Scarless laparoscopic repair of epigastric hernia in children

Background Despite the small size of the incision, the scar left by open repair of epigastric hernia in children is unaesthetic. Few laparoscopic approaches to epigastric hernia repair have been previously proposed, but none has gain wide acceptance from pediatric surgeons. In this study, we present our experience with a scarless laparo- scopic approach using a percutaneous suturing technique for epigastric hernia repair in children. Methods Ten consecutive patients presenting with epi- gastric hernia 15 mm or further from the umbilicus were submitted to laparoscopic hernia repair. A 5-mm 308-angle laparoscope is introduced through a umbilical trocar and a 3-mm laparoscopic dissector is introduced through a stab incision in the right flank. After opening and dissecting the parietal peritoneum, the fascial defect is identified and closed using 2–0 polyglactin thread through a percutaneous suturing technique. Intraoperative and postoperative clinical data were collected. Results All patients were successfully submitted to la- paroscopic epigastric hernia repair. Median age at surgery was 79 months old and the median distance from the um- bilicus to the epigastric defect was 4 cm. Operative time ranged from 35 to 75 min. Every hernia was successfully closed without any incidents. Follow-up period ranges from 2 to 12 months. No postoperative complications or recurrence was registered. No scar was visible in these patients. Conclusion This scarless laparoscopic technique for epi- gastric hernia repair is safe and reliable. We believe this technique might become gold standard of care in the near future

Five really easy steps to build a homemade low-cost simulator

Published online march 2012Aim. The aim of this study was to evaluate how simple it is to build a homemade low-cost simulator using a simple 5-step scheme. Methods. A scheme explaining how to build an endoscopic surgery simulator in 5 easy steps was presented to 26 surgeons. The simulator required a pair of scissors and easy-to-find materials. Its total cost was less than €35. The participants assessed the simulator using common endoscopic training toys or ex vivo tissue and completed an anonymous query comparing it with other commercial simulators that they had experienced before. Results. In all, 84.6% found the simulator really easy to build. Every participant felt that he or she could do the same simulator themselves. Comparing with other commercial available box simulators, the majority of participants found the homemade simulator easier to (a) mount and dismount, (b) transport, (c) clean, and (d) use when practicing alone. Conclusions. Anyone can build its own simulator for a small amount of money.The author(s) received no financial support for the research, authorship, and/or publication of this article

The quality of demographic data in 1804 comparing Paraíba do Norte (Brazil), Angola and Goa

O estudo da população do Império Português conta com um vasto corpus de dados estatísticos, desde meados do século xviii. No entanto, estas fontes revelam uma grande diversidade de conteúdos, devido à organização de dados e a realidades sociais diferentes. Esta circunstância pressupõe a necessidade de se proceder a uma análise muito cuidadosa da qualidade das fontes, antes de identificar e reconstruir os principais indicadores emográficos da população colonial. É nosso objetivo proceder, de forma exploratória, a uma crítica interna das fontes e analisar, sempre que possível, a qualidade dos dados através de métodos testados, em mapas de 1804 de Goa, Angola e Paraíba do Norte (Brasil).The study of the Portuguese empire population has a vast corpus of statistical data since middle eighteenth century. However, these sources reveal a great diversity in contents, due to the data organization and different social realities. This circumstance presupposes the need to proceed to a very careful analysis of sources quality, before identifying and rebuild the main demographic indicators of the colonial population. It is our goal to proceed in an exploratory manner, and to do an internal critique analysis of the sources, and analyze always as possible the quality of data by tested methods, in 1804 charts of Goa, Angola and Paraíba do Norte (Brazil).info:eu-repo/semantics/publishedVersio

