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In the past, a severe inflammation was a difficulty to complete a laparoscopic cholecystectomy for the increased risk of vasculo-biliary injuries. Today, if in laparoscopy a “critical view of safety” (CVS) is not possible, to avoid damages, several laparoscopic rescue procedures have been proposed. The first one and the most safe is to change technique abandoning the research of CVS to perform a laparoscopic subtotal cholecystectomy. Mandatory is that the decision of changing the surgical strategy should be made before doing vascular or biliary injuries. In this chapter, all the tricks to complete the usual cholecystectomy are reported. But when the safety of the patient is in danger, we report all the alternative laparoscopic techniques to finish the procedure safely. Finally, all the outcomes conclude the chapter.

Laparoscopic cholecystectomy is the gold standard for gallstone disease. But when a high grade of inflammation is present, the identification of the bile duct, the cystic duct, and the cystic artery became difficult. In this case, conversion to open surgery represents a good option for the safety of the patient. Two techniques for open surgery in case of difficult cholecystectomy are reported in the literature: partial and subtotal cholecystectomy. All the evolutive surgical steps adopted for this technique in the last centuries, all the algorithms to anticipate the conversions from laparoscopy, actual surgical techniques, and complications are reported in the present chapter.

Injury to the genitourinary tract, although only occurring in approximately 10% of trauma cases, is an important topic. Most kidney damage results from closed trauma, generally due to car accidents, falls, or assaults. Recent improvements in imaging techniques, as well as the development of a validated renal injury scoring system, have shifted the therapeutic algorithm towards a more conservative approach than surgery. The medical history collection and a thorough physical examination of the chest, back, and abdomen including airway, breathing, and circulation assessment and vital sign monitoring are the cornerstones of the initial approach to renal trauma management. The more recent guidelines indicate computer tomography (CT) with contrast enhancement in stable patients presenting with gross or microscopic hematuria with a systolic blood pressure below 90 mmHg. CT allows for recognition of arterial extravasation and/or renal collecting system injuries, as well as assessment of preexisting renal pathology and evaluation of any damage to the contralateral kidney or other organs. Ultrasound (US) evaluation represents a valid alternative to CT thanks to its safety and reproducibility even in hemodynamically unstable patients. The use of contrast-enhanced ultrasound (CEUS) significantly improves the diagnostic performance of ultrasound with a good correlation with CT findings, thus proposing itself for the next future as the first-choice imaging technique in the follow-up of nonsurgical renal traumas.

Background Splenectomy is sometimes necessary after abdominal trauma, but splenectomized patients are at risk of sepsis due to impaired immunological functions. To overcome this risk, autotransplantation of the spleen by using a new technique has been proposed, but so far, a demonstration of functionality of the transplanted tissue is lacking. Methods We therefore evaluated 5 patients who underwent a splenic autotransplant in comparison with 5 splenectomized patients without splenic autotransplant and 7 normal subjects. Results We confirmed that the patients not undergoing autotransplantation, when compared to normal subjects, had a higher platelet count, higher percentage of micronucleated reticulocytes (p = 0.002), increased levels of naive B lymphocytes (p = 0.01), a defect of class-switched memory (p = 0.001) and class-unswitched memory B cells (p = 0.002), and increased levels of PD1 on T lymphocytes CD8+ (p = 0.08). In contrast, no significant differences for any of the abovementioned parameters were recorded between patients who underwent spleen autotransplantation and normal subjects. Conclusion These findings suggest that splenic autotransplantation is able to restore an adequate hemocatheretic activity as well as recover the immunological deficit after splenectomy.

