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Objective The likelihood of common bile duct (CBD) stones considers liver blood tests (LBTs) if they are markedly altered only. The aim of our study was to find a reliable tool based on LBTs to predict the presence of CBD stones. Methods We retrospectively considered all patients who underwent magnetic resonance cholangiopancreatography (MRCP) because of suspected CBD stones from January 2014 to June 2019. Demographic, clinical data, and LBT values were collected and analyzed. Results We selected 191 patients, 64 (33.5%) with positive MRCP and 127 (66.5%) with negative MRCP. The analysis showed that our compound LBT-based score had 83.6%, 90.7%, and 90.6% sensitivity, specificity, and negative predictive values, respectively, in determining MRCP results. Conclusion We designed a weighted score with high diagnostic power in determining MRCP results that could help in differentiating between candidates for primary cholecystectomy and patients who benefit from preoperative MRCP.

BackgroundRobotic ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are commonly placed laterally to meet the distance from the fascial defect. The aim of our study is to reort our experience of epigastric hernias treatment with the trocars’ insertion in the suprapubic region.MethodsA retrospective search on a prospectively collected dataset was performed to identify patients treated for primary or incisional hernias of the epigastric region with a robotic-assisted approach. In all cases, three 8-mm trocars were inserted in the suprapubic area and the preperitoneal or the posterior rectus sheath spaces dissected to ensure a proper mesh overlap. After hernia reduction, the fascia was closed with a running suture, the mesh placed and the peritoneum sutured.ResultsTwelve patients were selected. Median age was 58.5 years (interquartile range (IQR) 47.8–67.3) and four patients were male (33.3%). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR 13.75-31), median larger mesh diameter was 13.5 cm (IQR 9.5–15.0) and median operative time was 136.5 minutes (IQR 120-186.5). No intraoperative complication or conversion to open surgery occurred. Postoperatively, two patients presented a seroma and the median length of hospital stay was 2.0 days (IQR 1.75-3).ConclusionsIn the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one. Further studies are needed to assess the benefits and limitations of such technique.Trial registrationRetrospectively registered (Comitato Etico Cantonale Ticino n. 2019-01132 CE3495)

Learning curves describe the rate of performance improvements according to the surgeon’s caseload, followed by a plateau where limited additional improvements are observed. The aim of this study was to evaluate the learning curve for robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias in surgeons already experienced in laparoscopic TAPP. The study was approved by local ethic committee. Male patients undergoing rTAPP for inguinal hernia from October 2017 to December 2019 at the Bellinzona Regional Hospital were selected from a prospective database. Demographic and clinical data, including operative time, conversion to laparoscopic or open surgery, intra- and postoperative complications were collected and analyzed. Over the study period, 170 rTAPP were performed by three surgeons in 132 patients, and mean age was 60.1 ± 13.7 years. The cumulative summation (CUSUM) test showed a significant operative time reduction after the 43rd operation, once the 90% proficiency on the logarithmic tendency line was achieved. The corrected operative time resulted 71.1 ± 22.0 vs. 60.8 ± 13.5 min during and after the learning curve (p = 0.011). Only one intraoperative complication occurred during the learning curve and required an orchiectomy. Postoperatively, three complications (one seroma, one hematoma, and one mesh infection) required invasive interventions during the learning curve, while no cases were recorded after it (p = 0.312). Our study shows that the rTAPP, performed by experienced laparoscopists, has a learning curve which requires 43 inguinal hernia repairs to achieve 90% proficiency and to significantly reduce the operative time.

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as “pseudorecurrence”, may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons’ preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: (“gallbladder” OR “cholecystectomy”) AND “umbilical” AND (“epigastric” OR “subxiphoid”). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site ( P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Objective Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, in particular in a surgical day care setting. The aim of this study was to investigate the use of pudendal nerve block (PNB) in patients undergoing hemorrhoidectomy. Methods PubMed, Google Scholar, Cochrane Library and Web of Science databases were searched up to December 2020. Randomized trials evaluating the PNB use on postoperative outcomes in patients undergoing hemorrhoidectomy were selected. Opioid consumption, pain on the visual analogue scale, length of hospital stay and readmission rate were the main outcomes of interest and were plotted by using a random-effect model. Results The literature search revealed 749 articles, of which 14 with were deemed eligible. A total of 1,214 patients was included, of whom 565 received the PNB and 649 did not. After hemorrhoidectomy, patients in the PNB group received opioids less frequently (RR 0.364, 95%CI 0.292 to 0.454, p Conclusion This systematic review and meta-analysis shows significant advantages of the PNB use. A reduction in opioid consumption, postoperative pain, complications and length of stay can be demonstrated. Despite limitations, PNB in patients undergoing hemorrhoidectomy should be taken into account.

