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Aim The eTEP approach for ventral hernia is becoming a promising treatment option for obese patients as a scheduled procedure, in specialized high volumen centers. Is it feasible also in emergency surgey? M&M We present a case of a 73 year old female patient with an incarcerated ventral hernia, presenting itself as a bowel obstruction on the early postoperative period after a prosthetic knee surgery. The patient had a previous midline laparotomy (Cesarian), two onlay ventral hernia repairs, and body mass index of 32. The CT imaging findings revealed a bowel obstruction close to incarcerated ventral hernia. We performed an endoscopic retromuscular sac exploration, reduced the incarcerated hernia, ruled out bowel damage, completed intraperitoneal adhesiolysis and followed through with an eTEP procedure, closing anterior and posterior rectus sheat running sutures. We began closing supraumbilical abdominal wall using inferior trocars and finished closing infraumbilical part using superior trocars. Then we introduced and deployed a polypropylene 26×15 cm mesh. No mesh fixation or drains were used. Results Bowel obstruction was solved after surgery. Oral liquids intake started on the second postoperative day. Despite of knee pain, sedentary lifestyle, depressive disorder and obesity, the patient started walking, assisted by physiotherapist also on second postoperative day. Intravenous naproxen and acetaminophen were used as painkillers. Discharged on postoperative day 10 because of knee wound celulitis. Conclusions eTEP approach seams feasible also in emergency surgeries in specialized centers.

Aim Laparoscopic total extraperitoneal approach (TEP) is a widely recognised treatment for hernia repair. As a reference group in minimally invasive hernia repair, with more than 1200 TEP cases performed in the last 5 years, and with more than 25 years of experience, we want to share our TEP systematisation in 10 steps, as we teach in our international courses. Material and Methods We describe the technique in 10 simple steps, attaching small video-clips to illustrate each one. Results Demostration of the 10 TEP steps: Conclusions Together with proctoring, this systematic way of teaching TEP technique allows a safer and shorter learning curve, by providing a series of simple steps to follow and repeat.

Aim Laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia can be technically challenging. The learning curve is long, unless you have supervision and systematisation of the procedure. After learning curve of TEP is achieved, it is time to broaden horizons, and repair ventral hernias using the extended totally extraperitoneal laparoscopic technique (ETEP). The purpose of this paper is to describe the key points and pitfalls in the ETEP learning curve, coming from the expertise of TEP hernia repair. Material and Methods After overcoming the learning curve of laparoscopic TEP inguinal hernia repair, with more than 110 consecutives procedures performed in an experienced centre, and having reduced operative times and maintaining a minimal complication rate, I start my learning curve of ETEP with supervision and systematisation of the technique. We will move from the key points already known from the TEP learning curve, identifying similarities to the more complex points of ETEP learning curve. Results and conclusions The extrapolable key points from TEP are: The critical points, which need enhanced surveillance, are: It is important to emphasise that this technique requires patience and proctoring.

We present the clinical case of a 58 year old patient with a left subcostal incisional hernia, years after an emergent aortic thrombectomy and aortobifemoral bypass. The physical examination revealed a lateral subcostal bulge near the anterior axillary line. CT findings showed a left lateral 5 cm defect without significant muscular atrophy. An endoscopic ipsilateral transversus abdominal release (TAR) and preperitoneal mesh repair was successfully performed. 1: Port placement. We used one 10 mm port and two 5 mm ports in a left near-midline position. 2: Retrorectal and Bogros space dissection. Locating the arcuate line and opening the posterior rectus sheath we then proceeded with the left transversus abdominal release (in a down to up direction). 3: Hernia dissection. After the hernial sac is identified we opened it to explore the peritoneal cavity and release the possible adhesions if encountered. 4: Full space dissection. Once the defect dissection is finished, we fully completed the TAR in order to achieve a satisfactory space for the mesh placement. 5: Defect closure. We performed a two-plane resorbable continuous barbed suture. 6: Mesh placement. We measured the surgical space in order to insert a tailored mesh and lay it without fixation or drain. Clinical outcome: The patient is discharged on postoperative day 1 and took acetaminophen 3 times daily for 48 hours, due to good pain control. On the first postoperative followup (10 days) the patient had resumed usual activities, driving and was already back to work. He was advised to avoid heavy efforts.

