ABSTRACT BACKGROUND: One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and incisional hernia development. The choice of the fascial closure method and closing with minimal tension and trauma is crucial for optimal results, emphasizing the importance of uniform pressure along the suture line to withstand intra-abdominal pressure. AIMS: To evaluate the resistance to pressure and tension of stapled and sutured hand-sewn fascial closure in the abdominal wall. METHODS: Nine abdominal wall flaps from human cadavers and 12 pigs were used for the experimentation. An abdominal defect was induced after the resection of the abdominal wall and the creation of a flap in the cadaveric model and after performing a midline incision in the porcine models. The models were randomized into three groups. Group 1 was treated with a one-layer hand-sewn small bite suture, Group 2 was treated with a two-layer hand-sewn small bite suture, and Group 3 was treated with a two-layer stapled closure. Tension measurements were assessed in cadaveric models, and intra-abdominal pressure was measured in porcine models. RESULTS: In the human cadaveric model, the median threshold for fascial rupture was 300N (300-350) in Group 1, 400N (350-500) in Group 2, and 350N (300-380) in Group 3. Statistical comparisons revealed non-significant differences between Group 1 and Group 2 (p=0.072, p>0.05), Group 1 and Group 3 (p=0.346, p>0.05), and Group 2 and Group 3 (p=0.184, p>0.05). For porcine subjects, Group 1 showed a median pressure of 80 mmHg (85-105), Group 2 had a median of 92.5 mmHg (65-95), and Group 3 had a median of 102.5 mmHg (80-135). Statistical comparisons indicated non-significant differences between Group 1 and Group 2 (p=0.243, p>0.05), Group 1 and Group 3 (p=0.468, p>0.05), and Group 2 and Group 3 (p=0.083, p>0.05). CONCLUSIONS: Stapled and conventional suturing resist similar pressure and tension thresholds. BACKGROUND development results intraabdominal intra AIMS handsewn hand sewn METHODS experimentation groups onelayer one layer twolayer two RESULTS N 300350 300 350 (300-350 350500 500 (350-500 300380 380 (300-380 nonsignificant non significant p=0.072, p0072 p 0 072 (p=0.072 p>0.05, p005 p>0.05 , 05 p>0.05) p=0.346, p0346 346 (p=0.346 p=0.184, p0184 184 (p=0.184 p>0.05. . subjects 8 85105, 85105 85 105 (85-105) 925 92 5 92. 6595, 6595 65 95 (65-95) 1025 102 102. 80135. 80135 135 (80-135) p=0.243, p0243 243 (p=0.243 p=0.468, p0468 468 (p=0.468 p=0.083, p0083 083 (p=0.083 CONCLUSIONS thresholds 30035 30 35 (300-35 35050 50 (350-50 30038 38 (300-38 p=0.072 p007 07 (p=0.07 p00 p>0.0 p=0.346 p034 34 (p=0.34 p=0.184 p018 18 (p=0.18 8510 10 (85-105 9 659 6 (65-95 8013 13 (80-135 p=0.243 p024 24 (p=0.24 p=0.468 p046 46 (p=0.46 p=0.083 p008 08 (p=0.08 3003 (300-3 3505 (350-5 p=0.07 (p=0.0 p0 p>0. p=0.34 p03 (p=0.3 p=0.18 p01 (p=0.1 851 (85-10 (65-9 801 (80-13 p=0.24 p02 (p=0.2 p=0.46 p04 4 (p=0.4 p=0.08 (300- (350- p=0.0 (p=0. p>0 p=0.3 p=0.1 (85-1 (65- (80-1 p=0.2 p=0.4 (300 (350 p=0. (p=0 p> (85- (65 (80- (30 (35 p=0 (p= (85 (6 (80 (3 p= (p (8 (