Francesco Mongelli,1 Massimo Lucchelli,2 Davide La Regina,3 Dimitri Christoforidis,1 Andrea Saporito,4 Alberto Vannelli,5 Matteo Di Giuseppe3 1Department of Surgery, Ospedale Regionale di Lugano, Lugano, Switzerland; 2Financial Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 3Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 4Department of Anesthesia, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 5Department of Surgery, Ospedale Valduce, Como, ItalyCorrespondence: Francesco MongelliOspedale Regionale di Lugano, via Tesserete 46, Lugano, 6900, SwitzerlandTel +41764706297Fax +41918119066Email francesco.mongelli@mail.comBackground: Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.Methods: From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.Results: Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482± 386 vs 613± 543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606± 816 vs 2769± 1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of − 243 ± 881 EUR/pain unit on the VAS.Conclusion: Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.Keywords: pudendal nerve, nerve block, cost-benefit analysis, postoperative pain, hospital costs

Background: Radical prostatectomy (RP) represents an important acquired risk factor for the development of primary inguinal hernias (IH) with an estimated incidence rates of 15.9% within the first 2 years after surgery. The prostatectomy-related preperitoneal fibrotic reaction can make the laparoendoscopic repair of the IH technically difficult, even if safety and feasibility have not been extensively evaluated yet. We conducted a systematic review of the available literature. Methods: A comprehensive computer literature search of PubMed and MEDLINE databases was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Terms used to search were ('laparoscopic' OR 'laparoscopy') AND ('inguinal' OR 'groin' OR 'hernia') AND 'prostatectomy'. Results: The literature search from PubMed and MEDLINE databases revealed 156 articles. Five articles were considered eligible for the analysis, including 229 patients who underwent 277 hernia repairs. The pooled analysis indicates no statistically significant difference of post-operative complications (Risk Ratios [RR] 2.06; 95% confidence interval [CI] 0.85–4.97), conversion to open surgery (RR 3.91; 95% CI 0.85–18.04) and recurrence of hernia (RR 1.39; 95% CI 0.39–4.93) between the post-prostatectomy group and the control group. There was a statistically significant difference of minor intraoperative complications (RR 4.42; CI 1.05–18.64), due to an injury of the inferior epigastric vessels. Conclusions: Our systematic review suggests that, in experienced hands, safety, feasibility and clinical outcomes of minimally invasive repair of IH in patients previously treated with prostatectomy, are comparable to those patients without previous RP.

Introduction: The advances in robotic surgery have permitted the application of such technology to various surgical fields including hernia repairs. This video depicts the treatment of two primary ...

Anastomotic leakage after colorectal surgery is a complication that requires additional treatments strongly affecting the economic outcomes. We evaluated the use of resources and the economic burden associated with anastomotic leaks following colorectal surgery. Between January 2015 and December 2016, we retrospectively evaluated patients who underwent colorectal surgery with primary anastomosis. We compared the medical resource utilization and the DRG-based reimbursement of cases with uncomplicated surgery and cases complicated by anastomotic leakage. Of the 95 patients included in the study, 87 (92%) presented an uneventful postoperative course and 8 patients (8%) developed an anastomotic leakage requiring surgery. The statistical analysis showed no significant differences in terms of demographics, risks factor, and operative results, except the length of hospital stay (9.7 vs. 29.1 days, p

Mesenteric ischemia comprises a series of pathologies where that results in an inadequate blood supply of the digestive tract. The different forms and manifestations of intestinal ischemia are dependent on various factors: the location of the intestine involved, the length of time that the tissues remain ischemic, underlying disease, comorbidities, the extent of hypoxic insult and the physio-pathologic response of the tissues affected. It is possible to distinguish between the acute and chronic forms of intestinal ischemia. Additionally, the location of the involved intestine determines the clinical diagnosis, with involvement of small intestine, arising predominantly from mesenteric ischemia, or of colon, leading to ischemic colitis.