Aim The purpose of the study is to analyze whether a previous medical history of lower abdominal surgery (or pelvic radiotherapy) involves a different postoperative outcome in TEP inguinal repairs. Material & Methods We performed a retrospective analysis of 1252 TEP procedures included from 2015 to 2019 at our institution. We compared the short-term intraoperative difficulties and the postoperative outcome in patients with and without previous lower abdominal surgeries. The postoperative data collected included variables such as comorbidities, hernia classification, intraoperative complications, rate of conversion to open surgery, admission status, postoperative follow-up, chronic pain, and hernia recurrence. We defined a “surgical success” dichotomous variable only for patients in an outpatient setting. It included cases with no complications during surgery, no need for conversión, and no chronic pain, no readmission or recurrence during followup. Results Out of the 1252 TEP procedures, 250 (19%) had previous lower abdominal surgery (or pelvic radiotherapy). At the time of applying the “surgical success” variable we found a statistically significant difference in the conversion to open surgery rate between both groups (0.7% versus 5.6% p value 0.005). No differences were found in complications, readmissions, chronic pain, functional recovery or recurrence rates. Conclusions TEP procedure in patients with previous lower abdominal surgery showed a higher rate of conversion to open surgery compared to previously non operated patientes. The fact of having previous surgery did not imply however a worse postoperative outcome after a TEP procedure.

Resumen Tumor Miofibroblastico De Vejiga El tumor miofibroblasticos es un tumor mesenquimal benigno de caracter excepcional, siendo su localizacion mas habitual es el pulmon; mientras que su aparicion en la vejiga, es excepcional, no existiendo mas de 100 casos publicados, de este tipo de tumor en la vejiga. Este tipo de tumor queclinica y radiologicamente, se comporta como un tumor maligno. El diagnostico patologico es complejo, debido a su similitud con los sarcomas, siendo necesario recurrir a la inmunohistoquimica para un diagnostico de certeza.El tratamiento mediante reseccion amplia suele ser suficiente no existiendo en la actualidad ningun caso de metastasis a distancia, ni de malignizacion. Presentamos un nuevo caso de este tumor, realizando una amplia revision bibliografica.

El tumor de células renales supone el 1% de los tumores del adulto, mientras que el carcinoma transicional tiene una incidencia del 7%. La aparición simultánea de un carcinoma de células renales, y un tumor transicional de pelvis en el mismo riñón, suponen un hecho excepcional no existiendo más de 30 casos publicados en el mundo, presentando una incidencia aproximada del 0,14% de la patología tumoral renal. Presentamos un nuevo caso de esta inusual asociación que supone el 4 caso referenciado en la literatura en español.

Se presenta un nuevo caso de carcinoma renal sarcomatoide, en un varón de 67 años con recidiva locorregional a los 4 meses de la cirugía, con dos episodios de hemorragia retroperironeal tras la segunda intervención. El objetivo de este trabajo es aportar un nuevo caso y hacer una revisión de la bibliografía.

The renal cell tumour supposes 1% of the adult's tumors, while the transitional carcinoma has an incidence of 7%. The simultaneous appearance of a carcinoma of renal cells, and a transitional tumour of pelvis in the same kidney, they suppose an exceptional fact not existing but of 30 cases published in the world, presenting an approximate incidence of 0.14% of the pathology renal tumoral. We present a new case of this unusual association that supposes the 4 case indexed in the literature in Spanish.

The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. The diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistochemics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

The myofibroblastic tumor, is a mesenchymal benign tumor of exceptional character, being its localization but habitual it is the lung; while its appearance in the bladder, is exceptional, not existing but of 100 published cases, of this tumor type in the bladder. This tumor type that clinic and radiologics, behave as a wicked tumor. The pathological diagnosis is complex, due to its similarity with the sarcomas, being necessary to appeal to the inmunohistochemics for a I diagnose of certainty. The treatment by means of wide resection is usually enough not existing any case of metastasis at the present time at distance, neither of malignization. We present a new case of this neoplasm, carrying out a wide bibliographical revision.