RESUMO RACIONAL: Uma das principais complicações associadas a grandes incisões em cirurgia abdominal é o risco aumentado de ruptura do fechamento fascial e desenvolvimento de hérnia incisional. A escolha do método de fechamento fascial e o fechamento com tensão e trauma mínimos é crucial para resultados ideais, enfatizando a importância da pressão uniforme ao longo da linha de sutura, para suportar a pressão intra-abdominal. OBJETIVOS: Avaliar a resistência à pressão e tensão do fechamento fascial grampeado e suturado à mão na parede abdominal. MÉTODOS: Nove retalhos de parede abdominal de cadáveres humanos e 12 suínos foram empregados para experimentação. Um defeito abdominal foi induzido após a ressecção da parede abdominal e criação de um retalho no modelo cadavérico e após a realização de uma incisão na linha média nos modelos suínos. Os modelos foram randomizados em três grupos. O Grupo 1 foi tratado com uma sutura manual continua, em uma camada, o Grupo 2 foi tratado com uma sutura manual continua, em duas camadas e o Grupo 3 foi tratado com um fechamento grampeado de duas camadas. As medidas de tensão foram avaliadas em modelos cadavéricos e a pressão intra-abdominal foi medida em modelos suínos. RESULTADOS: No modelo cadavérico humano, o limiar médio para ruptura fascial foi de 300N (300-350) no Grupo 1, 400N (350-500) no Grupo 2 e 350N (300-380) no Grupo 3. As comparações estatísticas não revelaram diferenças significativas entre Grupo 1 e Grupo 2 (p=0,072, p>0,05), Grupo 1 e Grupo 3 (p=0,346, p>0,05) e Grupo 2 e Grupo 3 (p=0,184, p>0,05). Nos suínos, o Grupo 1 apresentou uma pressão mediana de 80 mmHg (85-105), o Grupo 2 teve uma mediana de 92,5 mmHg (65-95) e o Grupo 3 teve uma mediana de 102,5 mmHg (80-135). As comparações estatísticas indicaram diferenças não significativas entre Grupo 1 e Grupo 2 (p=0,243, p>0,05), Grupo 1 e Grupo 3 (p=0,468, p>0,05) e Grupo 2 e Grupo 3 (p=0,083, p>0,05). CONCLUSÕES: As suturas grampeadas e convencionais resistem a limiares de pressão e tensão semelhantes. RACIONAL incisional ideais intraabdominal. intraabdominal intra OBJETIVOS MÉTODOS experimentação grupos continua camada RESULTADOS humano N 300350 300 350 (300-350 350500 500 (350-500 300380 380 (300-380 p=0,072, p0072 p 0 072 (p=0,072 p>0,05, p005 p>0,05 , 05 p=0,346, p0346 346 (p=0,346 p=0,184, p0184 184 (p=0,184 p>0,05. . 8 85105, 85105 85 105 (85-105) 925 92 5 92, 6595 65 95 (65-95 1025 102 102, 80135. 80135 135 (80-135) p=0,243, p0243 243 (p=0,243 p=0,468, p0468 468 (p=0,468 p=0,083, p0083 083 (p=0,083 CONCLUSÕES semelhantes 30035 30 35 (300-35 35050 50 (350-50 30038 38 (300-38 p=0,072 p007 07 (p=0,07 p00 p>0,0 p=0,346 p034 34 (p=0,34 p=0,184 p018 18 (p=0,18 8510 10 (85-105 9 659 6 (65-9 8013 13 (80-135 p=0,243 p024 24 (p=0,24 p=0,468 p046 46 (p=0,46 p=0,083 p008 08 (p=0,08 3003 (300-3 3505 (350-5 p=0,07 (p=0,0 p0 p>0, p=0,34 p03 (p=0,3 p=0,18 p01 (p=0,1 851 (85-10 (65- 801 (80-13 p=0,24 p02 (p=0,2 p=0,46 p04 4 (p=0,4 p=0,08 (300- (350- p=0,0 (p=0, p>0 p=0,3 p=0,1 (85-1 (65 (80-1 p=0,2 p=0,4 (300 (350 p=0, (p=0 p> (85- (6 (80- (30 (35 p=0 (p= (85 ( (80 (3 p= (p (8

ABSTRACT Schistosomiasis is an infectious disease caused by parasitic flatworms of the genus Schistosoma. The species Schistosoma mansoni is associated with hepatosplenic disease. Schistosomiasis involving the gallbladder alone is highly unusual, with a few cases reported. Herein, we present the case of a woman from a region with endemic schistosomiasis who presented with a painless solid lesion and wall thickening of the gallbladder. She underwent an uneventful laparoscopic cholecystectomy. Microscopic examination of the surgical specimen revealed Schistosoma mansoni eggs associated with granulomatous reaction, leading to the diagnosis of schistosomiasis of the gallbladder, prompting subsequent treatment with praziquantel and follow-up. This case illustrates the importance of suspicion for this diagnosis in endemic areas, as it can be misdiagnosed with malignancy if not examined microscopically. Complications and treatment strategies are poorly characterized for the few cases of schistosomiasis; reporting this case can serve as a helpful reminder of a rare presentation of this disease. unusual reported Herein cholecystectomy reaction followup. followup follow up. up follow-up areas microscopically