Background: Post-polypectomy coagulation syndrome (PECS) is a well-known adverse event after endoscopic polypectomy for colorectal lesions. To date, there are no standardized guidelines for the antimicrobial prophylaxis. The aim of this meta-analysis is to evaluate the usefulness of antibiotics in patients undergoing endoscopic mucosal or submucosal resections. Methods: A comprehensive literature search of PubMed, MEDLINE, EMBASE, and Web of Science databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating the role of prophylactic antibiotic administration in reducing the PECS after endoscopic polypectomy were considered. The terms used to search were (“antimicrobial”OR”antibiotics”OR”prophylaxis”OR”prophylactic”) AND (“resection”OR”polypectomy”OR”dissection”) AND (“endoscopic”OR”mucosal”OR”submucosal”) AND (“colon”OR”colorectal”OR”colonic”OR”rectum”). Data of included studies were collected and analysed. Results: The literature search revealed 262 articles, 3 of whom were randomized trials and one was a retrospective study. Patients included were 850 (548 treated with antibiotics and 302 received no treatment). The overall incidence rate was 2.4 and 19.9% in treatment and control groups, respectively. The pooled analysis showed a reduction of 83% of postoperative events in the antibiotics group (relative risk 0.181; 95% CI 0.100–0.326, p < 0.001). Conclusions: In our meta-analysis, the antibiotic prophylaxis showed a positive effect in reducing the incidence of postoperative adverse events other than perforation and bleeding in patients treated with endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions. Despite the low-level of evidence of this meta-analysis, the antibiotic prophylaxis should be taken into account. Further multicenter, large-sample, randomized controlled studies are needed to confirm our results and to evaluate whether specific subgroups of patients could actually benefit from an antibiotic prophylaxis.

Abstract After cholecystectomy,the presence of dysplasia at resection margins on the cystic duct is rare and evidences lack. A 44-year-old woman underwent a cholecystectomy and a low-grade dysplasia of the cystic duct with involvement of the resection margin was found. A robot-assisted resection of the cystic duct stump was performed as close as possible to the common bile duct and the patient had an uneventful recovery. The histological examination did not show dysplasia on the proximal resection margin. In our experience, the surgical treatment of low-grade dysplasia on the resection margins after cholecystectomy provided optimal results. Further studies are needed to investigate the role of surgery and follow-up of this uncommon condition.

Background: In the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related group (DRG) era. Factors that affect whether ...

Acute cholecystitis is a common disease and a frequent cause of emergency admission to surgical wards. Evidence regarding antibiotic administration in urgent procedures is limited and remains a contentious issue. According to the Tokyo guidelines, the antibiotic administration should be guided by the severity of cholecystitis, but internationally accepted guidelines are lacking. In particular, the need to perform antibiotic therapy after laparoscopic cholecystectomy is controversial for mild and moderate acute calculous cholecystitis (Tokio I and II). We performed a comprehensive computer literature search of PubMed and MEDLINE databases in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. We selected patients treated with cholecystectomy for mild or moderate acute calculous cholecystitis (Tokio I or II), only randomized controlled trials, (post-operative antibiotic administration versus placebo or untreated), data about local or systemic infection rate in the next 30 days after surgery. Three hundred and fifty-nine articles were identified, and three articles were considered eligible for the meta-analysis, including 676 patients. Overall surgical site infections were documented in 18 (5.49%) of 328 patients treated with post-operative antibiotics versus 25 (7.18%) of 348 patients treated without post-operative antibiotics. Overall results and the subgroup analysis (superficial and deep incisional infection and organ/space infection) showed no statistically significant reduction of surgical site infections rate under antibiotic therapy. Our meta-analysis shows no significant benefit of extended antibiotic therapy in reducing SSI after cholecystectomy for mild and moderate acute cholecystitis (Tokio I and II). Further RCTs with adequate statistical power and involving a higher number of patients with subgroups are needed to better evaluate the benefit of post-operative antibiotic treatment in reducing the rate of organ/space surgical site infections.

The use of Endobronchial coils are a relatively new brochoscopic technique for lung volume reduction. They appear to be safe and effective in improving quality of life, reducing morbidity and mortality related to the primary disease, while avoiding the many risks of morbidity and mortality associated with surgery. Nevertheless, some complications, such as pneumothorax, are relatively common in the periprocedural period. We describe a case of pneumothorax that occurred several days after brochoscopic technique for lung volume reduction due to direct perforation of the visceral pleura by a coil. The patient presented with a large pneumothorax associated with significant air leak, requiring surgical intervention. Exploration of the chest cavity showed a pleural tear caused by a coil. To our knowledge, this is an adverse event that has never been described before, suggesting the possible migration of the coil from the original position.

