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Following an inguinal hernia repair with open or laparoscopic technique, 1-15% of patients show persistent neuralgia, a severe, potentially debilitating, complication. Several therapeutic procedures have been proposed, but consensus regarding choice of treatment has not yet been achieved. We performed a prospective study on 32 such cases. Patients underwent anaesthetic infiltration to identify, when possible, the involved nerve, and we then carried out a step-by-step therapeutic protocol. In the initial phase, patients were treated with oral analgesic and afterwards with repeated infiltrations of anaesthetic and cortisone. Surgery was reserved for patients not responding to the infiltrations, though with no good success. The authors believe that noninvasive methods are to be preferred, whereas neurectomy interventions should be reserved for selected cases.

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.

The nature of polypoid lesions of the gallbladder is difficult to define. Surgical indication still remains controversial but in some cases mandatory. In this clinical study data were retrospectively evaluated in 25 patients with polypoid lesions who underwent laparoscopic surgery to elucidate the ultrasonic findings and to establish criteria for the best treatment.

Incisional hernia is one of the commonest long-term complications of open abdominal surgery. Especially in old patients (over 70 years), the incisional hernias represent an invalidating pathology whose treatment, for the high incidence of associated respiratory and cardiovascular disease, offers difficulties related to the preoperative and postoperative management as well as to the surgical treatment. This paper reports the Author's experience about the surgical treatment of large incisional hernia (> 10 cm) with open prosthetic mesh repair in geriatric patients.

Background: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury., Methods: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles., Results: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24)., Conclusion: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

Necrotizing fasciitis is a rare and dramatic soft-tissue; infection starting from the subcutaneous tissue, involving the fascia and the underlying muscle and causes necrosis and, suddenly, gangrene. Most frequently the necrotizing fasciitis is localized in anorectal or genitourinary region and in traumatized muscles. Its mortality rate is 20%. Predisposing factors for these infections have included advanced age, obesity, hypertension, atherosclerosis, malnutrition, renal failure, immunosuppression and, primarily, diabetes mellitus. The infection is caused by a lot of gram +, gram -, and anaerobic bacteria that act synergistically. The early diagnosis, a correct chemotherapy, an aggressive surgical treatment of the necrotic area and hyperbaric oxygen treatment allow the patient's recovery, dramatically reducing the functional consequences. The Authors analyze retrospectively five cases of necrotizing fasciitis observed in the last two years (August 2001-August 2003) and stress clinical findings and surgical treatment.

The intraoperative injury of the external branch of the Superior Laryngeal Nerve (SLN) is a disregarded complication of thyroid surgery that becomes a serious one for particular professional groups. The Authors retrospectively evaluate 124 cases of total thyroidectomies performed by the same surgeon from 1999 to 2002. Clinically evaluated SLN lesions (hypomobility of the vocal cord) was registered in six patients (4.8%). Routine identification of SLN and meticulous dissection of the superior thyroid vessels must be the technical benchmark to avoid nerve injury, even if bulky disease, anatomic variations and previous surgery may increase the chance of nerve damaging.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

A 85-year-old male developed a false, non septic, non anastomotic aneurysm, 20 years after right aorto-femoral Dacron grafting for claudication. On account of the proximity to the femoral anastomosis, and the association with a profunda femoris stenosis, a conventional surgical repair was preferred to an endovascular treatment. The patient underwent a successful aneurysm resection followed by PTFE interposition between the primary graft and the profunda femoris artery, with uneventful recovery.

The authors report a case of lower gastrointestinal hemorrhage in a 69-year-old male, in which the sequence colonoscopy-angiography identified the source of bleeding as a rare Angiodysplasia (AD) of the rectum. Such vascular abnormalities are one of the most common causes of major lower gastrointestinal tract bleeding in the elderly and usually occurs predominantly in the right side of the colon. The clinical presentation of Angiodysplasia is varied and accurate diagnosis usually requires a combination of diagnostic techniques such as colonoscopy and angiography. The optimal management is uncertain and should be individualized for each patient depending on severity and rate of rebleeding. A conservative medical approach is indicated for many patients, while endoscopic treatment does not seem modify the risk of recurrent bleeding. In case of massive hemorrhage or recurrent bleeding surgery still represents the definitive treatment for Angiodysplasia. However the risk of rebleeding following surgery is a considerable problem and varies in literature from 5% to 30%.

The breast is an unusual site for metastatic disease, and generally the lesion appears same times after the diagnosis of the primary malignancy. Authors report a case of a breast metastasis from a hypernephroma, six years after nefrectomy.

The Authors analyse the main problems concerning malignant tumours of the small intestine. They report a case of jejunal adenocarcinoma recently observed. They emphasise the importance of surgery, both diagnostic and therapeutic, even in advanced stages, for the treatment of this neoplasm.