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To analyze the minimally invasive surgical maneuvers currently performed to remove pancreatic tail, with or without preservation of the spleen, for benign and borderline malignant neoplasms.We described operative steps and technical pitfalls encountered during laparoscopic and robotic distal pancreatectomy. The methodology of research focused on recruitment of evidence-based surgical strategies and critical analysis of modern minimally invasive techniques.Laparoscopic and robotic distal pancreatectomy have gradually accepted by pancreatic surgeons and clinical evidences document its growing interest. The choice of patient positioning, port placement, surgical dissection and operative techniques used for pancreatic parenchymal transection is not codified and changes according to personal preference. The technical variability in minimally invasive approach to pancreatic surgery strongly depends depends on surgeon's training and to limited application of these procedures in single institutions.Pancreatic surgeons worldwide accept laparoscopic and robotic distal pancreatectomy but the best intraoperative praxis is not defined in clinical routine. To date, the pancreatic resection adopts hybrid techniques and the conduction of minimally invasive resection depends to surgeon's experience, patient body habitus and location of pancreatic lesion. Although several technical variations have described, no standardization of the operative minimally invasive surgical method is convincingly built.Laparoscopy, Minimally invasive surgery, Pancreas, Robotic pancreatectomy.Analizzare le manovre chirurgiche mininvasive attualmente in uso e necessarie per asportare la coda del pancreas, con o senza la tecnica di preservazione della milza, nei casi di neoplasie pancreatiche benigne e borderline.riportiamo la descrizione dei tempi operatori e la valutazione delle difficoltà tecniche riscontrate durante la pancreasectomia distale laparoscopica e robotica. Il metodo di ricerca si focalizza sul reclutamento delle strategie chirurgiche più attuali e basate sull’evidenza clinica, oltre che sull’analisi critica delle moderne tecniche mininvasive.La pancreasectomia distale laparoscopica e robotica sono state gradualmente accettate dai chirurghi del pancreas e le evidenze cliniche dimostrano il dilagante interesse scientifico. La scelta della posizione operatoria del paziente, la disposizione dei trocars sulla parete addominale, la scelta delle tecniche operatorie di dissezione e la condotta chirurgica di resezione del parenchima pancreatico non sono state codificate e variano secondo l’esperienza del chirurgo. La variabilità dell’approccio mininvasivo dipende notevolmente dal training del chirurgo e dalle limitate applicazioni della metodica stessa nei singoli centri.In tutto il mondo i chirurgi del pancreas hanno accettato le tecniche di pancreasectomia distale laparoscopica e robotica ma la strategia chirurgica operatoria non è stata codificata nella pratica clinica. Ad oggi la resezione del pancreas viene condotta con tecniche ibride e la variabilità dell’approccio chirurgico mininvasivo dipende in modo significativo dall’esperienza del chirurgo, dall’abitus del paziente e dalla localizzazione della lesione pancreatica. Nonostante le numerose variazioni di tecnica chirurgica finora descritte durante l’intervento di pancreasectomia distale, nessuna standardizzazione del metodo operatorio mininvasivo è stato definito in modo convincente.