Congenital abdominal bands are a very rare entity and are often silent for a person's entire life. In a very few circumstances, however, they can manifest with clinical symptoms. Diagnosis of these bands is very challenging as the patient has never submitted for abdominal surgery and imaging, laboratory tests and clinical examination can be silent or unspecific. Two patients were admitted to and operated on in our hospital between June 2017 and July 2018. All patients had a bowel obstruction at the time of presentation, presenting no emission of faeces or gas. Conservative therapy was tried in one case, and surgical intervention was required. At surgery, both patients were found to have congenital bands causing the occlusion. The postoperative courses were uneventful. Small bowel obstruction (SBO) by congenital bands remains a challenging disease for surgeons. Diagnosis of SBO has to be suspected even if radiology does not indicate any relevant features. Laparoscopy should be the preferred approach, but if not feasible, then open surgery can resolve the case. KEY WORDS: Adhesions, Congenital bands, Intestinal occlusion, Laparoscopy.Le aderenze addominali congenite sono molto rare, solitamente asintomatiche tali da passare misconosciute per tutta la vita. In rari casi, tuttavia, possono manifestarsi con sintomi clinici. La diagnosi è molto impegnativa poiché il paziente non riporta in anamnesi interventi o esami radiologici addominali pregressi. Inoltre gli esami ematochimici e l’esame clinico possono essere non indicativi o non specifici. Due pazienti sono stati ricoverati e operati presso la nostra unità operativa complessa di Chirurgia Generale tra giugno 2017 e luglio 2018. Entrambi i pazienti presentavano un quadro di occlusione intestinale al momento del ricovero con alvo chiuso a feci e gas. In un caso è stata tentata la terapia conservativa. Entrambi i pazienti sono stati sottoposti a trattamento chirurgico che ha evidenziato la presenza di una briglia aderenziale congenita, causa dell’occlusione. Il decorso post operatorio è stato regolare in assenza di complicanze. L’ostruzione dell’intestino tenue (SBO) causata da briglie aderenziali congenite è una patologia rara rappresentante una sfida per il chirurgo. La diagnosi di SBO deve essere sospettata, anche quando gli esami radiologici non evidenziano alcuna patologica responsabile del quadro occlusivo intestinale in pazienti che non sono mai stati sottoposti a chirurgia addominale. La laparoscopia va utilizzata come primo approccio, riservandosi comunque la possibilità della chirurgia.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors’ approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

OBJECTIVE The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. MATERIALS AND METHODS From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed. RESULTS Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days. CONCLUSIONS These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.

Introduction Primary anorectal malignant melanoma is a rare and aggressive tumor that carries a poor prognosis. Anorectal melanoma (ARM) is often misdiagnosed as hemorrhoids adenocarcinoma polips and rectal cancer. ARM spreads along sub-mucosal planes and is often to wide-spread for complete resection at time of diagnosis and almost all patients die because of metastases. Presentation of the case A 77-year-old male patient presented a history of recurrent rectal bleeding and whose histopathological diagnosis was melanoma. Discussion The treatment of choice remains controversial. Surgery with complete resection represents the typical treatment. However standard operative procedures related to the area of resection and lymph dissection have yet to be established. Abdominal perineal resection (APR) with or without bilateral inguinal lymphadenectomy or wide local excision (WLE) have been used to manage patients with ARM. Conclusion The higher serum levels of LDH and YKL-40 are suggestive for Anorectal Melanoma diagnosis. The decrease of these findings may be associated with good prognosis. The review of both APR and WLE options suggests no significant difference in survival among patients., Highlights • Anorectal melanoma (ARM) is a systemic disease. • Regardless how aggressive is ARM, no surgical treatment will truly change the outcome. • If surgical teqchniques are available, patients should undergo to wide local excision. • In case of recurrence, the abdominal resection should be considered as the best surgical treatment.

Background The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. Case presentation A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. Conclusion An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Key Clinical Message Laparoscopic cholecystectomy is a well‐known procedure for the treatment of most gallbladder diseases. Sometimes, it could be very difficult, in the presence of aberrations regarding the cystic duct, the cystic artery, or the gallbladder itself. Fluorescence laparoscopy using indocyanine green could be very useful for all the situations of anatomy aberrations.

Traumatic injuries constitute a major risk for patients in emergency units. Point-of-care ultrasound may be a determinant in reducing the deleterious impact of complications and in prognosis.We describe the case of a 28-year-old female who reported cranial trauma, abdominal and thoracic trauma, and suspected bilateral fracture of the femur.Ultrasound was useful for evaluating and monitoring multiple organ failure.Combining cost-effective advantages with bedside real-time imaging, ultrasound is a powerful adjunct to standard clinical assessment in the management of polytrauma when it is administered at the point of care.le patologie traumatiche rappresentano il maggiore rischio dei pazienti nelle Unità di Emergenza. L’ecografia consentendo una diagnosi precoce sia del tipo di trauma sia delle complicanze che da questo potrebbero derivane, può rappresentare un mezzo importante per la prognosi e per l’eventuale terapia.A tale scopo, noi presentiamo un caso paradigmatico di una paziente di 28 anni che, a seguito di un incidente, aveva riportato dei traumi al cranio, all’addome e al torace e sospetta frattura bilaterale al femore. Al momento del ricovero la paziente era monitorizzata tramite ecografia. I dati venivano confermati sia dalla sintomatologia clinica obiettiva, sia dalla tomografia assiale computerizzata.l’uso dell’ecografia ha consentito una diagnosi precoce non solo del tipo di trauma, ma anche ha permesso un corretto intervento terapeutico ed un monitoraggio anche dell’attività cardiaca.L’ecografia presenta vantaggi dal punto di vista costo-beneficio ed è utile sia ai fini diagnostici, sia ai fini terapeutici.

First implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD's implant.An extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient's number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence.A total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique.Despite the increased use of percutaneous technique for TIVADs' implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

Introduction.Aim of the present work is to review the literature to point out the role of laparoscopic reversal of Hartmann procedure.Material and Methods.Number of patients, age, sex, etiology, Hinchey classification, interval between procedure and reversal, position of the first trocars, mean operative time (min), number and causes of conversion, length of stay, mortality, complications, and quality of life were considered.Results.238 males (52.4%) and 216 females (47.6%) between 38 and 67 years were analyzed. The etiology was diverticulitis in 292 patients (72.1%), carcinoma in 43 patients (10.6%), and other in 70 patients (17.3%). Only 7 articles (22.6%) reported Hinchey classification. The interval between initial procedure and reversal was between 50 and 330 days. The initial trocar was open positioned in 182 patients (43.2%) through umbilical incision, in 177 patients (41.9%) in right upper quadrant, and in 63 patients (14.9%) in colostomy site. The operative time was between 69 and 285 minutes. A total of 83 patients (12.1%) were converted and the causes were reported in 67.4%. The length of stay was between 3 and 12 days. 5 patients (0.7%) died. The complications concern 112 cases (16.4%).Conclusion.The laparoscopic Hartmann’s reversal is safer and achieves faster positive results.

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

Background When a totally implantable venous access device (TIVAD) is implanted in the femoral or saphenous vein, the port can be placed in the abdominal wall, thigh, or anteroinferior thoracic wall. This study analyzed the relationship between the position of the port and patient comfort. Methods All patients who underwent TIVAD implantation from 1995 to 2011 were included in the study. Sex, age, indication for TIVAD implantation, contraindication for implantation in a vein draining into the superior vena cava, surgical technique, length of procedure, complications, difficulties recorded by nurses, and patient comfort or discomfort were recorded. Results The TIVAD was implanted in the saphenous vein in 6 of 581 patients (1.3%) who received a TIVAD, consisting of four male subjects and two female subjects aged 35 to 56 years (mean age: 47.3 years), who all underwent TIVAD implantation for the treatment of a solid tumor. The port was positioned in the anteroinferior thoracic wall in one patient, the abdominal wall in one patient, the anterior thigh in three patients, and the lateral thigh in one patient. The mean procedure duration was 52 minutes (range: 20–135 minutes). No immediate or early complications were recorded. The nurses had difficulty in puncturing the port in the abdominal wall. Patient comfort levels were high when the port was placed in the anterior thigh. Conclusion The anterior thigh may be the most useful and comfortable position for the port of a TIVAD implanted in the inferior vena cava. Larger studies should be undertaken to confirm this.

Introduction Alpha-fetoprotein (AFP) is an oncofetal protein produced by hepatocellular carcinoma (HCC). AFP level can also be elevated in other neoplastic or non-neoplastic conditions. An elevated AFP level has high diagnostic significance for HCC; at a level of >200 ng/mL, the probability of HCC is >90%. The aim of the present paper is to report a patient who underwent curative resection of HCC, who had a persistently elevated AFP level postoperatively but did not develop recurrence during a 2-year follow-up period. A review of the literature is also presented. Case report An 82-year-old male was referred following a computed tomography scan showing a 160 mm diameter mass in the left lobe of the liver. This huge mass was diagnosed as HCC, arising in the absence of cirrhosis or viral hepatitis. After tumor removal, the patient’s high AFP level persisted for 2 years. Conclusion As steatosis was the only pathological change in the remnant liver, this may have caused the persistently elevated AFP level in this patient.