ABSTRACT BACKGROUND: Robotic-assisted surgery research has grown dramatically in the past two decades and the advantages over traditional videolaparoscopy have been extensively debated. For hernias, the robotic system can increase intraoperative strategies, especially in complex hernias or incisional hernias. AIMS: This study aimed to compare the direct cost differences between robotic and laparoscopic hernia repair and determine each source of expenditure that may be related to the increased costs in a robotic program from the perspective of a Brazilian public institution. METHODS: This study investigated the differences in direct costs from the data generated from a trial protocol (ReBEC: RBR-5s6mnrf). Patients with incisional hernia were randomly assigned to receive laparoscopic ventral incisional hernia repair (LVIHR) or robotic ventral incisional hernia repair (RVIHR). The direct medical costs of hernia treatment were described in the Brazilian currency (R$). RESULTS: A total of 19 patients submitted to LVIHR were compared with 18 submitted to RVIHR. The amount spent on operation room time (RVIHR: 2,447.91±644.79; LVIHR: 1,989.67±763.00; p=0.030), inhaled medical gases in operating room (RVIHR: 270.57±211.51; LVIHR: 84.55±252.34; p=0.023), human resources in operating room (RVIHR: 3,164.43±894.97; LVIHR: 2,120.16±663.78; p<0.001), material resources (RVIHR: 3,204.32±351.55; LVIHR: 736.51±972.32; p<0.001), and medications (RVIHR: 823.40±175.47; LVIHR: 288.50±352.55; p<0.001) for RVIHR was higher than that for LVIHR, implying a higher total cost to RVIHR (RVIHR: 14,712.24±3,520.82; LVIHR: 10,295.95±3,453.59; p<0.001). No significant difference was noted in costs related to the hospital stay, human resources in intensive care unit and ward, diagnostic tests, and meshes. CONCLUSION: Robotic system adds a significant overall cost to traditional laparoscopic hernia repair. The cost of the medical and robotic devices and longer operative times are the main factors driving the difference in costs. BACKGROUND Roboticassisted assisted debated strategies AIMS institution METHODS ReBEC (ReBEC RBR5s6mnrf. RBR5s6mnrf RBRsmnrf RBR 5s6mnrf . s mnrf RBR-5s6mnrf) (LVIHR (RVIHR) R$. R R$ (R$) RESULTS 1 (RVIHR 2,447.91±644.79 24479164479 2 447 91 644 79 1,989.67±763.00 19896776300 989 67 763 00 p=0.030, p0030 p p=0.030 , 0 030 p=0.030) 270.57±211.51 2705721151 270 57 211 51 84.55±252.34 845525234 84 55 252 34 p=0.023, p0023 p=0.023 023 p=0.023) 3,164.43±894.97 31644389497 3 164 43 894 97 2,120.16±663.78 21201666378 120 16 663 78 p<0.001, p0001 p<0.001 001 3,204.32±351.55 32043235155 204 32 351 736.51±972.32 7365197232 736 972 823.40±175.47 8234017547 823 40 175 47 288.50±352.55 2885035255 288 50 352 14,712.24±3,520.82 1471224352082 14 712 24 520 82 10,295.95±3,453.59 1029595345359 10 295 95 453 59 p<0.001. stay ward tests meshes CONCLUSION smnrf RBR-5s6mnrf (R$ 2,447.91±644.7 2447916447 44 9 64 7 1,989.67±763.0 1989677630 98 6 76 p003 p=0.03 03 270.57±211.5 270572115 27 5 21 84.55±252.3 84552523 8 25 p002 p=0.02 02 3,164.43±894.9 3164438949 4 89 2,120.16±663.7 2120166637 12 66 p000 p<0.00 3,204.32±351.5 3204323515 20 35 736.51±972.3 736519723 73 823.40±175.4 823401754 17 288.50±352.5 288503525 28 14,712.24±3,520.8 147122435208 71 52 10,295.95±3,453.5 102959534535 29 45 (R 2,447.91±644. 