Describe a rare case of Richter's hernia with caecum incarceration into a right femoral hernia and provide a narrative literature review about its surgical management.A 46-year-old woman presented to the Emergency Department and to our surgical unit with a two-days history of worsening abdominal pain in the right lower quadrant without nausea or vomiting, associated with an irreducible lump. Computed tomography of the abdomen described a right inguinal hernia containing small bowel with perivisceral fluid in it without signs of small bowel occlusion nor perforation.A Richter 's femoral hernia with necrotic caecum wall was found but the appendix was not involved. Through a mini-laparotomy, tangential caecal resection and appendectomy were performed. The femoral defect was repaired with a polypropylene mesh-plug placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fifth post-operative day.Femoral hernias account for only 2-4% of all groin hernias and occur through a small fascial defect in the femoral canal. Due to its narrowness, it leads to a high risk of incarceration and strangulation thus explaining the increased mortality in the emergency setting (up to 10 fold compared with the elective repair). In some cases, symptoms are no specific and uncommon findings have been reported. Surgical exploration is mandatory in the presence of signs of bowel strangulation or perforation and different approaches (either open or laparoscopically) have been described in literature.Caecum wall necrosis secondary to an incarcerated Richter's femoral hernia is a rare but dangerous event. Surgical approach is selected on surgeon's expertise. The use of prosthetic mesh is always recommended.Bowel necrosis, Emergency surgery, Hernia repair, Richter's hernia.L’ernia crurale rappresenta circa il 2-4% di tutta la patologia erniaria ed insorge in seguito ad un difetto fasciale a livello del canale femorale, situato inferiormente al ligamento inguinale. Si manifesta più frequentemente nelle donne, nelle quali sono assai più frequenti complicanze maggiori come l’incarceramento e lo strangolamento. La presentazione clinica dipende dal contenuto erniario ed il coinvolgimento di visceri endoaddominali quali intestino tenue, appendice, cieco è stato riportato in letteratura. L’ernia crurale si presenta spesso, pertanto, in modo acuto e complicato. Riportiamo il caso di una paziente di 46 anni giunta alla nostra osservazione per l’insorgenza di dolore addominale ingravescente in assenza di nausea e vomito. L’esame fisico ha rilevato la presenza di una massa irriducibile in regione inguinale destra. La TC addome ha diagnosticato un’ernia inguinale destra delle dimensioni di circa 4.5 x 2.5 cm a contenuto ileale in assenza di segni di occlusione o perforazione. All’esplorazione chirurgica, nel sacco erniario era presente parte del fondo ciecale (un raro tipo di ernia di Richter) senza coinvolgimento dell’appendice, con chiari segni di ischemia irreversibile. Pertanto, dopo aver riparato il difetto erniario con un mesh - plug in polipropilene, si è proceduto a resezione tangenziale della porzione di cieco necrotico con suturatrice meccanica lineare. Le elevate mortalità e morbidità associate a questa patologia sono da riferire alla necessità di trattamento chirurgico in urgenza in più di un terzo dei casi (in un caso su quattro si rende necessaria una resezione intestinale). Sebbene l’approccio mininvasivo si sia dimostrato essere tecnicamente fattibile e sicuro in elezione, il suo utilizzo in emergenza è condizionato da numerosi fattori e pertanto non ne è stata ancora riconosciuta la superiorità rispetto all’approccio tradizionale. In conclusione, l’ernia femorale, in particolar modo quando vi è un pinzamento di un viscere che usualmente non risulta impegnato a causa dei propri mezzi di fissità embriologici (es. colon), non è facilmente inquadrabile né da un punto di vista clinico né radioradiologico, e soprattutto in presenza di complicanze, talora fatali, si impone un trattamento efficace e tempestivo.

BackgroundWe utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure.MethodsA total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay.ResultsTranscystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique.ConclusionsThe one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient’s case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

Simple Summary The indication for performing a neck dissection in patients with differentiated thyroid cancers is metastatic involvement of the cervical nodes. Potential complications from lateral neck dissection include injury to the thoracic duct, cervical major vessels and nerves. There is a lack of review reporting the incidence of these complications and their diagnostic and therapeutic approach. Our review may help endocrine surgeons and clinicians to recognize and face up to these challenging problems. Abstract Neck dissection is a surgical procedure reserved for thyroid cancer cases with clinically evident lymphatic invasion. Although neck dissection is a reliable and safe procedure, it can determine a significant morbidity involving a variety of structures of nervous, vascular and endocrine typology. A careful pre-operative study is therefore essential to better plan surgery. Surgical experience, combined with accurate surgical preparation and merged with adequate and specific techniques, can certainly help reduce the percentage of complications. In recent years, however, technology has also proved to be useful. Its crucial role was already recognized in the safeguard of the integrity of the laryngeal nerve through neuro-monitoring, but new technologies are emerging to help the preservation also of the parathyroid glands and other structures, such as the thoracic duct. These surgical skills combined with the latest technological advancements, that allow us to reduce the incidence of complications after neck dissection for thyroid cancer, will be reported in the present article. This topic is of significant interest for the endocrine and metabolic surgeons’ community.

