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Background: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. Methods: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: “ < 25%, 25–50%, 51–75% or > 75%”, both for open and minimally-invasive surgery. Results: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. Conclusion: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon’s preference, economic features, and specific drawbacks of the energy employed.

Background: Splenic flexure cancer (SFC), identified as tumors raised in the distal transverse colon and proximal descending colon, accounts for 2 to 5% of all surgically treated colorectal cancers. Despite the fact that the laparoscopic approach has become the gold standard for many colorectal procedures, it has never been extensively investigated in SFC due to lack of an agreed consensus on the appropriate operative procedure. The aim of this multicenter retrospective study is to evaluate the oncologic value of laparoscopic segmental resection with complete mesocolic excision (CME) for cancer located in the splenic flexure. Methods: All data of consecutive patients who had undergone laparoscopic resection with CME for SFC from January 2005 to December 2017 at five different tertiary centers were retrospectively analyzed. The Kaplan–Meier (KM) test was used to assess the overall survival (OS) and the disease-free survival (DFS) rates after surgery. Univariate Cox regression was used to explore the association between OS and other independent factors. Results: Recurrence was observed in 13 (11.6%) patients and a significant association between disease stage and recurrence (P< 0.001) was found with a higher proportion of stage IV patients in the recurrence group (46.1% vs. 7.1%). During a median follow-up of 43 months (range 12–149), 13 deaths occurred, all of them due to disease progression. KM curves for all stages showed an estimated survival rate of 51% at 148 months. Conclusion: Laparoscopic segmental resection with CME appears to be an oncologically safe and effective procedure for treatment of SFC and may be considered as a standard surgical method for elective management of the disease. In the future, routine lymph node mapping could be used to confirm this hypothesis.

According to many Societies’ guidelines, patients presenting with clinical T4 colorectal cancer should conventionally be approached by a laparotomy. Results of emerging series are questioning this attitude. We retrospectively analysed the oncologic outcomes of 147 patients operated on between June 2008 and September 2015 for histologically proven pT4 colon cancers. All patients were treated with curative intent, either by a laparoscopic or open “en bloc” resection. Median operative time, blood loss and hospital length of stay were significantly reduced in the laparoscopic group. Postoperative surgical complication rate and 30-day mortality did not significantly differ between the two groups ( p= 0.09 and p= 0.99, respectively). R1 resection rate and lymph nodes harvest, as well, did not remarkably differ when comparing the two groups. In the laparoscopic group, conversion rate was 19%. Long-term outcomes were not affected in patients who had undergone conversion. Five-year overall survival and disease-free survival did not significantly differ between the two groups (44.6% and 40.3% vs. 39.4% and 38.9%). Locally advanced stages (IIIB–IIIC) and R1 resections were detected as independent prognostic factors for overall survival. Laparoscopic approach might be safe and acceptable for locally advanced colon cancer and does not jeopardize the oncologic results. Conversion to open surgery should be a part of a strategy as it does not seem to adversely affect perioperative and long-term outcomes. We consider laparoscopy, in expert hands, the last diagnostic tool and the first therapeutic approach for well-selected locally advanced colon cancers. Larger prospective studies are needed to widely assess this issue.

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication. From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction. Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect. In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery. From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9 %) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed. Reoperation was carried out laparoscopically in 79 (94.0 %) patients. Five (6.0 %) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1 %) that was managed by peritoneal lavage and ileostomy in 91.7 % of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0 %. Five patients required additional surgery: four (5.1 %) after RL and one after a converted procedure. There were five (6.0 %) deaths from septic shock, myocardial infarction, and pulmonary embolism. Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.