244791644 1,989.67±763. 198967763 p00 p=0.0 270.57±211. 27057211 84.55±252. 8455252 3,164.43±894. 316443894 2,120.16±663. 212016663 p<0.0 3,204.32±351. 320432351 736.51±972. 73651972 823.40±175. 82340175 288.50±352. 28850352 14,712.24±3,520. 14712243520 10,295.95±3,453. 10295953453 2,447.91±644 24479164 1,989.67±763 19896776 p0 p=0. 270.57±211 2705721 84.55±252 845525 3,164.43±894 31644389 2,120.16±663 21201666 p<0. 3,204.32±351 32043235 736.51±972 7365197 823.40±175 8234017 288.50±352 2885035 14,712.24±3,520 1471224352 10,295.95±3,453 1029595345 2,447.91±64 2447916 1,989.67±76 1989677 p=0 270.57±21 270572 84.55±25 84552 3,164.43±89 3164438 2,120.16±66 2120166 p<0 3,204.32±35 3204323 736.51±97 736519 823.40±17 823401 288.50±35 288503 14,712.24±3,52 147122435 10,295.95±3,45 102959534 2,447.91±6 244791 1,989.67±7 198967 p= 270.57±2 27057 84.55±2 8455 3,164.43±8 316443 2,120.16±6 212016 p< 3,204.32±3 320432 736.51±9 73651 823.40±1 82340 288.50±3 28850 14,712.24±3,5 14712243 10,295.95±3,4 10295953 2,447.91± 24479 1,989.67± 19896 270.57± 2705 84.55± 845 3,164.43± 31644 2,120.16± 21201 3,204.32± 32043 736.51± 7365 823.40± 8234 288.50± 2885 14,712.24±3, 1471224 10,295.95±3, 1029595 2,447.91 2447 1,989.67 1989 270.57 84.55 3,164.43 3164 2,120.16 2120 3,204.32 3204 736.51 823.40 288.50 14,712.24±3 147122 10,295.95±3 102959 2,447.9 244 1,989.6 198 270.5 84.5 3,164.4 316 2,120.1 212 3,204.3 320 736.5 823.4 288.5 14,712.24± 14712 10,295.95± 10295 2,447. 1,989. 270. 84. 3,164. 31 2,120. 3,204. 736. 823. 288. 14,712.24 1471 10,295.95 1029 2,447 1,989 3,164 2,120 3,204 14,712.2 147 10,295.9 102 2,44 1,98 3,16 2,12 3,20 14,712. 10,295. 2,4 1,9 3,1 2,1 3,2 14,712 10,295 2, 1, 3, 14,71 10,29 14,7 10,2 14, 10,

RESUMO RACIONAL: A pesquisa em cirurgia robótica assistida cresceu dramaticamente nas últimas duas décadas e as vantagens sobre a videolaparoscopia tradicional têm sido amplamente debatidas. Para as hérnias, o sistema robótico pode aumentar as estratégias intraoperatórias, principalmente em hérnias complexas ou hérnias incisionais. OBJETIVOS: Comparar as diferenças de custo direto entre a hernioplastia incisional robótica e a laparoscópica e determinar cada fonte de gasto que pode estar relacionada ao aumento de custos em um programa de robótica na perspectiva de uma instituição pública brasileira. MÉTODOS: Investigar as diferenças nos custos diretos dos dados gerados a partir de um protocolo de ensaio clínico (ReBEC: RBR-5s6mnrf). Pacientes com hérnia incisional foram aleatoriamente designados para serem submetidos a reparo robótico ou laparoscópico (RVIHR). Os custos foram descritos na moeda brasileira (R$). RESULTADOS: Dezenove pacientes submetidos à cirurgia robótica foram comparados com dezoito submetidos à cirurgia laparoscópica. O valor gasto com tempo de centro cirúrgico (Robótica: 2.447,91±644,79; Robótica: 1.989,67±763,00; p=0,030), gases medicinais inalados em centro cirúrgico (Robótica: 270,57±211,51; Robótica: 84,55±252,34; p=0,023), recursos humanos em centro cirúrgico (Robótica: 3.164,43±894,97; Laparoscópica: 2.120,16±663,78; p<0,001), recursos materiais (Robótica : 3.204,32±351,55; Robótica: 736,51±972,32; p<0,001) e medicamentos (Robótica: 823,40±175,47; Robótica: 288,50 ± 352,55; p<0,001) para cirurgia robótica foi maior que cirurgia laparoscópica, implicando em maior