The incidence of retroperitoneal primitive tumour varies from the 0.3 to 3%. The sarcomas suppose the group but it frequents of retroperitoneal tumour, being the Schwannoma an unusual tumour with an incidence from 1% to 50% of the retroperitoneal primary tumours. The schwannoma also denominated neurinoma or neurolenoma, it is a derived tumour of the cells of Schwann of the outlying nerves. It is characterized by their clinical and radiological inespecify, being the diagnose pathological, with intense positive inmunohistoquimics to the protein S-100. The election treatment is the surgical remove, with wide margins; not being described cases of malignización neither of metastasis at distance, but if the recurrence existence at probably secondary local level to incomplete resection.

The Virus of the Human Papiloma (HPV), classically he/she has been related with infections of sexual transmission and processes wicked oncologists of the feminine genital apparatus and with less frequency of the masculine one. The new technical diagnostics, based on molecular biology (by means of polymerase chain reaction), they help to a better epidemic approach, an improvement in the I diagnose viral, and a correct therapeutic focus. The object of this work is to revise the current state of the HPV from the points of view etiopathogenics, epidemic, clinical, diagnosis, therapeutic and preservative.

HEMATURIA AND SHARP RENAL FAILURE AS DEBUT OF SECONDARY BLADDER AMILOIDOSIS. PRESENTATION OF A NEW CASE AND REVISION OF THE LITERATURE The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. He diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistoquimics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

Sacral root neuromodulation is an effective technique for the treatment of Chronic Micturition Dysfunction (CMD) refractory to conventional therapy. New indications such as chronic pelvic pain and interstitial cystitis are currently making their way within the urologic setting. Several groups of gastric surgeons are now choosing this technique for the management of rectal diseases (constipation, sphincter dysfunction). This paper contributes our experience in the treatment of patients with CMD and the comparative results at one year from implant in all patients.From December 1998 through July 2003, 18 neuromodulation definite implants were performed. The main indication was CMD in 62.5% patients. Follow up of patients was done at one month and three months, and every six months thereafter. Follow up is conducted through a micturition diary and QoL questionnaire. Electrode implant in the first 16 patients was achieved by open surgery. The next 2 patients had the electrode placed by a percutaneous technique using the "Tined Lead" kit.Results at one year after implant were compared in all patients. The total number of neuromodulation implants placed was 18, 14 (77.7%) of which were women and 4 (22.3%) men. Mean age was 52.56 years. Implant indication was CMD in 72.2% patients, mixed incontinence (urinary and faecal) in 22.1%, and interstitial cystic disease in 5.5%. Symptoms improvement at one year from implant, as determined by a micturition diary and QoL questionnaire was 76.4%. Clinical improvement was greater in patients with urgency symptoms than in patients with predominance of voiding symptoms.

Resumen El Virus del Papiloma Humano (VPH), clasicamente se ha relacionado con infecciones de transmision sexual y procesos oncologicos malignos del aparato genital femenino y con menos frecuencia del masculino. Las nuevas tecnicas diagnosticas, basadas en biologia molecular (mediante reaccion en cadena de la polimerasa), ayudan a una mejor aproximacion epidemiologica, una mejora en el diagnostico viral, y un correcto enfoque terapeutico. El objeto de este trabajo es revisar el estado actual del VPH desde los puntos de vista etiopatogenico, epidemiologico, clinico, diagnostico, terapeutico y profilactico.

