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Pneumoperitoneum is often caused by perforation of hollow viscera, but when an etiology is not identified, it is said to be idiopathic. It is considered a rare condition, as in the last 30 years, just over 20 cases have been described. We present a rare case of an incidental finding of a pneumoperitoneum in a 36 years old female patient.

The technique of a single-port laparoscopy was developed over the last years as an attempt to lower surgical aggression and improve the aesthetic results of the minimally invasive surgery. A new robotic platform used with the da Vinci® Robotic System Single-Site System® (Intuitive Surgical, Sunnyvale, California, United States) was recently launched on the global market and is still not documented in Brazil. The authors report on the first four robotic single-port cholecystectomies performed with this da Vinci® Robotic System in Brazil.

Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. Surgery remains the best long-term treatment for deep infiltrating endometriosis affecting the bowel. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery and can be succesfully employed for endometiosis- related procedures.

In recent years, there has been renewed interest in using robotics in bariatric surgery for the treatment of morbid obesity. However, the high cost of a robotic surgical system has hindered its widespread use in developing countries. This study aims to compare the rate of morbidity, weight loss, and relative costs between laparoscopic (LSG) and robotic-assisted sleeve gastrectomy (RSG) performed for the treatment of obesity in a single center in Brazil. From January 2011 to March 2013, 48 severely obese patients underwent either LSG or RSG at our institution and were prospectively followed up for 12 months. Patients were free to choose either approach and were informed of any extra costs that may be incurred Thirty-two patients underwent LSG and 16 patients, RSG. No significant differences were observed between LSG and RSG groups regarding age, sex, BMI, incidence of comorbidities, duration of surgery, and length of hospital stay. Also, there were no significant between-group differences in BMI values evaluated at 6 and 12 months after surgery. Surgical costs were almost twice as high and total hospital costs were approximately 50 % higher in the robotic approach compared to the laparoscopic approach Both RSG and LSG had excellent and similar post-operative clinical outcomes. However, the much higher costs of purchasing and maintaining the robotic system are still precluding the use of RSG as a routine approach in the treatment of morbid obesity in Brazil.

BACKGROUND: Central pancreatectomy is an alternative technique for benign or low-grade malignant tumors. Laparoscopic central pancreatectomy has been rarely performed, with only 48 cases reported in the English literature. The aim of this paper was to review all published cases together with 3 cases from our institution. METHODS: All published articles indexed on PubMed were included. Terms used were "laparoscopic central pancreatectomy" or "laparoscopic middle pancreatectomy." Variables studied were the operative time, the type of reconstruction, indications, the use of robotic or hand assistance, blood loss, transfusion, pancreatic fistula, hospital stay, follow-up, development of exocrine and/or endocrine insufficiency, morbidity, and mortality. RESULTS: A total of 51 patients were identified. Twenty-one patients underwent total laparoscopy (41.2%), 27 required robotic assistance (52.9%), one required hand assistance (1.9%), and there were 2 conversions. In 18 cases (35.3%), pancreatic reconstruction involved a Roux-en-Y pancreatojejunostomy, and in 32 cases, pancreatogastrostomy (62.7%). The mean operative time was 356 minutes. Blood loss was minimal in most cases, and only 1 patient required blood transfusion (1.9%). Mortality was nil, but morbidity was high, mainly because of pancreatic fistula (46%). The mean hospital stay was 13.8 days. All patients underwent laparoscopic central pancreatectomy for benign or low-grade neoplasms. The mean follow-up duration was 19.6 months (range, 2 to 48 mo). No patient presented exocrine or endocrine insufficiency. CONCLUSIONS: Laparoscopic central pancreatectomy is a feasible and useful technique for the removal of tumors located in the neck of the pancreas. There are very few centers performing this operation, and therefore, a literature review was necessary to identify its indications and technical possibilities, and to promote its use.