Intussusception is a common condition in children, it is rare in adults. Adult intussusception differs from pediatric intussusception in various respects, including etiology clinical characteristics and therapy.We present and discuss a new case of intussusception in children and adults.In child the Barium Enema x-ray examination is identified an endoluminal filling defect to refer to the apex of the invaginated loop at the rectal level, with slow ascent during the progressive injection of the radiopaque contrast medium. At the end of the procedure, incomplete reduction of the picture is documented. The patient undergoes emergency surgery where the presence of an ileo-ceco-colic invagination is documented. Intussusception is reduced by taxis. In the adult laparoscopic right hemicolectomy was performed. High-grade B-cell Burkitt's lymphoma was confirmed by immunohistochemistry.In contrast to intussusceptions in children, in the adult population, a demonstrable etiology is found in most of the cases. In adults surgery is always indicated. The non-invasive resolutive intervention most commonly used in the child and best known consists in the rectal introduction of a radiopaque contrast medium (air or barium) at controlled pressure until.Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.Intussusception in children, Intussusception in adults, Intussusception symptoms, Radiology and treatment.L’intussuscezione è una condizione comune nei bambini ma rara negli adulti. L’intussuscezione dell’adulto differisce dall’intussuscezione pediatrica sotto vari aspetti, comprese l’eziologia la sintomatologia e la terapia.Presentiamo e discutiamo un caso di intussuscezione nel bambino e nell’adulto.Nel bambino all’esame radiografico con clistere di bario viene identificato un difetto di riempimento endoluminale riferito all’apice dell’ansa invaginata a livello rettale, con risalita lenta durante l’iniezione progressiva del mezzo di contrasto radiopaco. Al termine della procedura viene documentata la riduzione incompleta del quadro. Il paziente viene sottoposto ad intervento chirurgico d’urgenza dove è documentata la presenza di una invaginazione ileo-ceco-colica. L’intussuscezione è ridotta per “taxis’’. Nell’adulto è stata eseguita l’emicolectomia destra laparoscopica. Il linfoma di Burkitt a cellule B di alto grado veniva diagnosticato .Contrariamente alle intussuscezioni nei bambini, nella popolazione adulta, un’eziologia è dimostrabile nella maggior parte dei casi. Negli adulti la chirurgia è sempre indicata . Nei bambini, invece si cerca di trattare la patologia in maniera conservativa, con l’introduzione per via rettale di mezzo di contrasto radiopaco (aria o bario) a pressione controllata.Sebbene le intussuscezioni si verifichino a tutte le età, ci sono grandi differenze nella presentazione clinica, nell’approccio diagnostico e nella gestione tra la popolazione pediatrica e quella adulta. L’intussuscezione è notevolmente diversa in questi due gruppi di età e deve essere clinicamente approcciata in modo differente.

Cecal volvulus represents 25-40% of all colonic volvulus. Symptoms include abdominal distension, constipation, nausea and vomiting where it may be intermittent. Abdominal X-rays and computed tomography (CT) may help with diagnosis and recommended treatment is resection of mobile caecum. Although rarely identified as a source of abdominal pain, cecal volvulus has clinical significance as it can lead to a number of serious complications including bowel obstruction, perforation and ischemia. We report here on our experience and also examine the relevant literature to differentiate cecal volvulus from other forms of bowel obstruction. General surgeons should be aware of this disease and consider it in the differential diagnosis of acute abdomen.

Background. Laparoscopic reversal of Hartmann’s procedure (LHR) offers reduced morbidity compared with open Hartmann’s reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. Materials and Methods. Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient’s age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. Results. The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value p value p value

