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Introduction: Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF.Methods: We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient's complete healing, the evaluation of FI, recurrence rate and manometry parameters.Results: All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 "de novo" temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range.Conclusion: The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients. [ABSTRACT FROM AUTHOR]

Chronic anal fissure's (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 "de novo" post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSI) are a common cause of health care-associated infections. They are localized in the surgical incision site and can lead to deep tissues spreading. Among the wide spectrum of SSIs, we will consider specifically group A streptococcus cellulitis. This kind of infection can have a negative evolution and result in necrotizing fasciitis (NF), previously known as streptococcal gangrene. The term NF indicates a rare necrotizing infection involving any of the soft tissue layers that still have a high mortality rate from 7% to 76%. An early diagnosis and urgent treatment are key to ensuring the safety of the patients' life. A 64-year-old man underwent a complete surgical removal of an inguinal lipoma. A few hours after the procedure, he developed initial signs of streptococcal cellulitis. Thanks to an early diagnosis, a multidisciplinary management was established and after 20 days the patient was discharged from our department in good, general clinical conditions. Our experience has shown how good clinical control and the early evaluation of any clinical warning signs beginning in the very first few hours after the surgical procedure are important in order to prevent clinical and local conditions from worsening. Moreover, we underline the great utility of a combined management led by a multidisciplinary team based on antimicrobial therapy, hyperbaric oxygen therapy and surgical approach that could be the key to ensure safety of the patients' life. [ABSTRACT FROM AUTHOR]

Introduction: Etiopathogenesis of Chronic Anal Anterior Fissure (CAAF) remains poorly understood. Some anatomical, clinical and functional features suggest that pathophysiology may be linked to a reduced anal canal pressure. LIS appear illogical as a treatment for CAAF and the employ of techniques aiming to save the integrity of the sphincterial system appears more sensible. The aim of this study was to evaluate 5 years results of fissurectomy and anoplasty with cutaneous V-Y advancement flap in patients affected by CAAF without IAS hypertonia., Methods: We enrolled 20 women, affected by idiopathic and non-recurrent CAAF without hypertonic IAS. All patients were followed up for 5 years after surgery with evaluation of anal continence, short and long term post-operative complications, recurrence rate., Results: At 5 years follow up we did not record any new case of anal incontinence and the pre-existing ones havent worsened. We observed 2 recurrences, which occurred within 2 years after surgery and healed after medical therapy. The manometric values were similar than those recorded prior to surgery., Conclusion: Our study suggests that the procedure performed allows us to preserve anal continence and avoid worsening of its pre-existing alteration., Key Words: Anal canal, Anoplasty, Fissure, Fissurectomy, Proctology, Sphincterotomy.

Purpose: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there's a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS., Methods: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity., Results: All patients healed within 40 days after surgery. We didn't observe any "de novo" post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn't record statistically significant differences in pre- and post-operative manometry findings., Conclusion: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Introduction: The role of augmented internal anal sphincter (IAS) tone in the genesis of chronic anal fissure (CAF) is still unclear. Lateral internal sphincterotomy (LIS) is the most employed surgical procedure, aiming to reduce the IAS tone leaving a permanent anatomical alteration and it is burdened by high risk post-operative anal incontinence (AI). The aim of this work was to evaluate if the pre-operative manometric alterations of CAFs with hypertonic IAS would normalize after sphincter preserving surgical procedure., Methods: We enrolled 108 consecutive patients affected by idiopathic and non-recurrent CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement and pharmacological sphincterotomy, matched with 54 healthy subject in a 1 to 2 ratio, and followed up for at least for 2 years. The goals were patient's complete healing, the evaluation of AI, recurrence rate and manometry parameters., Results: All wounds healed within 40 days after surgery. We recorded 7 cases of recurrences healed with medical therapy. We recorded 3 "de novo" post-operative cases of AI all temporary and low grade. Pre-operative values of maximum resting pressure (MRP) and detection of ultraslow wave activity (USWA) were significantly higher than in the healthy control group, but both come back to be similar to those recorded in healthy subject after 24 months from the surgery., Conclusion: The high healing rate without post-operative "de novo" AI cases with the normalization of manometric parameters suggest that fissurectomy and anoplasty with V-Y cutaneous advancement flap and pharmacological sphincterotomy is an adequate procedure for the treatment of CAF with IAS hypertonia., Key Words: Anal fissure, Anoplasty, Fissurectomy, Proctology, Sphincterotomy.

