surgeons; a remarkable fact when considering that the surgical specialties have been predominantly filled by men. The fact that surgeons mostly coincide with the views of students means that role models should be reviewed to promote vocations.