Hybrid thoracic NOTES : a translational research project

Tese de doutoramento em MedicinaNatural Orifice Transluminal Endoscopic Surgery (NOTES) is considered the next step on minimally invasive surgery. NOTES uses endoscopes entering through any single or combination of natural orifices - mouth, urethra, vagina, and anus, in order to perform surgery inside the thorax or the abdomen. Its main purpose is providing scarless and less painful surgery to patients. To perform NOTES in the thorax, gastroenterologists and surgeons have focused mainly on transesophageal access. Although the esophagus gives a direct access to the mediastinum and the pleural cavity, this hollow tube is in direct relation with important vital organs, namely heart, great vessels, vagus and phrenic nerves and all the respiratory tract. This makes an inside-out esophagotomy very risky. We suggested adding a single transthoracic port, in order to visualize and control the exact site of esophagotomy creation. We hypothesized that this hybrid approach would also be useful to tackle some of the hurdles of transesophageal endoscopic surgery. A single transthoracic port would permit the introduction of rigid instruments (for effective triangulation and counter-traction), insufflation of carbon dioxide (CO2) and monitoring pneumothorax pressure. The aims of this PhD thesis were delineated to test the reliability of hybrid thoracic NOTES to perform thoracoscopic complex procedures. We carried out three experimental protocols in the porcine model with survival assessment - upper lobe pulmonary lobectomy, left atrial appendage (LAA) ligation, and thymectomy. In this last protocol we tested hybrid transesophageal access in the human cadaver. In all the experiments, transesophageal access was created under transthoracic thoracoscopic visual control without incidents. Instruments were inserted both through the esophagus and through the thoracic wall, permitting dissection, coagulation, ligation and suture, mimicking the two hands of a surgeon. All the procedures had pneumothorax pressure controlled by connecting a CO2 insufflator tube to the transthoracic port. The site of transthoracic entry was useful for postoperative drainage. Taking all together, the results of our experiments prove that hybrid thoracic NOTES is reliable. Looking at the recent widespread of submucosal endoscopic dissection in esophageal procedures, in particular the per-oral endoscopic myotomy (POEM) for achalasia patients, we believe that translation of thoracic NOTES to humans might not take long. When time comes, we should keep in mind that hybrid thoracic NOTES is the safest way to go.A Cirurgia Endoscópica Transluminal por Orifício Naturais, mais conhecida por NOTES (Natural Orifice Transluminal Endoscopic Surgery) é considerada o próximo passo evolutivo na cirurgia minimamente invasiva. O NOTES utiliza endoscópios introduzidos por um ou mais orifícios naturais – boca, uretra, vagina e ânus, de forma a permitir a execução de cirurgias dentro do tórax ou do abdómen. Os principais objectivos do NOTES são oferecer ao doente uma cirurgia sem cicatriz e menos dolorosa. No NOTES torácico, gastroenterologistas e cirurgiões têm se focado a sua atenção no acesso transesofágico. Embora o esófago permita um acesso directo à cavidade pleural e ao mediastino, este tubo oco está em relação directa com órgãos vitais, nomeadamente o coração, os grandes vasos, os nervos vagos e frénicos assim como a maior parte do trato respiratório. Isto faz da esofagotomia de dentro para fora, um procedimento arriscado. O nosso grupo sugeriu acrescentar ao acesso transesofágico um port único trans-torácico, de forma a conseguir-se um bom controlo visual do local da esofagotomia. Colocámos a hipótese de esta abordagem híbrida poder ser a solução de outros problemas do NOTES transesofágico. A introdução de um port trans-torácico permitiria a introdução de instrumentos rígidos (para uma triangulação e contra-tracção eficazes), a insuflação de dióxido de carbono e a monitorização da pressão do pneumotórax criado. Os objectivos desta tese foram desenhados para testar a eficácia e a segurança do NOTES torácico híbrido na execução de procedimentos toracoscópicos complexos. Foram realizados três protocolos experimentais no modelo do porco com sobrevida – lobectomia pulmonar superior esquerda, laqueação do apêndice auricular esquerdo e timectomia. Testámos também o acesso transesofágico híbrido no cadáver humano. Em todas as experiências, o acesso transesofágico foi criado sob contolo toracoscópico trans-torácico, sem incidentes. Os instrumentos de trabalho foram introduzidos pelo esófago e pela parede torácica permitindo dissecção, coagulação, laqueação e sutura, mimetizando as duas mãos de um cirurgião. Todos os procedimentos foram realizados sob pneumotórax controlado, ligando o insuflador de dióxido de carbono ao port trans-torácico. O local de entrada do port trans-torácico serviu para a colocação do dreno torácico no pós-operatório imediato. Resumindo, os resultados das nossas experiências provam que o NOTES torácico híbrido é seguro e eficaz. Olhando para a recente aceitação e disseminação das técnicas de dissecção endoscópica submucosa para procedimentos no esófago, em particular a miotomia endoscópica para o tratamento da acalásia, acreditamos que a translacção do NOTES torácico poderá ser tentada num futuro muito próximo. Quando esse dia chegar, deveremos ter em mente que o NOTES torácico híbrido é a forma mais segura de o fazer.This project was funded by the FCT Grants project PTDC/SAUOSM/ 105578/2008

