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Background and Aim: The wide diffusion and increasing use of laparoscopic surgery prompts the authors to broaden discussion to its validity and diagnostic-therapeutic use in emergency abdominal surgery. The aim was to evaluate the efficacy of laparoscopic surgery in the light of reports in the international literature and in relation to the situation in our hospital., Methods: From April 1994 to May 1998, out of 1016 emergency abdominal operations performed at our hospital, 783 (77.5%) used a laparoscopic approach for diagnostic and therapeutic purposes: intestinal occlusion: 26 cases; gastrointestinal ulcer pathology: 15 cases; hepatobiliary pathology: 398 cases; "pelvic" pathology: 305 cases; colic pathology: 39 cases. These represent 24.4% of all laparoscopic procedures carried out during the same period. We preferred to use immediate laparotomic access in patients with the following characteristics: anamnesis of previous surgery for malignant pathologies; anamnesis of more than two major abdominal operations; massive intestinal distension; patients whose general conditions were a contraindication to a laparoscopic approach., Results: The conversion rate was 6.2% (49 cases) with morbidity of 3.4% (25 cases) and a mortality rate of 0.2% (2 cases). A final diagnosis was made in 763 patients (97.4%) with the possibility of treating 719 of them (94.2%), again using a laparoscopic approach., Conclusions: It is right to regard the laparoscopic approach in emergency abdominal surgery as a feasible and safe model, offering a high potential for diagnosis and therapy if appropriately performed by an expert and well coordinated team. The increased experience of mini-invasive surgery and the improved range of instruments available make the laparoscopic approach a valid alternative to laparotomy, even in the event of emergency abdominal pathologies.

A standardized technique of left laparoscopic hemicolectomy is explained based upon the experience of the authors through the study of 166 cases and other cases described in literature. In the above study all of the single steps and the material needed for this technique, which is one of the most complex in laparoscopic surgery, are explained.

Duodenal diverticuli are often asymptomatic and are occasionally found during the course of X-ray tests or autopsy. They are sometimes manifested in the form of symptoms related to a complication (hemorrhage, perforation, occlusion). The paper reports a case of gastrointestinal hemorrhage caused by a duodenal diverticulum which was then successfully operated. The Authors affirm that in these cases the resection of the portion of the duodenum with the diverticulum (provided the papilla is not affected) is preferable to direct hemostasis or duodenocephalopancreatectomy.

IOU (intraoperative ultrasound) is nowadays an indispensable technique for the surgeon to confirm the information collected from preoperative tests or to gain further information that may modify surgical strategy. A series of 350 patients were studied with IOU: in 67 cases the liver was involved, with 23 malignant lesions. In the latter group, 10 lesions were found which had been missed even at palpation; the size of 9 of them could be correctly assessed, which had been overestimated in 8 cases and underestimated in 1 before surgery. Moreover, in 39.1% of the cases, the information yielded by IOU determined a change in surgical strategy, favoring a more accurate dissection of the lesion. Surgery was modified depending on the recognition of: nonpalpable lesions (5 cases); portal thrombosis (1 case); lesions bigger (2 cases)--smaller (2 cases) than preoperatively diagnosed. Moreover, IOU was a useful tool to guide the surgeon during intervention, by yielding accurate anatomical information on the segment/segments hosting the lesion.

Personal experience on 10 patients splenectomised for trauma and subjected to splenic autotransplantation on omental pockets is reported. After describing autotransplant candidate selection criteria and the surgical technique followed, the flattering results are reported. Particularly interesting was the fact that no local suppuration was encountered and the transplant took in all patients, as demonstrated by scans carried out with labelled red globules and radiocolloid.

The authors describe their experience with colo-rectal haemorrhage. They stress the tendency towards spontaneous arrest of such haemorrhages (92.6% of cases) as the usefulness of emergency colonoscopy in diagnosing the cause and/or site of the haemorrhagic lesion (85.7% of positive results in the present series). Therapy may be conservative (endoscopic or in the course of angiography) or surgical. Surgery is indicated in cases failing to respond to conservative therapy and in cases of unarrestable haemorrhage and usually consists in segmental resection of the portion of the intestinal tract involved.

Endometriosis on a caesarean scar is a well-known, though not frequent event. The lesion generally presents as a painful nodule of the abdominal wall during the menstrual cycle. Pain cyclicity is a useful sign for diagnosis. Treatment consists of removal. Three cases are reported.

Sixty-one non-traumatic perforations in free peritoneum are reported. The principal aetiology is diverticulitis (35 cases) followed by cancer (22 cases). 18 derivations were carried out, 34 colectomies without anastomosis, 5 ideal colectomies and 4 diverticulectomies. Total mortality was 19.7-14% for diverticulitis, 22.2% for perforations at the cancer site, 50% from diastasic perforations. Stress is laid on the need to treat colic perforation by colectomy without anastomosis, confining derivation openeum. Sixty-one cases.

The authors report a case of chylothorax due to blunt trauma with fracture of the spine in a man aged 60. After mentioning the possible pathogenesis and clinics of the case shown, the Authors explain the treatment successfully adopted, that is, the ligature of thorax duct at his inlet in the thorax through right thoracotomy on the 5th intercostal space.

Seven-hundred-two needle aspirates were taken from palpable lymph nodes between january 1982 and june 1987. Cytohistological correlation in about 70% of the preparations showed that the technique is capable of detecting neoplastic cells in 99% of metastases and in 90% of lymphoma cases. Certain technical aspects of smear preparation are pointed out with a view to reducing the percentage of inadequate samples (14% in the present series) and the position of the technique among other diagnostic procedures is discussed, with evaluation of advantages and limitations.

The diagnostic and therapeutic approach to the maiagement of lesions caused by ingestion of caustic substances has made substantial progress in the past few years and has now been codified. The linch-pins of the present approach are emergency endoscopy for an immediate assessment of the lesions and total parenteral nutrition to reduce the morbidity in patients whose lesions may be expected to take a long time to heal or may require surgical repair. The diagnostic and therapeutic protocol advocated derives from a close examination of the literature and from personal experience.

The authors report on 16 cases of recent traumatic diaphragmatic lesions in polytraumatized patients referred to them over the period 1979-86. After examining the diagnostic problems relating to this type of lesion, the authors describe the anatomico-topographical, clinical and therapeutic aspects. They conclude by stressing the need to explore the diaphragmatic cupulae systematically in the course of surgery for blunt abdominal trauma.

The authors report two cases of haemoperitoneum due to intra-abdominal rupture of the round ligament in cirrhotic patients with portal hypertension. A review of the literature on the subject reveals the rarity of such observations. The eventuality must be borne in mind, however, in the treatment of the haemorrhagic complications of portal hypertension in view of the associated high mortality. Simple ligature of the bleeding varix is the operation which offers the greatest possibility of survival.