Introduction Splenectomy is performed mostly because of traumatic events that cause rupture of the spleen. Postsplenectomy, a patient has a higher risk of developing sepsis. Autotransplantation of splenic tissue decreases the risk of opportunistic infection and sepsis, but its role in patients with human immunodeficiency virus is debated because the spleen is a replication site, especially during the asymptomatic phase of this infection. We present a case of a patient with human immunodeficiency virus infection who was admitted to our hospital for a traumatic rupture of the spleen and underwent spleen autotransplantation. Case presentation A 36-year-old Caucasian man was admitted to the shock trauma center of our hospital after a car accident. Anamnesis showed that the patient had been human immunodeficiency virus-positive for 13 years. A computed tomography scan showed abundant fluid collection in his superior and inferior abdomen caused by splenic rupture, with no other associated intra-abdominal lesions. During surgery, the spleen appeared severely damaged. A splenectomy was performed, and 35 g of splenic tissue was autotransplanted in a pouch created in the omentum. No complications occurred after surgery, and our patient was discharged from our hospital nine days after the operation. One year later, computed tomography and scintigraphy showed that the transplanted tissue was functioning well. Conclusions Autotransplantation of splenic tissue decreases the risk of opportunistic infection and sepsis, and it might also be useful in patients with human immunodeficiency virus. Other studies need to be done to validate this hypothesis.

Asymptomatic Morgagni hernia can be discovered in adults as an incidental finding or because of acute gastrointestinal symptoms. We report a case of a 76-year-old man with an incidental diagnosis of seizure attack. Obesity and the increased abdominal pressure caused by abdominal muscles contraction during seizure could have contributed to the clinical presentation. The omentum, small bowel, and transverse colon were found in the right side of the chest using an open transabdominal approach. The hernia sac was excised and the diaphragmatic defect closed by direct suturing. The postoperative period was uneventful and the shortness of breath attributed to obesity disappeared.

Aim of this work was to analyze retrospectively two groups of patients who underwent hepatic resection using two different techniques, to determine whether exists a difference in hepatic tolerance and in the early outcome.We retrospectively analyzed seventy-one patients divided into group 1, treated with kellyclasia and Pringle maneuver, and group 2 treated with a radiofrequency device. The following parameters were analyzed: age; sex; type of disease, number of major/minor resections; total operative time and transection time; number and time of clampings; blood loss; pre- and postoperative transaminases and total bilirubin; length of hospitalization; morbidity and mortality.Median total operative time and median hospital stay were similar in both groups but median median blood loss was higher in group 1. ALT levels in group 1 were higher than in group 2. Morbidity and mortality were observed only in group 1.Kelly-crush is related to a lower parenchymal tolerance as shown by the higher increase in postoperative alanine aminotransferase levels.

Background We evaluated treatment modalities and survival in patients with hepatocellular carcinoma (HCC), by pre-treatment and 3-month post-treatment serum alpha-fetoprotein (AFP) levels and pre-treatment tumor diameters. Methods We retrospectively reviewed 57 patients treated for HCC in our department from January 2002 to December 2012, including their sex, type of hepatitis, Child class, pre-treatment tumor size, pre-treatment levels of albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), red blood cells, hemoglobin, and total bilirubin, pre- and 3-month post-treatment serum AFP, and treatment modality (transarterial chemoembolization, resection or radiofrequency ablation). Survival was analyzed at 1, 3, and 5 years after treatment. Results The 57 patients included 44 men and 13 women, of whom 44 had hepatitis C virus (HCV) infection, 3 had hepatitis B virus (HBV) infection, 3 had both HBV and HCV infection, 1 had both HBV and hepatitis D virus infection, and 3 had alcohol-related liver cirrhosis. Both pre- and post-treatment serum AFP levels significantly correlated with recurrent tumor size (P

Background During recent years laparoscopic cholecystectomy has dramatically increased, sometimes resulting in overtreatment. Aim of this work was to retrospectively analyze all laparoscopic cholecystectomies performed in a single center in order to find the percentage of patients whose surgical treatment may be explained with this general trend, and to speculate about the possible causes. Methods 831 patients who underwent a laparoscopic cholecystectomy from 1999 to 2008 were retrospectively analyzed. Results At discharge, 43.08% of patients were operated on because of at least one previous episode of biliary colic before the one at admission; 14.08% of patients presented with acute lithiasic cholecystitis; 14.68% were operated on because of an increase in bilirubin level; 1.56% were operated on because of a previous episode of jaundice with normal bilirubin at admission; 0.72% had gallbladder adenomas, 0.72% had cholangitis, 0.36% had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. By excluding all these patients, 21.18% were operated on without indications. Conclusions The broadening of indications for laparoscopic cholecystectomy is undisputed and can be considered a consequence of new technologies that have been introduced, increased demand from patients, and the need for practice by inexperienced surgeons. If not prevented, this trend could continue indefinitely.