Natural Orifice Transesophageal Endoscopic Surgery: State of the Art

The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome

Transesophageal pulmonary lobectomy with single transthoracic port assistance: study with survival assessment in a porcine model

BACKGROUND AND STUDY AIMS: Thoracoscopic pulmonary lobectomy is being performed in an increasing number of patients. The aims of the current study were to assess natural orifice transluminal endoscopic surgery (NOTES) as an alternative to transthoracic endoscopic surgery, and to test the feasibility of peroral transesophageal right upper pulmonary lobectomy with the assistance of a single transthoracic trocar. METHODS: In 10 acute and 4 survival pigs, right upper pulmonary lobectomy was performed using a forward-viewing double-channel gastroscope and an operative thoracoscope with a 5-mm working channel inserted through a single transthoracic 12-mm) port. Time, safety, and feasibility of the following steps were recorded in all animals: esophagotomy, hilar dissection, individual ligation of the hilum elements, pulmonary lobectomy, and specimen retrieval. In the survival experiments, esophagotomy was closed using a reticulated laparoscopy suture device and an esophageal stent was placed. These animals were kept alive and monitored for 2 weeks. RESULTS: Esophagotomy was performed safely in all animals (mean procedure duration 5.4 ± 1.7 minutes). Dissection of the right upper lobe hilum elements (bronchus, arteries, and veins) was carried out without adverse events. Individual ligation of the hilum elements was performed in all but two cases (time for dissection and ligation 44.2 ± 14.8 minutes). Lobectomy and specimen retrieval were completed in all animals (9.5 ± 3.1 minutes). Esophagotomy closure and stent placement were carried out in 20.0 ± 2.8 minutes in the survival animals. These animals fed normally and gained weight postoperatively without signs of disease. Endoscopic examination before necropsy revealed a pseudo-diverticulum in one animal, and wound dehiscence with confined collection/recess in the remaining animals. CONCLUSIONS: Transesophageal right upper pulmonary lobectomy using single transthoracic trocar assistance is feasible and may represent a step towards scar-free pulmonary lobectomy.This project was funded by the FCT Grants project PTDC/SAUOSM/105578/2008

Left atrial appendage ligation with single transthoracic port assistance : a study of survival assessment in a porcine model (with videos)

Background: Left atrial appendage (LAA) exclusion is a well-known procedure for the prevention of stroke in high-risk patients with atrial fibrillation and contraindication to long-term oral anticoagulant therapy. Objective: To evaluate a natural orifice transluminal endoscopic surgery (NOTES) approach for LAA ligation. Design: In 4 acute and 6 survival pigs, we performed LAA by using a forward-viewing, single-channelgastroscope and an operative thoracoscope with a 3-mm working channel (introduced through an 8-mm single transthoracic port). Setting: Animal laboratory. Interventions: The gastroscope was introduced in the thoracic cavity through an esophageal submucosal tunnel. An end loop introduced through the gastroscope was used to legate the LAA. In the survival experiments, the esophageal mucosa was closed using hemoclips. Main Outcome Measurements: The time, safety, and feasibility of the procedure were recorded. In the survival experiments, endoscopy and postmortem examination were performed on postoperative day 14. Results: Creation of a submucosal tunnel and esophagotomy were safely performed in all animals without incidents. The mean time for esophagotomy was 17.0 6.3 minutes. Pericardial dissection and LAA ligation were performed in all animals but 1. The mean time for LAA ligation was 34.4 19.1 minutes. No adverse events occurred during the survival period. Endoscopy showed complete esophageal closure. Postmortem examination revealed pleural adhesions on the site of pericardial dissection, and the LAA was fibrotic with the endoloop in place. Limitations: Animal study. Conclusions: LAA ligation with single transthoracic trocar assistance is feasible and may be an alternative to anticoagulant therapy or to permanent intracardiac implants in patients with atrial fibrillation.This project was funded by the Grants FCT project PTDC/SAU-OSM/105578/2008