J. Coloproctol. (Rio J.) vol.37 número2

jcoloproctol(rioj).2017;37(2):140–143

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Minimal

abdominal

incisions

João

Carlos

Magi

,

Bruna

Fernandes

dos

Santos

,

Lucas

Rodrigues

Boarini

,

Pietro

Dadalto

de

Oliveira

,

Galdino

José

Sitonio

Formiga

b_{SociedadeBrasileiradeColoproctologia(SBCP),RiodeJaneiro,RJ,Brazil}

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Articlehistory:

Received24October2016 Accepted18December2016 Availableonline3February2017

Keywords:

Minimalincisionsurgery Minilaparotomy

Minimallyinvasiveprocedures Transitreconstruction

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Minimallyinvasiveproceduresaimtoresolvethediseasewithminimaltraumatothebody, resultinginarapidreturntoactivitiesandinreductionsofinfection,complications,costs andpain.Minimallyincisedlaparotomy,sometimesreferredtoasminilaparotomy,isan exampleofsuchminimallyinvasiveprocedures.Theaimofthisstudyistodemonstrate thefeasibilityandutilityoflaparotomywithminimalincisionbasedontheliteratureand exemplifyingwithacase.Thecaseinquestiondescribesreconstructionoftheintestinal transitwiththeuseofthisincision.Male,young,HIV-positivepatientinalatepostoperative ofileotiflectomy,terminalileostomyandclosingoftheascendingcolonbyanacute perforat-ingabdomen,duetoileocolonictuberculosis.Thebariumenemashowedaproximalstump oftherightcolonneartheileostomy.Theaccesstothecavitywasmadethroughtheorifice resultingfromthereleaseofthestoma,withalateral-lateralileo-colonicanastomosiswith a25mmcircularstaplerandmanualclosureoftheilealstump.Thesesurgeriesrequire theirowntactics,suchasrigorinthelysisofadhesions,tissuetraction,andhemostasis,in additiontorequiringsurgeondexterity–butwithouttheneedforinvestmentsin technol-ogy;moreover,thelearningcurveisreportedasbeinglowerthanthatforvideolaparoscopy. Laparotomywithminimalincisionshouldbeconsideredasavalidandviableoptioninthe treatmentofsurgicalconditions.

©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileirade Coloproctologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Incisões

abdominais

mínimas

Palavras-chave:

Cirurgiacomincisãomínima Minilaparotomia

Procedimentosminimamente invasivos

Reconstruc¸ãodetrânsito

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Procedimentosminimamenteinvasivosvisamresolveradoenc¸acomomínimodetrauma ao organismo, resultando em retorno rápido às atividades, reduc¸ões nas infecc¸ões, complicac¸ões,custosenador.Alaparotomiacomincisãomínima,algumasvezesreferida comominilaparotomia,éumexemplodessesprocedimentosminimamenteinvasivos.O objetivodestetrabalhoédemonstraraviabilidadeeutilidadedaslaparotomiascomincisão mínima combase naliteratura e exemplificando comum caso. Ocaso descreveuma

∗ _{Correspondingauthor.}

E-mail:joao.magi@ig.com.br(J.C.Magi).

http://dx.doi.org/10.1016/j.jcol.2016.12.005

jcoloproctol(rioj).2017;37(2):140–143

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reconstruc¸ãodetrânsitointestinalcomousodestaincisão.Pacientemasculino,jovem, HIV-positivo,pós-operatóriotardiodeileotiflectomia,ileostomiaterminalefechamentodocólon ascendenteporabdomeagudoperfurativodevidoaumatuberculoseíleo-colônica.Enema opacomostravacotoproximaldocólondireitopróximodaileostomia.Oacessoàcavidade foifeitoatravésdoorifícioresultantedaliberac¸ãodoostoma–realizac¸ãodeanastomose íleo-colônicalátero-lateralcomgrampeadorcircularde25mmefechamentomanualdocoto ileal.Estascirurgiasexigemtáticaspróprias,comorigornalisedeaderências,trac¸ãodos tecidosehemostasia,alémdedemandardestrezadocirurgião;contudo,semnecessidadede investimentosemtecnologiae,alémdisso,acurvadeaprendizadoérelatadacomomenor queadavideolaparoscopia.Alaparotomiacomincisãomínimadeveserconsideradacomo opc¸ãoválidaeviávelnotratamentodeafecc¸õescirúrgicas.

©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade Coloproctologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Minimallyinvasiveproceduresare performedtoresolvethe diseasewithminimaltraumatothe body.Thebenefitsare lowerinfectionandcomplicationrates,lowercosts,lesspain, afasterreturn toactivitiesand, especiallyinlaparotomies with minimal incisions, less scarring and, thus, a better estheticresult.1,2

Withagoodindicationandinexperiencedhands, laparo-tomies(fromthe Greek:laparos=abdomen,tomos=cut) with minimalincisionsarebeneficialforthepatient.The minila-parotomyfortuballigation,describedinthelastcentury,is anexample ofthese procedures.3 _{In additiontoimproving}

surgicalprocedures,advancesintechnologyhaveenabledthe surgeontomakemoreaccuratediagnoses,aswellastoshow greaterconfidenceintheproceduretobeperformed,withan increasinguseoflaparotomieswithminimalincisions.4_The

aimofthisstudyistodemonstratethefeasibilityandutilityof thelaparotomywithminimalincision,basedontheliterature andonthecasereported.

