SUMMARY OBJECTIVE: Robotic surgery is currently on the rise and has been widely applied all over the world. Gynecology offers great opportunities for the development of innovative techniques due to the magnitude of surgical needs. The aim of this study was to correlate perioperative complications, surgical time, and length of hospital stay with surgical diagnosis, procedure performed, and surgeon experience in robot-assisted gynecological surgeries in a 10-year period. METHODS: This was a retrospective, transversal, cross-sectional study involving 632 patients who underwent robotic gynecological surgery from January 2008 to December 2017 in a community hospital in Sao Paulo, Brazil. Medical records of robot-assisted gynecological operations were searched for perioperative complications, operative time, and length of hospital stay, correlating these outcomes with surgical diagnosis, procedure performed, and surgeon experience, considering those with 20 or less robotic procedures and surgeons with more than 20 cases in their career as in-training or qualified surgeons, respectively. RESULTS: Endometriosis (381 cases) was the most common surgical indication, followed by uterine myoma (171 patients). Qualified surgeons had 64% less complications than in-training surgeons (p=0.03) and achieved 20% lower surgical time and 15% shorter length of hospital stay. CONCLUSION: In this study, qualified surgeons with more than 20 robotic procedures had better perioperative outcomes and less complications than in-training surgeons during their first 20 robotic surgeries.

Resumo Objetivo Analisar os resultados perioperatórios e a segurança da realização de cirurgias ginecológicas por laparoscopia robô-assistida durante a implementação da técnica num hospital comunitário ao longo de 6 anos. Métodos Este foi umestudo retrospectivo observacional, comanálise dos prontuários de 274 pacientes que se submeteramà cirurgia robótica de setembro de 2008 a dezembro de 2014. Avaliamos idade, índice de massa corpórea (IMC), diagnóstico, procedimentos realizados, classificação da Sociedade Americana de Anestesiologia (ASA), presença de um preceptor (cirurgião experiente, compelomenos 20casos robóticos), tempocirúrgico, taxa de transfusão, complicações perioperatórias, taxa de conversão, tempo de internação, encaminhamento para Unidade de Terapia Intensiva (UTI) e mortalidade. Comparamos taxa de transfusão, complicações perioperatórias e taxa de conversão entre procedimentos realizados por cirurgiões experientes com a técnica e cirurgiões iniciantes na robótica, sempre assistidos por um preceptor experiente. Resultados Durante o período observado, 3 cirurgiões experientes realizaram 187 cirurgias, enquanto que 87 cirurgias foram realizadas por 20 equipes menos experientes, sempre com a presença de um preceptor. A mediana da idade foi 38 anos, e a mediana do IMC foi 23,3 kg/m2. O diagnósticomais frequente foi endometriose (57%) e a grande maioria das pacientes foi classificada como ASA I ou ASA II (99,6%). O tempo de cirurgia teve uma mediana de 225 minutos, e o tempo de permanência hospitalar teve uma mediana de 2 dias. Observamos 5,8% de taxa de transfusão, 0,8% de taxa de complicações perioperatórias, 1,1% de taxa de conversão para laparoscopia ou laparotomia e não houve pacientes encaminhadas à UTI, nem óbitos. Não houve diferença nos índices de transfusão, complicações e conversão entre cirurgiões experientes e cirurgiões iniciantes na robótica, assistidos por umpreceptor experiente. Conclusão Em nossa casuística, a laparoscopia robô-assistida demonstrou ser uma técnica segura para cirurgias ginecológicas, e a presença de um preceptor experiente foi considerada um ponto de destaque no modelo de segurança adotado para a introdução da cirurgia robótica em ginecologia num hospital de grande volume e, principalmente, na sua expansão entre diversas equipes cirúrgicas, mantendo a segurança das pacientes.