In the last few years, robotic surgery has started to take its place in pancreatic surgery. Robotic surgery provides advantages such as enhanced visualisation and freedom of dissection within a confined space and also allows economical surgery. The aim of this study was to evaluate the feasibility, safety and short-term outcome of the robotic approach using the da Vinci robotic system in pancreatic/peripancreatic tumors other than pancreatic carcinomas. Fifteen patients with eight intraductal papillary mucinous neoplasms, four pancreatic neuroendocrine and three periampulary tumors were included in this initial series. Seven left pancreatectomies, five pancreatoduodenectomies and two total pancreatectomies were performed at Albert Einstein Hospital, São Paulo, Brazil. The mean operating room time for all the procedures was 503 min (315-775 min). Blood transfusion was necessary in one patient (3 units). The mean length of stay for all patients was 16 days (5-52 days). Large series of robotic pancreatic surgery should be described and the decision as to its routine use will come from cumulative experience. This surgical system allows difficult procedures to be performed more easily, effectively and precisely.

Intestinal transplantation has shown exceptional growth over the past 10 years. At the end of the 1990’s, intestinal transplantation moved out of the experimental realm to become a routine practice in treating patients with severe complications related to total parenteral nutrition and intestinal failure. In the last years, several centers reported an increasing improvement in survival outcomes (about 80%), during the first 12 months after surgery, but long-term survival is still a challenge. Several advances led to clinical application of transplants. Immunosuppression involved in intestinal and multivisceral transplantation was the biggest gain for this procedure in the past decade due to tacrolimus, and new inducing drugs, mono- and polyclonal anti-lymphocyte antibodies. Despite the advancement of rigid immunosuppression protocols, rejection is still very frequent in the first 12 months, and can result in long-term graft loss. The future of intestinal transplantation and multivisceral transplantation appears promising. The major challenge is early recognition of acute rejection in order to prevent graft loss, opportunistic infections associated to complications, post-transplant lymphoproliferative disease and graft versus host disease; and consequently, improve results in the long run.

Ferimentos traumáticos do esôfago não iatrogênicos são de difícil manejo clínico e requerem condutas individualizadas e cuidadosas. Frente à baixa incidência dessa afecção, a maioria dos centros não possui experiência suficiente para a definição de uma conduta padronizada para o manejo de tais lesões. O tratamento conservador da perfuração do esôfago permanece um tema controverso, embora relatos mais recentes tenham documentado sua eficácia, especialmente após a perfuração, em pacientes que não apresentam outras lesões associadas, instabilidade hemodinâmica ou sinais de sepse. É apresentado aqui o caso de um paciente com ferimento por projétil no esôfago cervical tratado exclusivamente com manejo conservador, tendo sido realizados drenagem da lesão, suporte nutricional por meio de sonda nasoenteral e antibioticoterapia, com evolução satisfatória. Non-iatrogenic traumatic cervical esophageal perforations are usually hard to manage in the clinical setting, and often require a careful and individualized approach. The low incidence of this particular problem leads to a restricted clinical experience among most centers and justify the lack of a standardized surgical approach. Conservative treatment of esophageal perforation remains a controversial topic, although early and sporadic reports have registered the efficacy of non-operative care, especially following perforation in patients that do not sustain any other kind of injuries, and who are hemodynamically stable and non-septic. We report a case of a patient sustaining a single cervical gunshot wound compromising the cervical esophagus and who was treated exclusively with cervical drainage, enteral support and antibiotics. Universidade de Santo Amaro General Surgery Residency Program Hospital Municipal Dr. Moyses Deutsch Emergency Service Universidade de Santo Amaro Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas Universidade Federal de São Paulo (UNIFESP) Hospital Municipal Dr. Moyses Deutsch Hospital Municipal Dr. Moyses Deutsch General Surgery Service Universidade Federal de São Paulo, EPM, São Paulo, Brazil SciELO

Gallbladder rupture following blunt abdominal trauma is a rare event recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis and treatment. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma.