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

Perioperative complications of congenital diaphragmatic hernia repair

Although improvements have been made, the management of congenital diaphragmatic hernia (CDH) remains a major challenge for perinatologists and neonatal surgeons. Many aspects of the disease remain unknown and, being a rare entity, evidence-based data are hard to find. Surgical morbidity is considerable and affects long-term quality of life. Perioperative complications have been reviewed focusing on thoracoscopic repair. Intraoperative acidosis was more severe during thoracoscopy when compared with open surgery (OS), though it is possible that later neurodevelopment was not affected. Even so, strategies have been outlined to reduce acidosis, such as decreasing carbon dioxide (CO2) insufflation after reduction of the herniated viscera into the abdomen is complete. The risk of pleural complications decreased after introduction of gentle ventilation techniques and minimally invasive surgery (MIS); thus, the use of a prophylactic intraoperative thoracic tube is not routinely required. Recurrence rate was higher in large CDH and following MIS repair. Technical demands play an important role, therefore, in avoiding complications; every step of the OS technique must be strictly accomplished. In large defects, the use of prosthetic patch might reduce recurrence rate, even by MIS repair, once again only if technical demands are overcome with meticulous rules of suturing. Thoracoscopy significantly reduced the incidence of bowel obstruction and recovery time and improved cosmesis. The best approach of CDH is yet to be found, and it goes far beyond the management of perioperative complications. Meanwhile randomized controlled studies, namely on the outcome of thoracoscopic repair, are required to inform further practice.info:eu-repo/semantics/publishedVersio

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

Automatic pre-bended customized prosthesis for pectus excavatum minimal invasive surgery correction

Pectus excavatum is the most common deformity of the thorax. A minimally invasive surgical correction is commonly carried out to remodel the anterior chest wall, by employing an intrathoracic convex prosthesis in substernal position. The process of prosthesis modeling and bending still remains an area of improvement. The authors developed a new system, i3DExcavatum, which can automatically model and bend the bar preoperatively based on a thoracic CT-scan. This paper presents a comparison between automatic and manual bending. The i3DExcavatum was used to personalize prosthesis for 41 patients who underwent pectus excavatum surgical correction between 2007 and 2012. Regarding the anatomic variations, the soft tissue thicknesses external to the ribs show that symmetric or asymmetric patients have always asymmetric variations by comparing both patients’ sides. It highlighted that the prosthesis bar should be modeled according to each patient ribs position and dimension. The average differences between the skin and costal line curvature lengths were 84±4 mm and 96±11mm, for male and female patients, respectively. On the other hand, the i3DExcavatum ensured a smooth curvature of the surgical prosthesis and was capable to predict and simulate a virtual shape and size of the bar for asymmetric or symmetric patients. In conclusion, the i3DExcavatum allows preoperative personalization according to the thoracic morphology of each patient. It reduces surgery time and minimizes the margin error induced by the manual bended bar shape that only uses a template that copies the chest wall curvature

Nanovacunas: Diseño de nanoestructuras para inmunización

En la presente tesis doctoral se plantea el diseño y desarrollo racional de nanoestructuras como vehículos para la liberación de antígenos. Para ello, y con el objetivo de incrementar la respuesta inmune a antígenos de distinta naturaleza se eligieron biomateriales tales como polisacáridos, poli aminoácidos y lípidos, con propiedades inmunoestimulantes y/o inmunoadyuvantes. A partir de ellos, se desarrollaran tres tipos de nanoestructuras: i) Sistemas basados en el recubrimiento de antígeno particulados mediante biopolímeros tales como la protamina, la poliarginina, el sulfato de dextrano, el alginato o el polinucleótido, poli (I:C); ii) Nanopartículas de quitosano conteniendo moléculas inmunoestimulantes poly (I:C) encapsulado y asociadas a un péptido T-Helper; iii) Nanoemulsiones y nanoemulsiones recubiertas (nanocápsulas) basados en la lisofosfatidilcolina, el ácido linoléico, el escualeno y el quitosano. Estas nanoestructuras fueran constituidos por nanotecnologías sencillas y fácilmente escalables, tales como la complejación iónica, gelificación iónica y el desplazamiento del solvente según las características de los biomateriales utilizados y de la naturaleza del antígeno a que se destina. Los sistemas desarrollados presentan en general una adecuada estabilidad en suspensión y pudieron ser liofilizados sin alterar sus propiedades fisicoquímicas originales. A estos sistemas se asociaron diferentes antígenos tales como el antígeno recombinante particulado de la hepatitis B y un antígeno peptídico derivado del virus del papiloma humano. Las formulaciones resultantes fueron analizadas mediante una variedad de técnicas in vitro y/o in vivo. En general, las nanoestructuras desarrolladas demostraron tener un interesante potencial como adyuvantes de vacunas, habiendo logrado modular la respuesta inmune frente a antígenos de distinta naturaleza tras su administración parenteral y/o mucosa. Más allá de estos resultados, el trabajo recogido en esta tesis pone de manifiesto el valor que la nanotecnología puede aportar como herramienta excepcional para el desarrollo de nuevos sistemas adyuvantes para vacunas más eficaces y seguras

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

Follow-up of the survivors of congenital diaphragmatic hernia

INTRODUCTION: Survivors of congenital diaphragmatic hernia have increased with the introduction of new treatment modalities and have been reported to experience ongoing medical morbidity until adulthood. AIM: To describe the long-term functional impact of congenital diaphragmatic repair on the survivors of a single institution cohort of newborns over a 14-year period. METHODS: The follow up medical charts of 39 congenital diaphragmatic hernia survivors treated at a tertiary neonatal intensive care unit, from January 1997 to December 2010, were analyzed. RESULTS: The median age at follow up was 70 (4-162) months. Gastrointestinal sequelae were the most common with 12 (30.7%) patients affected by failure to thrive. Chronic lung disease occurred in 5 (12.8%) patients, neurodevelopmental delay in 5 (12.8%), musculoskeletal sequelae in 6 (15.3%), recurrence of hernia in 4 (10.2%) and 2 (7.6%) were deceased. CONCLUSION: Congenital diaphragmatic hernia survivors are a group of patients that requires long term periodic follow up in a multidisciplinary setting to provide adequate support and improve their quality of life

Development and validation of an instrument measuring the strength of the human resource management system

info:eu-repo/semantics/publishedVersio