Purpose Approximately 1 to 3.5% of cholecystectomies are found to have incidental dysplasia on histological examination. Cases of positive resection margins on the cystic stump are rare and evidence lack. The aim of this article was to systematically review the literature and to suggest a possible management algorithm. Methods We searched PubMed, Cochrane Library and Google Scholar databases by combining “cholecystectomy” AND “dysplasia” AND “cystic” according to PRISMA guidelines. Studies providing information about cystic duct dysplasia with positive resection margin after cholecystectomy were included. Results The searches identified 109 articles from PubMed and 4 articles from Cochrane Library and Google Scholar, of which three were eligible. Five were found to have post-operative high-grade dysplasia, one patient had a carcinoma and one had a low-grade dysplasia. Median follow-up was of 10.5 months (range: 0.5 – 26.6 months), no evidence of recurrence was found in patients with dysplasia, while the patient with diagnosis of cholangiocarcinoma died during follow-up. Conclusions Patients with positive resection margins for dysplasia after cholecystectomy should be considered for a surgical treatment. The latter depends on several factors related to the patient and the grade of dysplasia itself. Simple cystic duct stump excision has been suggested and it seems to be safe and effective with no evidence of recurrence during follow-up when a R0 resection is achieved. A multidisciplinary approach and a surveillance program should be always taken into account.

First described by Gagner et al. and Higashihara et al. in 1992 laparoscopic adrenalectomy is now considered the gold standard treatment for removal of adrenal masses. Reduction in post-operative stay, wound related complications, pain and faster return to normal activities in comparison to standard open technique represent the main benefits of the minimally invasive approach. Current indications for laparoscopic transperitoneal approach to the adrenal glands are removal of benign functioning and non-functioning tumors of the adrenal gland

The aim of this study was to verify feasibility and safety of single incision laparoscopic cholecystectomy using conventional surgical instruments. Twenty patients underwent single incision laparoscopic cholecystectomy. Indications for cholecystectomy were symptomatic cholelithiasis. Operative time, postoperative length of stay, intraoperative and postoperative complications, postoperative pain (by visual analogue scale), and patient cosmetic satisfaction were considered. All 20 procedures were successfully concluded without additional skin incisions. The mean operative time was 69 ± 16 min with a trend toward a reduction in operating time with increasing surgical experience. Intraoperative bile leakages for gallbladder rupture were observed in only three cases. No postoperative complications were recorded. The median pain scale value was 3 and the median value of cosmetic satisfaction was 3. The mean postoperative length of stay was 1.3 ± 0.9 days. Single incision laparoscopic cholecystectomy with conventional surgical instruments is a feasible and safe procedure, but additional studies in larger series are needed to confirm our results.

This study was designed to describe the surgical technique for single-incision laparoscopic right colectomy and present preliminary short-term results. Laparoscopic surgery has been fully validated as alternative, minimally invasive treatment for different benign and malignant conditions. In the attempt to reduce even more the surgical trauma, natural orifices transluminal endoscopic surgery (NOTES™) and single-incision laparoscopic surgery (SILS) have been proposed. Although the lack of proper instrumentations makes NOTES™ not fully suitable for advanced procedures, SILS might play a significant role, although, to date, only limited series and few case reports of single-incision right colectomy are present in the literature.After signed, informed consent was obtained, patients with malignant tumors or large polyps of the right colon underwent single-incision colonic resection through a 3-cm incision using two different single-port devices and articulated or coaxial curved instruments. Preliminary results were analyzed retrospectively.A total of 36 patients were selected for SILS procedure. There were no intraoperative complications or conversions to the standard laparoscopic procedure. One patient had a postoperative urinary tract infection and one prolonged ileum that did not required any surgical intervention. No complications were reported in all the remaining cases. The mean postoperative stay was 5 ± 1.2 days (range, 4-14), and mean lymph node retrieval and tumor-free margins was 24 ± 7 (range, 29-15) and 8 ± 3 (range, 6-12) cm, respectively.Our preliminary results show that single-incision laparoscopic right colectomies are feasible and safe from the oncological point of view; nevertheless larger, randomized experiences are needed to demonstrate the benefits of SILS compared with standard laparoscopic resections.

Objective To present our personal technique for laparoscopic left nephrectomy for living donor transplant. Design, Setting, and Patient The surgical technique is described in detail both in the text and in a commentedvideo. The preoperative workup includes routine blood tests, chest radiography, electrocardiography, and high-definition abdominal computed tomographic angiography with 3-dimensional reconstruction to study the vascularization of the kidney. The patient is placed in right lateral decubitus, and 4 trocars are used. Intervention The left colon is fully mobilized, the gonadic vessels and left ureter are identified, and the hilar vessels are dissected up to the origin on the renal artery from the aorta; the kidney is then mobilized. A 5- to 7-cm sovrapubic incision is made without entering the peritoneum, and a 15-mm laparoscopic bag is introduced through a small incision. The ureter and gonadic vessels are divided between clips and the main vessels are divided using an endoscopic stapler with a vascular cartridge. The kidney is quickly inserted in the endobag and removed through the sovrapubic incision. Results The patients are allowed to drink the same day of the procedure, mobilized after 12 hours, and discharged on postoperative day 4 if no complications are recorded. Conclusion Laparoscopic left nephrectomy for living donor transplant can be safely performed with good results and an excellent postoperative course for the donor.