Abstract Objective To analyze the perioperative results and safety of performing gynecological surgeries using robot-assisted laparoscopy during implementation of the technique in a community hospital over a 6-year period. Methods This was a retrospective observational study in which the medical records of 274 patients who underwent robotic surgery from September 2008 to December 2014 were analyzed. We evaluated age, body mass index (BMI), diagnosis, procedures performed, American Society of Anesthesiologists (ASA) classification, the presence of a proctor (experienced surgeon with at least 20 robotic cases), operative time, transfusion rate, perioperative complications, conversion rate, length of stay, referral to the intensive care unit (ICU), and mortality. We compared transfusion rate, perioperative complications and conversion rate between procedures performed by experienced and beginner robotic surgeons assisted by an experienced proctor. Results During the observed period, 3 experienced robotic surgeons performed 187 surgeries,while 87 surgeries were performedby 20 less experienced teams, always with the assistance of a proctor. The median patient age was 38 years, and the median BMI was 23.3 kg/m2. The most frequent diagnosis was endometriosis (57%) and the great majority of the patients were classified as ASA I or ASA II (99.6%). The median operative time was 225 minutes, and the median length of stay was 2 days. We observed a 5.8% transfusion rate, 0.8% rate of perioperative complications, 1.1% conversion rate to laparoscopy or laparotomy, no patients referred to ICU, and no deaths. There were no differences in transfusion, complications and conversion rates between experienced robotic surgeons and beginner robotic surgeons assisted by an experienced proctor. Conclusion In our casuistic, robot-assisted laparoscopy demonstrated to be a safe technique for gynecological surgeries, and the presence of an experienced proctor was considered a highlight in the safety model adopted for the introduction of the robotic gynecological surgery in a high-volume hospital and, mainly, for its extension among several surgical teams, assuring patient safety.

OBJETIVO: Avaliar a relação entre a classificação histológica em pacientes operadas de endometriose e a qualidade de vida.MÉTODOS: Estudo observacional transversal, com avaliação de 32 biópsias de intestino, peritônio e ligamento uterossacro em 40 mulheres portadoras de endometriose profunda. Para a análise da qualidade de vida (QV) foi aplicado o questionário SF-36 antes da cirurgia e após 6 e 12 meses. As biópsias foram classificadas histologicamente em estromal puro (EP), glandular diferenciada (GD), indiferenciada (GI) e mista (GM), sendo que ficaram na amostra apenas o GI e GM, relacionadas aos oito domínios do SF-36.RESULTADOS: Observamos a seguinte distribuição de acordo com o tipo histológico: no peritônio 63% GI e 22% GM; no intestino 19% GI e 24% G e no uterossacro 41% GI e 35% GM. Quanto à QV e à classificação histológica, a evolução dos casos com implante no intestino mostrou que apenas o tipo GM apresentou melhora de 0 a 6 meses no aspecto social e no aspecto emocional. Ainda entre esses casos, o GI mostrou que os domínios estado geral da saúde (p=0,01) e aspecto social (p=0,04) têm relação significativa com a melhora da QV de 0 a 6 meses e uma tendência à melhora do estado geral da saúde de 0 a 12 meses. Quanto à dor (p=0,06) e ao aspecto emocional (p=0,05), observamos tendência à melhora na QV de 0 a 6 meses e na capacidade vital (p=0,1) de 0 a 6 e de 0 a 12 meses. No que se refere ao aspecto emocional, foi observado que entre as pacientes com tipo histológico GI, diferente do GM, não houve evolução favorável de 0 a 6 meses. No uterossacro não observamos relações significativas entre tipo histológico e QV.CONCLUSÃO: A melhora da QV em mulheres submetidas ao tratamento cirúrgico laparoscópico de endometriose profunda apresenta associação com grau de diferenciação histológica. Apenas as pacientes com endometriose classificada como indiferenciada e com lesões no peritônio mostraram melhora da QV após a cirurgia.

PURPOSE: To assess the relationship between the histological classification and the quality of life of patients operated for endometriosis. METHODS: A cross-sectional observational study, with assessment of 32 biopsies of the intestine, peritoneum and uterosacral ligament from 40 women with deep endometriosis. The quality of life (QOL) was determined by applying the SF-36 questionnaire pre-operatively and at 6 and 12 months postoperatively. Biopsies were histologically classified into pure stromal (EP), glandular differentiated (GD), glandular undifferentiated (GI) and mixed (GM), remaining in the sample only GI and GM, which are related to eight domains of the SF-36.RESULTS: According to the histologic type, the following distribution was observed: peritoneum 63% GI and 35% GM; intestine 19% GI and 24% GM; uterosacral ligament with 41% GI and 35% GM. Regarding the QOL and the histological classification, in the intestine only GM was associated with improvement of social and emotional aspects from 0 to 6 months; the domains general health status (p=0.01) and social aspect (p=0.04) were significantly related to improvement of the QOL from 0 to 6 months, and the general health status tended to improve from 0 to 12 months. Regarding pain (p=0.06) and the emotional aspect (p=0.05), the QOL tended to improve from 0 to 6 months and the vital capacity (p=0.1) improved from 0 to 6 months and from 0 to 12 months. Regarding the emotional aspect, evolution of the two histological types was not favorable for improvement in MG from 0 to 6 months. No significant relationships between histologic type and QOL were evident in the uterosacral ligament samples.CONCLUSION: Improvement in the QOL of women undergoing laparoscopic surgery for deep endometriosis is associated with the histologic grade. The peritoneal biopsy of GI revealed improved QOL after surgery.