Background: The gold standard treatment for incisional ventral hernia (IVH) is a surgical repair with mesh employment, nevertheless this procedure is burdened by several post-operative complications; among these latter, giant pseudocyst of abdominal wall (GPAW) formation is one of the most rare and its etiopathogenesis remains unclear., Case Report: We describe the case report of a 36 years old, diabetic and obese woman, previously underwent to a csection and IVH repair with on-lay mesh placement, presented to our unit with an asymptomatic left iliac fossa swelling. At ultrasound (US) and CT scan examination it appears to be a subcutaneous cyst of the anterior abdominal wall associated with a recurrent IVH. Therefore, she underwent to a surgical procedure in order to accomplish a complete excision of the lesion along with a repair of the incisional IVH, with a sub-lay mesh positioning. The extensive dead space resulting from the procedure was managed with a quilting suture. No recurrence or complications have been detected at 2 years follow up., Conclusion: GPAWs are a rare clinical entity following IVH repair, which occur commonly in female obese patients treated with on-lay mesh positioning. The only effective and definitive treatment is a complete surgical excision along with a correct management of the dead space resulting from the surgical procedure, in order to reduce the recurrence rate., Key Words: Abdominal wall, Incisional hernia, Mesh, Pseudocyst, Surgery.

Enterobius Vermicularis (EV) is the most commonly identified heminth incidentally found within the appendix of a clinically diagnosed appendicitis. This simple presence of EV may cause appendicular colic, primarily affecting children, it is an important cause of negative appendicectomy. We report a case of a young male who presented with clinical features of acute appendicitis. Laparoscopic appendicectomy was uneventful and pathologic examination revealed the presence of an EV infestation originating from the lumen of his vermiform appendix. KEY WORDS: Acute appendicitis, Diagnosis, Enterobius Vermicularis.

Background: Differential diagnosis of inguinal mass must include, especially in female patients, a wide variety of lesions among which our analysis will focus on mesothelial cyst of the round ligament of the uterus. A rare developmental lesion often misdiagnosed as hernias and accidentally detected during surgical exploration of the groin region., Case Report: Of a left inguinal mass causing local discomfort and progressive worsening of local pain. A pre-operative diagnosis of left symptomatic femoral hernia was made and the patient consented to surgical treatment. The surgical exploration of the inguinal and femoral canals revealed a femoral hernia associated to a clear fluid cystic lesion of around 2 cm arising from the round ligament. Histopathology demonstrated a mesothelial cyst of the round ligament CONCLUSIONS: Mesothelial cysts of the round ligament of the uterus must be taken into consideration in the differential diagnosis of groin swelling in female patients and a greater effort is needed in order to reach a preoperative diagnosis and prevent an over treatment. Key words: Mesothelial cyst, Preoperative diagnosis, Uterus.

