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BACKGROUND: This study is aimed to evaluate the pulmonary recruitment maneuver as a means to effectively reduce residual pneumoperitoneum and postoperative shoulder pain in patients undergoing conventional laparoscopic procedures and compare it to the instillation of intraperitoneal anesthetics. METHODS: Patients undergoing laparoscopic cholecystectomy, appendectomy or hernioplasty were randomized into two groups: pulmonary recruitment maneuver (PRM) and intraperitoneal anesthetic instillation (IAI). Six hours after surgery patients were asked to fill out a visual analog scale to identify shoulder pain and a chest X-ray was taken. Groups were analyzed for incidence of residual pneumoperitoneum and shoulder pain as well as for volume of residual subdiaphragmatic gas and intensity of pain. RESULTS: A total of 84 patients (42 per group) were included in the study. Patients in the PRM group had a lower incidence of subdiaphragmatic gas present in the chest X-ray (29% vs 55%) p = 0.01 and less volume of residual pneumoperitoneum (mean difference -.31(95%CI -7.36, 0.72), p = 0.02). They also were half as likely to present shoulder pain (24% vs 50%) p = 0.01 and showed less pain intensity than those in the IAI group (mean difference -2.04(95%CI - 3.25, - 0.84), p = 0.000). The risk of presenting shoulder pain when residual pneumoperitoneum was present showed an RR = 11.1, p = 0.0001 in the PRM group and an RR = 8.3, p = 0.000 in the IAI group. The volume of subdiaphragmatic gas was positively correlated with the intensity of shoulder pain (r = 0.54, p = 0.000). CONCLUSIONS: The pulmonary recruitment maneuver is effective in reducing the incidence and volume of residual pneumoperitoneum, as well as the incidence and intensity of shoulder pain in patients undergoing conventional laparoscopic procedures.

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Objetivo: Presentar el caso de una paciente con linfangioma cavernoso diagnosticado incidentalmente y tratado quirúrgicamente, primero por laparotomía y después, para su resolución final, mediante laparoscopia. Se discuten las ventajas de la cirugía miniinvasiva como método adyuvante en la resección del linfangioma residual después de una laparotomía extensa. Sede: Hospital de tercer nivel. Diseño: Presentación del caso y revisión de la literatura. Descripción del caso: Mujer de 43 años, en la cual se documentó masa quística aparentemente dependiente del ovario derecho, con marcadores tumorales para cáncer ovárico normales. Se programó para salpingoclasia y resección de quiste ovárico, por incisión Pfannenstiel, encontrando un quiste gigante de origen retroperitoneal, que se extendía desde el hueco pélvico hasta el abdomen superior. Fue extirpado casi en su totalidad, debido a la extensión de la tumoración, excepto en la porción pancreatoduodenal y retrohepática, ya que al intentar abordar esta zona, inició con sangrado transoperatorio y se desconocían las relaciones del tumor con estos órganos. Se difirió la resección de esta porción residual para complementar su estudio por imágenes e histopatología y llevarlo a cabo en un segundo tiempo quirúrgico. La tomografía postoperatoria no mostró dependencia pancreatoduodenal, biliar o vascular. Al mes, se programó para la resección laparoscópica del tumor residual. El reporte histopatológico fue linfangioma cavernoso en ambos casos. Conclusiones: El tratamiento para los linfangiomas retroperitoneales es la resección completa. La cirugía miniinvasiva es una alternativa útil, ventajosa y mejor aceptada por los pacientes en algunas reoperaciones planeadas, donde inicialmente se realizó cirugía abierta.

Objective: To present the case of a woman with cavernous lymphangioma incidentally diagnosed and surgically treated, first through laparotomy and later, for its final resolution, through laparoscopy. We discuss the advantages of mini-invasive surgery as an adjuvant method for the resection of a residual lymphangioma after extensive laparotomy. Setting: Third level health care hospital. Design: Case presentation and review of the literature. Case description: A 43-year-old woman, in whom a cystic mass, apparently depending on the right ovary was documented; tumor markers for ovarian cancer were normal. She was programmed to undergo salpingoplasty and resection of the ovarian cyst, through Pfannenstiel incision. During surgery a giant cyst of retroperitoneal origin was found, which extended from the pelvic hole to the upper abdomen. It was resected almost totally due to the extension of the tumor, except for the pancreatoduodenal and retrohepatic region, because, when attempting to approach this area, transoperative bleeding started and we did not know the relations of the tumor with these organs. The resection of this residual portion was deferred to be able to complement the diagnosis with imaging and histopathology studies and perform the resection at a second surgical time. Postoperative tomography revealed no pancreatoduodenal, biliary, or vascular dependence. After 1 month, the patient was programmed for laparoscopic resection of the residual tumor. The histopathological report corresponded to cavernous lymphangioma in both situations. Conclusions: Treatment of retroperitoneal lymphangiomas consists of complete resection. Mini-invasive surgery is a useful, valuable option and a better accepted alternative by patients in some planned re-operations where initially open surgery had been performed.

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BACKGROUND: Acute cholecystitis is the second most common surgical emergency in pregnant women. Although laparoscopic cholecystectomy has been described previously in these cases, there is still controversy regarding the most appropriate moment in which to perform the procedure. OBJECTIVE: To describe the clinical presentation and management of a female with 36.6 weeks of pregnancy and clinical signs of acute cholecystitis. Cesarean section to deliver a healthy newborn was immediately followed by laparoscopic cholecystectomy without complications. A 10 year literature review complements the analysis and discussion of the case. CLINICAL CASE: A 33 year-old female with 36.6 weeks of gestation presented a history of 24 hours with right upper quadrant and epigastric abdominal pain, nausea and vomiting. Symptoms were precipitated by cholecystokinetics and did not subside after expectant and pharmacologic medical treatment. The medical group decided with the patient's consent to interrupt the pregnancy via Cesarean section immediately followed by laparoscopic cholecystectomy. RESULTS: After Cesarean section through a Pfannenstiel incision, laparoscopic trocars were placed and cholecystectomy performed without complications. The postsurgical course was favorable and both patient and newborn were discharged on day four. CONCLUSIONS: Laparoscopic surgery cholecystectomy during pregnancy and in the immediate puerperium is feasible and safe. These combined procedures: rapid pregnancy interruption followed by a minimal invasive approach gives the benefits of laparoscopic surgery in these patients.

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The solitary fibrous nodule is a rare clinical disease that mainly affects the pleura, but has been occasionally described in other anatomical sites. This type of tumors can have malignant components and therefore it is important to differentiate them from other retroperitoneal masses. We describe the case of a patient with ectopic pregnancy in whom a solitary fibrous nodule with laparoscopy was found. A peritoneal pelvic tumor with smooth surface, 20,2 g, firm was detected. The mass was independent of colon, uterus, ovaries or salpinx and was very near to the iliac vessels on the right side. A small fragment was biopsied and sent to trans surgical histopathology study and the rest of the mass was removed completely without complications. The histopathologic report described that the tumor contained sclerosed cells with collagenous bands and sings of hemorrhage and calcification, compatible with a benign pelvic solitary fibrous tumor. The solitary fibrous nodule is a rare, benign disease, but with malignant potential. These tumors must be resected when they are incidentally found during other surgical procedures or if diagnosed preoperatively. The laparoscopic approach has advantages in the identification and resection these tumors.

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