Resumen Objetivo La neuromodulacion de raices sacras es una tecnica eficaz para el tratamiento de la Disfuncion Miccional Cronica (DMC), refractaria a tratamientos convencionales. En la actualidad estan surgiendo nuevas indicaciones en el ambito urologico, como el dolor pelvico cronico y la cistitis intersticial. Diversos grupos de cirujanos digestivos estan optando por esta tecnica para el tratamiento de patologia rectal (estrenimiento, disfuncion esfinteriana). Este trabajo aporta nuestra experiencia en el tratamiento de pacientes con DMC y los resultados comparativos al ano del implante de todos los pacientes. Material Y Metodos Desde diciembre de 1998 a julio del 2003 hemos realizados 18 implantes definitivos de neuromodulacion. La indicacion principal fue la DMC, en un 62,5% de los pacientes. El seguimiento de los pacientes lo realizamos al mes, tres meses, y posteriormente cada seis meses. Este se realiza mediante diario miccional y cuestionario de calidad de vida. El implante del electrodo en los 16 primeros pacientes se ha realizado mediante cirugia abierta, mientras que los 2 siguientes se ha colocado el electrodo mediante tecnica percutanea, utilizando el kit “Tined Lead”. Resultados Comparamos resultados al ano del implante en todos los pacientes. Se han realizado 18 implantes de neuromodulacion de los cuales 14 (77,7%) han sido en mujeres y 4 (22,3%) en varones. La edad media es de 52,56 anos. La indicacion del implante en un 72,2% de los pacientes fue por DMC, un 22,1% por incontinencia mixta (urinaria y fecal), y un 5,5% fue por cistopatia intersticial. La mejoria de los sintomas al ano del implante, medidos por el calendario miccional y el cuestionario de calidad de vida fue de 76,4%. La mejoria clinica fue mayor en los pacientes con sintomas de urgencia, que los pacientes con predominio de la sintomatologia de vaciado.

Acquired cystic renal disease (A.C.R.D.) is a risk factor for the development of renal carcinoma in the patient's own kidney after renal transplant (R.T.), development of a primitive tumor in the renal graft is infrequent, but the presence of metastasis of an epithelial tumor is very rare. This is the second case reported in the literature of metastasis of an epithelial tumor in the renal graft and the first case described of renal cell carcinoma metastasis (R.C.C.) in the renal graft. This paper describes the case of a patient with a normally functioning renal transplant and A.C.R.D. who develops RCC in his own kidney, with metastasis in the renal graft.

Primary testicular lymphoma is an uncommon testicular tumour that accounts for no more than 9% of all testicular tumours in those series with higher incidence; testicular lymphoma as haematopoietic tumours are also rare accounting for just 1% of all lymphomas; but due to their highly malignant histopathology they may become highly aggressive tumours. Patient age at presentation is over 60 years old which makes it the most frequent tumour for this age group. There is no standard protocol to treat this malignancy due to lack of extensive series. We contribute one case and make a literature review discussing the current therapeutic trends for this disease.

La enfermedad renal quística adquirida (E.R.Q.A), es un factor de riesgo para el desarrollo de carcinoma renal en los riñones propios, tras el trasplante renal (T.R.). El desarrollo de un tumor primitivo del injerto renal es infrecuente. De otro lado, la incidencia de tumor primitivo en el injerto renal es infrecuente, pero la presencia de metástasis en el de un tumor epitelial es excepcional, siendo este el segundo caso de literatura de metástasis de tumor epitelial en injerto renal; y el primer caso descrito de metástasis de carcinoma de células renales (C.C.R.), sobre injerto renal. El caso de un paciente con TR normofuncionante y ERQA que desarrolla CCR en riñón propio, con metástasis sobre el injerto renal.

We report a new case of sarcomatoid renal cell carcinoma, in a male of 67 years old, with locoregional recidive four months after first surgery, with two episodes of retroperitoneal hemorrhage after second surgery. The objective of this work is to contribute a new case and of doing one revision.

Testicular torsion in adult, is an uncommonly etiology, but we should make differencial diagnosis in every person over thirty years old, with acute scrotum. The wrong diagnosis raises the incidence orchiectomy in adults for vascular etiology. We report a male of 74 years old with acute scrotum and review of the literature.

Resumen Torsion testicular en el paciente geriatrico. y revision de la literatura: a proposito de un caso La torsion testicular en el adulto, es una nosologia infrecuente aunque debe de entrar dentro del diagnostico diferencial de cualquier adulto de mas de treinta anos, con cuadro de escroto agudo. El retraso e incorrecto diagnostico, aumenta la frecuencia de orquiectomias por procesos vasculares en el adulto frente al nino. Presentamos el caso de varon de 74 anos con escroto agudo, y revision de la literatura.