Perforated marginal ulcer after laparoscopic gastric bypass introduction: Perforated marginal ulcer is a serious event that usually requires reoperation and is associated with morbidity and mortality. Characterization and management of these patients is still debated. Objective: To describe a series of patients subjected to a laparoscopic gastric bypass (LGBP) that evolved with a perforated marginal ulcer. material and methods: Records of patients undergoing a LGBP the last 10 years and evolved with a perforated marginal ulcer were retrospectively reviewed. Clinical features, treatment and perioperative morbidity and mortality were analyzed. results: During this period 2,095 patients were subjected to a LGBP, 12 of them presented a perforated marginal ulcer, corresponding to 10 women and 2 men. Mean age was 39 (21-60) and mean body mass index at the time of initial surgery was 34 (29.3 to 38.6). Ten patients were smoker at the moment of perforation. The occurrence of this happened at a mean of 27 months (range 3-54, median 23.5) after surgery. Eleven cases had a surgical resolution, with a laparoscopic approach in 9 of them and laparotomy on 2. In all cases, a perforated ulcer in the jejunal side of the gastrojejunal anastomosis was found. There was no mortality or morbidity associated with surgery. conclusions: In our experience the occurrence of perforated marginal ulcer after a LGBP develops in a small percentage of patients. The laparoscopic approach is of choice, presenting a low morbidity and mortality. Smoking was present in most patients.

Laparoscopic liver resectionLaparoscopic liver resection is a technique that has boomed over time. Published related reports have increased exponentially in the last decade, leading to comparative studies and meta-analysis. Three types of technical approaches have been identified: pure laparoscopic, hand-assisted and hybrids procedures. While no precise indications exist for each method, the choice of each will depend on the type of surgical procedure and the surgeon's experience. Primarily only benign lesions were accepted for a laparoscopic intervention. Today malignant lesions, including metastases, are being resected via minimally invasive approach. Case selection may benefit in successful operative outcomes. Ideally, single lesions, less than 5 cm, peripheral and located at lateral or peripheral segments (II-VI) are better suited for laparoscopic liver resection. In addition, these procedures will be likely to succeed under expert experienced laparoscopic liver surgeons that have the best available technology within their reach. Reported results support the use of this technique when compared with open surgery in regards to minor: blood loss, use of opioids, time to oral intake, length of stay and complications. Furthermore, total costs are at least similar to the open approach. Most importantly, results from 5-year follow up studies of patients with malignant disease, in terms of disease-free survival and overall survival were equivalent to open surgery.Key words: Liver resection, laparoscopy. ResumenLa resección hepática laparoscópica constituye una técnica que ha tenido gran desarrollo con el tiempo. Los reportes publicados han aumentado, dando paso a estudios comparativos y meta análisis. Se han diferenciado tres tipos de procedimientos, los laparoscópicos puros, los mano-asistidos y los híbridos. Si bien no hay indicaciones precisas para cada técnica, la elección de cada una de ellas dependerá del procedimiento y la experiencia del cirujano. Inicialmente sólo se aceptaba la resección de lesiones benignas, mientras hoy también se acepta para lesiones malignas, incluyendo metástasis. Se ha definido que las lesiones ideales para resecar son: lesiones únicas, menores a 5 cm, de ubicación periférica y de los segmentos laterales o periféricos

Laparoscopic hepatectomyThe surgical technique employed in laparoscopic liver resection is characterized by its great complexity. It is also associated to a long learning curve, which determines that this procedure is only completed in certain reference centers by few highly trained surgeons. Other challenges related to this minimally invasive approach are greater operatory risk due to vascular control, necessity in employing highly sophisticated surgical technology and to have this expensive equipment. Though it involves stages common to other laparoscopic interventions in abdominal surgery, it also requires procedures-specific steps and knowledge such as the use of intraoperative laparoscopic ultrasound, indispensable when planning the surgical strategy and in fulfilling hepatic transection. Laparoscopic liver resection was initially used only in resecting small peripheral hepatic lesions. With the development of this technique, more complex operations have been completed such as segmentectomies and major hepatectomies. Now has even grown to develop in liver transplantation, especially in living donor cases. However, there is still controversy in employing this difficult technique in all resections, specifically in challenging procedures such as caudate or posterior segments excision. Through this article, the surgical technique employed in laparoscopic liver resection will be displayed, including pediatric living donor surgery.Key words: Hepatectomy, laparoscopy, surgical technique. ResumenLa técnica quirúrgica de la resección hepática laparoscópica se caracteriza por tener una complejidad importante determinando una curva de aprendizaje prolongada, lo que implica que se concentre en centros de referencia donde sólo algunos cirujanos capacitados puedan realizarlas. Además presenta un riesgo quirúrgico mayor, dado principalmente por la hemorragia, la necesidad de dispositivos quirúrgicos especiales y la posibilidad de contar con equipos laparoscópicos de óptima calidad. Si bien tiene secuencias similares a todas las técnicas laparoscópicas en cirugía abdominal, posee algunos pasos únicos tales como el uso de la ecografía intraoperatoria laparoscópica, instrumento imprescindible a la hora de planificar el abordaje a usar, y la transección hepática. Inicialmente sólo se aplicaba para resecar lesiones pequeñas y periféricas, sin embargo, con el desarrollo de la técnica se han descrito distintos tipos de resecciones, incluyendo hepatectomías mayores. También se ha desarrollado en el ámbito del trasplante, principalmente en lo que respecta a donante vivo. En este artículo se expone la técnica quirúrgica que usamos en las principales hepatectomías laparoscópicas, de segmentos laterales y hepatectomías derecha e izquierda, además de describir la técnica usada en nuestros casos de donante vivo pediátrico.Palabras clave: Hepatectomías, laparoscopia, técnicas quirúrgicas.