The authors present the case of a child with complex congenital heart defect, bilateral malformation of the thumbs, hearing loss, failure to thrive and delayed psychomotor development, oriented to the hematology consultation at the age of 9 years for the presence of thrombocytopenia and macrocytosis.

OBJETIVO: Diante das controvérsias encontradas na literatura, procurou-se verificar a influência do uso de albumina humana exógena sobre o estado nutricional e a evolução de parâmetros clínicos de recém-nascidos em nutrição parenteral total. MÉTODOS: Estudo caso-controle incluindo 30 recém-nascidos gravemente doentes com peso inferior a 2.500 g, divididos em dois grupos: 15 recém-nascidos recebendo nutrição parenteral total sem albumina (grupo controle C) e 15 com albumina humana (grupo A). Foram realizadas dosagens de proteínas totais, albumina, pré-albumina e proteína ligadora do retinol no início (3-4 dias) e no fim do estudo (10-11 dias de idade pós-natal). No sétimo dia de estudo, foi realizado balanço da retenção de nitrogênio. Foram avaliados os seguintes parâmetros clínicos: peso, idade de início da alimentação enteral, tempo para atingir volume enteral pleno, tempo de permanência na unidade de terapia intensiva, tempo total de internação e mortalidade. RESULTADOS: Houve diferença significativa (p < 0,05) nos níveis séricos de albumina e das proteínas totais entre os grupos ao final do estudo. Para os níveis de albumina, o grupo C obteve mediana de 2,95 g/dl (2,71-3,16 g/dl), e o grupo A, mediana de 4,10 g/dl (3,76-4,66 g/dl). Para os níveis de proteínas totais, os grupos obtiveram 4,9 g/dl (4,4-5,2 g/dl) e 5,6 g/dl (5,5-6,3 g/dl), respectivamente, porém sem repercussão sobre nenhum dos demais parâmetros avaliados. CONCLUSÕES: No presente estudo, não foram encontrados indicadores de benefício com o uso de albumina humana na nutrição parenteral total de recém-nascidos gravemente doentes que suportem a recomendação do seu uso, a não ser que o objetivo seja a elevação dos níveis da albuminemia.

OBJECTIVE: In view of the controversies found in the literature, the present study was conducted to determine the effect of the use of exogenous human albumin on the nutritional status of newborn infants submitted to total parenteral nutrition. METHODS: Thirty critically ill newborn infants weighing less than 2,500 g were divided into two groups: 15 infants receiving total parenteral nutrition without human albumin (C control group) and 15 with human albumin (group A). Total protein, albumin, prealbumin, and retinol-binding protein were determined at the beginning (3-4 days of postnatal age) and at the end of the study (10-11 days of postnatal age). On the seventh day of the study, nitrogen balance (retention) was measured. The following clinical parameters were evaluated: weight, age at the beginning of enteral nutrition, time to reach a full enteral volume, length of stay in the intensive care unit, total hospitalization time, and mortality. RESULTS: The results showed a significant difference (p < 0.05) in serum albumin and total protein levels (p < 0.05) between groups at the end of the study. Median albumin levels were 2.95 g/dl in group C (2.71-3.16 g/dl), whereas group A showed median albumin levels of 4.10 g/dl, (3.76-4.66 g/dl). Total protein levels were 4.9 g/dl (4.4-5.2 g/dl) and 5.6 g/dl (5.5-6.3 g/dl), respectively, with no repercussions on any of the remaining parameters evaluated. CONCLUSIONS: On the basis of the results obtained in the present study, no benefits were derived from the use of human albumin in total parenteral nutrition in severely ill newborns; therefore its use cannot be recommended, unless the objective is exclusively to elevate albumin levels.