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its incidence is extremely low (1 in 1,000,000 population) and in most of the cases the whole liver is interested and liver transplantation is the treatment of choice. In case of dilatation limited to the left or right lobe, liver resection can be performed. For many year the standard approach for liver resection has been a formal laparotomy by means of a large incision of abdomen that is characterized by significant post-operatie morbidity. More recently, minimally invasive, laparoscopic approach has been proposed as possible surgical technique for liver resection both for benign and malignant diseases. The main benefits of the minimally invasive approach is represented by a significant reduction of the surgical trauma that allows a faster recovery a less post-operative complications. This video shows a case of Caroli s disease occured in a 58 years old male admitted at the gastroenterology department for sudden onset of abdominal pain associated with fever (> 38 C degrees), nausea and shivering. Abdominal ultrasound demonstrated a significant dilatation of intra-hepatic left sited bile ducts with no evidences of gallbladder or common bile duct stones. Such findings were confirmed abdominal high resolution computer tomography. Laparoscopic left sectoriectomy was planned. Five trocars and 30 degrees optic was used, exploration of the abdominal cavity showed no adhesions or evidences of other diseases. In order to control blood inflow to the liver, vascular clamp was placed on the hepatic pedicle (Pringle s manouvre), Parenchymal division is carried out with a combined use of 5 mm bipolar forceps and 5 mm ultrasonic dissector. A severely dilated left hepatic duct was isolated and divided using a 45 mm endoscopic vascular stapler. Liver dissection was continued up to isolation of the main left portal branch that was then divided with a further cartridge of 45 mm vascular stapler. At his point the left liver remains attached only by the left hepatic vein: division of the triangular ligament was performed using monopolar hook and the hepatic vein isolated and the divided using vascular stapler. Haemostatis was refined by application of argon beam coagulation and no bleeding was revealed even after removal of the vascular clamp (total Pringle s time 27 minutes). Postoperative course was uneventful, minimal elevation of the liver function tests was recorded in post-operative day 1 but returned to normal at discharged on post-operative day 3.

One of the main benefits of minimally invasive surgery compared with open surgery is the significant reduction in the incidence of postoperative infections. Possible explanations include the smaller incision, minimal use of central venous catheters for parenteral nutrition, faster mobilization, reduction in postoperative pain, and better preservation of immune system function with a limited inflammatory response to tissue injury. We compare the incidence of postoperative infections after the most common laparoscopic surgical procedures with that after the corresponding open operation, and review the possible mechanisms behind these results.Review of the pertinent literature.Several randomized controlled trials (RCTs), as well as most retrospective studies, show a significant reduction in incisional complications with laparoscopic cholecystectomy in comparison with open surgery (mean 1.1% vs. 4%), as well as in urinary tract and pulmonary infections. In colorectal resection, laparoscopic surgery was characterized by a significant reduction in surgical site infections (mean 5% vs. 9.5%), and the infections that did occur tended to be less severe. Again, there were fewer urinary and pulmonary infections postoperatively. Acute appendicitis represents an interesting setting to study the effect of minimally invasive surgery on infections, as it involves a potentially contaminated field. Most of the results confirm that the rates of surgical site (mean 2% versus 8%) and respiratory (mean 0.3% versus 3%) infections favor laparoscopic surgery, but minimally invasive surgery seems to be characterized by a higher incidence of postoperative intra-abdominal abscess. The laparoscopic approach to splenectomy is clearly superior to standard laparotomy in terms of postoperative complications, including infections, although the rate of overwhelming postsplenectomy infection (OPSI) remains similar because this complication is related more to spleen removal than to the surgical approach.Most of the literature is in agreement that laparoscopic surgery is associated with better preservation of immune function and a reduction of the inflammatory response compared with open surgery. The rate of postoperative infections seems to be significantly lower.

Materials and methods Consecutive 87 patients who had laparoscopic resection of right colon, left colon, sigma and/or supraperitoneal rectum for colorectal carcinoma or adenoma with medium/severe dysplasia from June 2005 to August 2008 were included. Two age-matched cohorts of patients were compared: 45 patients (group 1) of 65 years or older and 42 patients younger than 65. All of the patients underwent preoperative exams, colonoscopy with multiple biopsy and CT-scan, and all data concerning demographics, disease, details of operations and postoperative events were collected prospectively.