Case

report

Male, 27-year-old, brown-colored patient. For the past four years,hehasbeendiagnosedwithHIVandileocolonic tuber-culosisafteranexploratory laparotomy withileotiflectomy, terminalileostomyand ascending colonclosure dueto an acuteperforatingabdomen,withclinicalinstabilityand dif-fuseperitonitis.Alsowithahistoryofmildasthma,controlled since childhood. In the outpatient follow-up, the patient started a treatment forintestinal tuberculosisand regular antiretroviraltherapywiththeinfectologyteam.Ayearago,he underwentalaparotomyduetoanobstructiveacuteabdomen duetoadhesions.InJune2016,thepatientwas referredto theServicetoperformareconstructionoftheintestinal tran-sit,aftercompensationofhisclinicaldiseases.Onphysical examination,weobserved overweight, aglobose abdomen, amedianxiphobicscarwitha15-cmwideincisionalhernia throughoutthesurgicalincision,andanileostomyinhisright flankwithoutprolapse orherniations.Additional examina-tions wereperformed: arectal colonoscopyupto theright

colonwithablindbottom,withnormalmucosa,anda bar-iumenemathatrevealedaproximalstumpoftherightcolon neartheileostomy(Fig.1).

Duringtheinventory,alotoffirmadhesionswerefound between the loops and with a hernia and the wall, mak-ingdifficulttheaccess.Adhesionsofasufficientsegmentof theileumandcolonweredislodged,inordertoperformthe anastomosis.Next,weperformedalateral-lateralileo-colonic anastomosiswitha25-mmcircularstaplerandwithamanual closureoftheilealstump(Fig.2).

Despite the eliminationofflatus onthe first postopera-tive day and the presence of liquid stools on the second day, the patient presented a subocclusive condition, with abdominaldistensionandnausea,necessitatingthepassage ofa nasogastrictube, fasting,and hydrationfor48h. Clin-ically, thepatientrecovereduneventfully afterconservative treatment and was discharged on the seventh postopera-tiveday(Fig.3).Thepatientreturnedtohisusualactivities 30 daysafter surgeryand wasasymptomatic atoutpatient follow-up.

Discussion

In comparisonto the main surgical time, the incisions of access totheabdominalcavity cancause abigger trauma. Aftertheadventofthevideolaparoscopicsurgeries andthe publicationofstudiesrelatedtothesurgicaltraumacaused bytheabdominalwallopening,itwasdemonstratedthatthe largertheincision,thegreaterthemorbidity.Thus, concep-tionssuchas“largeincisions,greatsurgeons”arenolonger universallyaccepted.1_{Anexampleoftheuseofminimal}

inci-sionsinlaparotomiesisthereconstructionoftheintestinal transit,inwhichtheorifice resultingfromstomareleaseis usedasanintra-abdominalaccessinthosecaseswherethe surgeonisabletoreachtheclosedloopfortheanastomosis. Anotherexampleistheremovalofcolontumors,wherethe incisionislargeenoughfortheremovalofthepieceandfor theintroductionofahand,fortheinventoryofthecavity.5,6

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Fig.1–Bariumenemabefore(A)andafter(B)intestinaltransitreconstruction(ITR).Arrow,ostomy.

notjustaminiatureofatraditionallaparotomy,butindeed constituteanothertypeofsurgery.

Laparotomywithminimalincision isconsidereda mini-mallyinvasiveprocedure.Thistypeofprocedureonlyrequires the dexterityof the surgeon, who uses traditional surgical instruments;thus,thereisnoneedformoreinvestmentsto aggregatetechnologywithnewequipment.Thereisindeed alearningcurve;however, authorsreportthat itissmaller thanthatforvideolaparoscopy,since,besidesthe instrumen-talfactor,onehasadirectvision ofthecavityandatactile perception.2,3

Comparedwithtraditionallaparotomies, minimally inci-sionalsurgeriescauselesssurgicaltraumaandentaillower hospitalcosts. Regarding videolaparoscopy, these surgeries

maybeindicatedinsituationsshowingalargeamountoffirm intra-abdominaladhesions,sincetheseareresponsibleforthe maincauseofconversioninlaparoscopicsurgery.Theyalsodo notdifferinthefinalestheticresult,comparedtothe laparo-scopicroute,becausetheydonotaddnewscars,inaddition totheprimaryscar.7,8

According to Souza et al., in the treatment of cha-gasicmegacolon,betterstatisticalresultswereobtainedwith “minilaparotomy”intermsofsurgicaltime,theneedfor post-operative analgesia, the beginning ofan oral diet,time of passageofflatusandlengthofhospitalstayversus videola-paroscopicsurgery.9

Thus,inadditiontorequiringless aggregatetechnology, having a lower cost and requiring less training, minimally

jcoloproctol(rioj).2017;37(2):140–143

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Fig.3–Finalappearanceoftheabdomen.Arrow,ITR incision.

incisedsurgeriesareagoodchoiceinsomesituations,such asinthereconstructionofintestinaltransit,asanalternative tovideolaparotomy,whichpresentaveryvariedincidencein theliteraturewithregardtoconversionratesinthepresence oflargenumbersoffirmintra-abdominaladhesions,asinthe casedescribedinthispaper.8

Conclusion

Laparotomytechniqueswithminimalincisionsshouldbe con-sideredasavalidandviableoptioninthetreatmentofsurgical conditions.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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