Objective: Umbilical hernia is a very frequent pathology, and plastic with prosthetic material is the most frequently used surgical procedure currently used for its repair. In patients with cirrhosis in asciic phase, this pathology is particularly frequent, with a tendency to rapidly increase in size and to become symptomatic. In the past treatment with traditional surgery in cirrhotic patients was considered problematic and was viewed with reserve, and only recently is the surgical approach recommended also in these patients. This study is aimed to evaluate the feasibility and safety of open umbilical hernia plastic with prosthetic material in cirrhotic and ascitic patients., Materials and Methods: Our case-control study was conducted on 35 male patients with ascitic phase liver cirrhosis and an equal number of non-cirrhotic patients, all suffering from uncomplicated but symptomatic umbilical hernia, treated surgically consecutively from March 2005 to March 2015. All patients underwent open umbilical hernioplasty with placement of a retromuscular pre-aponeurotic mesh., Results: Of the 35 patients with liver cirrhosis, 20% were classified in Class C, according to Child-Pugh, 28.5% had a MELD score> 15. We have not shown any post-operative mortality. In general, minor complications were observed, more frequent in cirrhotic patients than in healthy controls (p = 0.0315). Among the aforementioned complications the most frequent were hematomas and wound infections, more frequent in cirrhotic patients in Class C according to Child- Pugh and with MELD score> 15 (p <0.005)., Conclusions: Our study shows that umbilical hernia pathology in ascitic cirrhotic patients can be treated surgically with satisfactory results especially in Child-Pugh class A and B patients. The surgical approach of choice must, preferably, be the preferred prosthetic plastic after pre-operative optimization of the coagulation, nutritional and ascitic state., Key Words: Ascites, Hernioplasty ,Liver cirrhosis; Umbilical hernia.

Aim: Superior mesenteric vein thrombosis (SMVT) is an uncommon but potentially life-threatening postoperative complication of colorectal surgery. Risk factors and prognosis of SMVT have been poorly described and data to create gold standard criteria for diagnosis and management are lacking. SMVT has a wide spectrum of clinical presentation, hence, its early identification may be a diagnostic challenge., Case Report: 56 year old obese female patient with inherited prothrombotic condition underwent an open right hemicolectomy plus cholecystectomy; the immediate postoperative course was uneventful but on postoperative day 8, already at home, she experienced post-prandial abdominal pain without any other local or systemic signs or symptoms. The CT scan showed a complete thrombosis of the superior mesenteric vein without any bowel complications. Immediately submitted to systemic subcutaneous anticoagulation bridge therapy to a lifelong oral anticoagulation she had a complete clinical recovery on postoperative day 17, despite the persistence at CT scan of complete SMVT without any intestinal suffering., Discussion: SMVT is a multifactorial event where both local and general factors are involved. Conclusive data about comparison of SMVT incidence in laparoscopic vs open colorectal surgery and those about its incidence in cancer vs non cancer groups of patients in relation to the surgical technique are missing. Variability of clinical course and the absence of specific signs, symptoms and laboratory findings make diagnosis of SMVT challenging, therefore it is crucial to have high suspicion. As for the treatment, first line approach is systemic anticoagulation therapy with LMWH for at least 6 months, followed by oral anticoagulation, the earlier we initiate the therapy the greater rate of recanalization we will get., Conclusion: prompt diagnosis and more aggressive thromboprophylaxis in patients with inherited or acquired risk factors may prevent the negative evolution towards bowel necrosis of SMVT., Key Words: Colorectal surgery, Superior mesenteric vein thrombosis, Hypercoagulable disorders, Thromboprophylaxis.

Introduction: The routinely use of drains in thyroid surgery is a traditional and well-defined method, even if there is no clear evidence of significant improvement in patients outcomes. Aim of our study is to define the feasibility, safety and cost- effectiveness of fibrin sealant in total thyroidectomy in order to overcome the use of drains., Materials and Methods: We enrolled 262 patients (45 men and 217 women, mean age 54.7 yrs) undergone total thyroidectomy in University Hospital of Palermo (Italy), between July 2015 and October 2017. We randomized patients into group A (drain) and group B (no drain, fibrin sealant application)., Results: We registered statistical difference between the two groups in mean operative time, visual analogue scale of pain, post-operative stay, incidence of seromas and/or deep and superficial hematomas, re-operation and wound infection (reduced in the fibrin sealant group). No significant difference have been found in intraoperative blood loss, postoperative cough, post-operative use of analgesic and in incidence of hypoparathyroidism or recurrent palsy., Conclusions: Our study demonstrates that there is no evidence that the use of suction drains improves patients outcome and that routinely use of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure., Key Words: Complication, Drainage, Fibrin Sealant, Thyroidectomy.