custo total para cirurgia robótica (Robótica: 14.712,24±3.520,82; Laparoscópica: 10.295,95±3.453,59; p<0,001). Não foi observada diferença significativa nos custos relacionados à permanência hospitalar, recursos humanos em UTI e enfermaria, exames diagnósticos e telas. CONCLUSÕES: O sistema robótico adiciona um custo global significativo à hernioplastia incisional laparoscópica tradicional. O custo dos dispositivos médicos e robóticos, além de tempos cirúrgicos mais prolongados, são os principais fatores que impulsionam a diferença nos custos. RACIONAL debatidas intraoperatórias incisionais OBJETIVOS MÉTODOS ReBEC (ReBEC RBR5s6mnrf. RBR5s6mnrf RBRsmnrf RBR 5s6mnrf . s mnrf RBR-5s6mnrf) RVIHR. RVIHR (RVIHR) R$. R R$ (R$) RESULTADOS Robótica 2.447,91±644,79 24479164479 2 447 91 644 79 1.989,67±763,00 19896776300 1 989 67 763 00 p=0,030, p0030 p p=0,030 , 0 030 p=0,030) 270,57±211,51 2705721151 270 57 211 51 84,55±252,34 845525234 84 55 252 34 p=0,023, p0023 p=0,023 023 p=0,023) 3.164,43±894,97 31644389497 3 164 43 894 97 Laparoscópica 2.120,16±663,78 21201666378 120 16 663 78 p<0,001, p0001 p<0,001 001 3.204,32±351,55 32043235155 204 32 351 736,51±972,32 7365197232 736 972 823,40±175,47 8234017547 823 40 175 47 28850 288 50 288,5 352,55 35255 352 14.712,24±3.520,82 1471224352082 14 712 24 520 82 10.295,95±3.453,59 1029595345359 10 295 95 453 59 p<0,001. hospitalar enfermaria telas CONCLUSÕES robóticos prolongados smnrf RBR-5s6mnrf (RVIHR (R$ 2.447,91±644,7 2447916447 44 9 64 7 1.989,67±763,0 1989677630 98 6 76 p003 p=0,03 03 270,57±211,5 270572115 27 5 21 84,55±252,3 84552523 8 25 p002 p=0,02 02 3.164,43±894,9 3164438949 4 89 2.120,16±663,7 2120166637 12 66 p000 p<0,00 3.204,32±351,5 3204323515 20 35 736,51±972,3 736519723 73 823,40±175,4 823401754 17 2885 28 288, 352,5 3525 14.712,24±3.520,8 147122435208 71 52 10.295,95±3.453,5 102959534535 29 45 (R 2.447,91±644, 244791644 1.989,67±763, 198967763 p00 p=0,0 270,57±211, 27057211 84,55±252, 8455252 3.164,43±894, 316443894 2.120,16±663, 212016663 p<0,0 3.204,32±351, 320432351 736,51±972, 73651972 823,40±175, 82340175 352, 14.712,24±3.520, 14712243520 10.295,95±3.453, 10295953453 2.447,91±644 24479164 1.989,67±763 19896776 p0 p=0, 270,57±211 2705721 84,55±252 845525 3.164,43±894 31644389 2.120,16±663 21201666 p<0, 3.204,32±351 32043235 736,51±972 7365197 823,40±175 8234017 14.712,24±3.520 1471224352 10.295,95±3.453 1029595345 2.447,91±64 2447916 1.989,67±76 1989677 p=0 270,57±21 270572 84,55±25 84552 3.164,43±89 3164438 2.120,16±66 2120166 p<0 3.204,32±35 3204323 736,51±97 736519 823,40±17 823401 14.712,24±3.52 147122435 10.295,95±3.45 102959534 2.447,91±6 244791 1.989,67±7 198967 p= 270,57±2 27057 84,55±2 8455 3.164,43±8 316443 2.120,16±6 212016 p< 3.204,32±3 320432 736,51±9 73651 823,40±1 82340 14.712,24±3.5 14712243 10.295,95±3.4 10295953 2.447,91± 24479 1.989,67± 19896 270,57± 2705 84,55± 845 3.164,43± 31644 2.120,16± 21201 3.204,32± 32043 736,51± 7365 823,40± 8234 14.712,24±3. 1471224 10.295,95±3. 1029595 2.447,91 2447 1.989,67 1989 270,57 84,55 3.164,43 3164 2.120,16 2120 3.204,32 3204 736,51 823,40 14.712,24±3 147122 10.295,95±3 102959 2.447,9 244 1.989,6 198 270,5 84,5 3.164,4 316 2.120,1 212 3.204,3 320 736,5 823,4 14.712,24± 14712 10.295,95± 10295 2.447, 1.989, 19 270, 84, 3.164, 31 2.120, 3.204, 736, 823, 14.712,24 1471 10.295,95 1029 2.447 1.989 3.164 2.120 3.204 14.712,2 147 10.295,9 102 2.44 1.98 3.16 2.12 3.20 14.712, 10.295, 2.4 1.9 3.1 2.1 3.2 14.712 10.295 2. 1. 3. 14.71 10.29 14.7 10.2 14. 10.