RESUMO

A female patient, 59-year-old, was complaining of abdominal pain in the right hypochondrium and mesogastrium for 6 months. Ultrasonography and abdominal computed tomography were performed, both confirming a large hepatic cyst (10.6 cm × 7.6 cm × 7.3 cm) on the left lobe. A hybrid minilaparoscopic resection was proposed. We opted for unroofing the cyst, and the procedure was uneventfully performed, with a total surgical time of 60 min. In the post-operative the patient did well, with minimal abdominal pain, being discharged on the 5th post-operative day, after drain removal due to the use of intravenous antibiotic therapy.

RESUMO

BACKGROUND AND OBJECTIVES: Inguinal hernia repair is among the most common procedures performed worldwide and the laparoscopic totally extraperitoneal (TEP) approach is a recognized and effective surgical technique. Although technically advantageous because of the option of no mesh fixation and no need for creation of a peritoneal flap resulting, in less postoperative pain and faster recovery, TEP has not achieved the popularity it deserves, mainly because of its complexity and steep learning curve. Minilaparoscopy was first described in the 1990s and has recently gained significantly from better instrumentation that may increase TEP's effectiveness and acceptance. We performed a prospective study, to analyze the outcomes of minilaparoscopy in pain and operative time when compared to the conventional laparoscopic technique in hernia repair. METHODS: Fifty-eight laparoscopic inguinal hernia repairs were performed: 36 by traditional laparoscopic technique and 22 by minilaparoscopic instruments (mini). A study protocol was applied prospectively for data collection. Variables analyzed were early postoperative pain (at hour 6 after procedure), pain at discharge, use of on-demand analgesics, and operative time. RESULTS: The mini group presented reduced early postoperative pain and operative time. The present study also suggests less postoperative pain at discharge with mini procedures, although this difference was not statistically significant. No difference between the groups regarding on-demand use of analgesics was found. CONCLUSIONS: This study corroborates findings in previously published papers that have shown the feasibility of minilaparoscopy in laparoscopic TEP hernia repair and its benefits regarding postoperative pain, operative time, and aesthetic outcomes.

Assuntos

Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Telas Cirúrgicas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Recidiva , Resultado do Tratamento

RESUMO

The authors describe the technique they employed to perform needlescopic cholecystectomies in the Núcleo de Hospital de Aeronáutica de Manaus, from September 1997 to May 1999. A complete videolaparoscopic set of equipment was used in the procedure in association to an extra videocapture set for the microlaparoscope (video monitor, microcamera and light source). The procedure is mainly performed with the needlescopic instruments (MiniSite®) inserted in the epigastric, upper right abdominal quadrant and right flanc 2mm trocar sleeves, introduced through the anterior abdominal wall with 10 mm umbilical videolaparoscopic guidance. The microlaparoscope was employed through the epigastric port to monitor the 10 mm clip applier, inserted through the umbilical port to ligate the cistic elements. Likewise, it was employed to monitor gallbladder removal from the abdominal cavity through the umbilical wound. The 2 mm skin wounds were closed with sterile surgical tape. A total of 83 patients (11 males, 72 females), ranging from 17 to 87 years of age, with gallbladder diseases were operated. There was no patient selection in the study but most of the cases (89.2%) did not present inspissated gallbladder walls. The mean operative time was 92 ± 21 min and the average time of hospitalization was 16 h. The main peroperative incident observed was gallbladder puncture with bile leakage to the abdominal cavity (41%), which was considered due to the surgical teams learning curve in the method. Vomits were the main postoperative complication (51.8%) and there was no instance of wound infection. The complete method of needlescopic cholecystectomy was employed in 82% of the patients; in 6% of the patients, a 5 or 10 mm portal had to be put in place of one of the 2 mm to deal with thick walled gallbladders or to correct image problems encountered with the 2 mm laparoscope; in another 6% of the patients, an extra 10 mm suprapubic portal was employed to receive the 10 mm laparoscope when the umbilical portal was used with 5 and 10 mm instruments (in these cases the 2 mm laparoscope was not available due to fiberoptic deterioration). In 3.6 % of the surgeries, the needlescopic method had to be converted to the usual videolaparoscopic one (with two 5 mm and two 10 mm portals). Two operations had to be converted to conventional cholecystectomies (one due to equipment failure and the other due to a solid block of inflammatory adhesions to the hepatic hilar structures). The authors conclude that needlescopic cholecystectomies are feasible, demand the surgical team to go through a new learning curve period and are responsible for a longer operative time due to peculiarities of the instruments and equipment involved.

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Os autores descrevem a técnica que utilizaram para a realização da colecistectomia agulhascópica no Núcleo de Hospital de Aeronáutica de Manaus, de setembro de 1997 a maio de 1999, e os resultados iniciais obtidos em 83 pacientes (11 do sexo masculino e 72 do feminino, com idades variando de 17 a 87 anos) portadores de doenças da vesícula biliar. Empregaram, além de um equipamento completo de videolaparoscopia, um equipamento acessório composto de um monitor de vídeo, uma microcâmera, com seu processador de imagens, e uma fonte de luz, tudo para o laparoscópio de 1,7 mm MiniSite®. A operação foi realizada principalmente sob monitoramento videolaparoscópico de 10 mm pelo portal umbilical e por meio de três portais de 2 mm (epigástrico, hipocôndrio direito e flanco direito). Utilizou-se o videolaparoscópio de 2 mm pelo portal epigástrico quando se procedeu às ligaduras císticas, ocasião em que o laparoscópio de 10 mm umbilical era substituído pelo aplicador de clipes de 10 mm. Da mesma forma, a vesícula foi retirada da cavidade abdominal pelo portal umbilical sob monitoramento videolaparoscópico de 1,7 mm epigástrico. A maioria dos casos operados (89,2%) não apresentava espessamento da parede vesicular. O tempo cirúrgico médio do procedimento foi de 92 ± 21 min e o de internação foi de 16 h. A principal intercorrência operatória foi a perfuração da vesícula biliar (41%), atribuída à curva de aprendizado no método por que passa a equipe. Vômitos foram a principal complicação pós-operatória (51,8%), não tendo havido infecção de ferida operatória. Oitenta e dois por cento dos casos puderam ser terminados pelo método agulhascópico puro, enquanto em 6% e 3,6%, respectivamente, houve necessidade de trocar um dos portais de 2 mm por um de 5 ou de 10 mm e de converter o procedimento para videolaparoscopia usual. Em 6% dos casos, por problemas de imagem com o microlaparoscópio, realizou-se o procedimento agulhascópico com a assistência de um portal suprapúbico de 10 mm. Dois casos (2,4%) tiveram que ser convertidos para laparotomia convencional, um por problemas operacionais com o equipamento e outro por dificuldades técnicas transoperatórias. Os autores concluem ser o procedimento agulhascópico factível, demandar uma nova curva de aprendizado por parte da equipe e ser demorado em virtude das características de seus instrumental e equipamento.