The rates of post-operative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) are between 5% and 30%. Nowadays, pancreaticojejunostomy (PJ) represents the most common type of reconstruction after PD, but the ideal technique is still debated. Our randomized trial was conceived with the intent to evaluate if two variants of PJ could influence the post-operative outcome in term of early complications.Forty-eight consecutive patients treated with PD were randomized into 2 groups (Group 1 or Large Jejunal Incision or LJI group and Group 2 or Small Jejunal Incision or SJI group). Outcome measures were the operative time, postoperative complications, length of postoperative hospital stay, amylase content in drains.wenty-two patients were enrolled in the LJI and 26 in the SJI group. Median operative times did not differ between the 2 groups. The groups were homogeneous in respect to the median age of patients, the clinical presentation of jaundice and the presence of percutaneous biliary drainage (PBD). POPF developed in 3/22 (13.6%) and 1/26 (4%) patients among the LJI and SJI group respectively (3 grade B and 1 grade C respectively) (p=0.341). PPH occurred in 8/22 (36%) and 2/26 (8%) patients among the LJI and SJI group, respectively (p=0.018). The Amylase content in the drainage fluid measured at the 5th postoperative day showed a higher value in patients who underwent LJI anastomosis compared to those with SJI anastomosis [LJI group: 26.5 (6-254) U/l vs SJI group: 7 (0-38) U/l; p=0.051]. Delayed Gastric Emptying (DGE) was not different. The multivariate logistic regression analysis demonstrated both LJI anastomosis and DGE as independent predictors for pancreatic fistula (DGE: OR=20.04, CI 95%=1.92-208.83, P=0.012; LJI anastomosis: OR=24.58, CI 95%=1.71-354.32, P=0.019) and PPH (DGE: 30.5, CI 95%=3.02-308.16, P=0.004; LJI anastomosis: OR=12.71, CI 95%=1.23-131.55, P=0.033).Based on the present results, we suggest to adopt what a "pancreas duct-oriented" approach: if pancreas duct is large a SJI-PJ is recommended; if the duct isthan 3 mm, a LJI must be preferred. Our conclusion is that the association of some surgeons to perform always the techniques with them are more confident is a concept of the past: recent data suggest that the pancreatic surgeon must have the different techniques in his "armamentarium" and varying the technique depending on local characteristic of the pancreas to allow a tailored approach to the patient.Pancreaticojejunostomy, Pancreatic fistula, Surgical Sutcome.Il tasso di fistola pancreatica post-operatoria (POPF) post- duodenopancreatectomia (PD) oscilla tra il 5% e il 30%. Ad oggi, nonostante la tecnica ideale è ancora oggi oggetto di dibattito scientifico, la pancreaticodigiunostomia (PJ) risulta essere la tipologia più frequente di ricostruzione dopo PD. Questo studio è un trial randomizzatofinalizzato a valutare come due variantitecniche di PJ possanoinfluenzarel’outcome postoperatorio in termini di complicanzeprecoci.Quarantotto (48) pazienti sottoposti a PD sono stati randomizzati in due (2) gruppi (Gruppo1 o Large Jejunal Incision o Gruppo LJI, e il Gruppo 2 o Small Jejunal Incision o Gruppo SJI). Le variabili post operatorie valutate sono state il tempo operatorio medio, le complicanze post-operatorie, la degenza ospedaliera ed il contenuto di amilasi nel liquido di drenaggio.Venti-due pazienti sono stati arruolati nel gruppo LJI e venti-sei nel gruppo SJI. I due gruppi sono risultati omogenei per quanto riguarda età media, presentazione clinica con ittero e la presenza di drenaggio biliare percutaneo (PBD). Nei 2 gruppi non si sono osservate differenze in termini di tempo operatorio medio. In 3/22 (13.6%) pazienti del gruppo LJI e in 1/26 (4%) pazienti del gruppo SJI (3grado B e 1 grado C, rispettivamente) (p=0.341) hanno sviluppato una fistola pancreatica post operatoria. L’emorragia post-pancreatectomia (PPH) si è sviluppata rispettivamente in 8/22 (36%) pazienti del gruppo LJI e 2/26 (8%) pazienti del gruppo SJI, rispettivamente (p=0.018). Il dosaggio dell’amilasemia eseguito in quinta giornata post operatoria nel liquido di drenaggio ha evidenziato un valorepiù alto neipazienti del gruppo LJI rispettoaipazienti del gruppo SJI [gruppo LJI: 26.5 (6-254) U/l vs gruppo SJI: 7 (0-38) U/l; p=0.051]. Non sono state osservate differenze statisticamente significative in termini di ritardato svuotamento gastrico [Delayed Gastric Emptying (DGE)]. L’analisi di regressione logistica ha dimostrato come sial’anastomosi LJI che DGE risultanoesserefattoriindipendentipredittivi di POPF (DGE: OR=20.04, CI 95%=1.92- 208.83, P=0.012; anastomosiLJI: OR=24.58, CI 95%=1.71-354.32, P=0.019) e PPH (DGE: 30.5, CI 95%=3.02-308.16, P=0.004; anastomosi LJI: OR=12.71, CI 95%=1.23-131.55, P=0.033).I risultati del presente studio ci consentono di suggerire un approccio basato sul dotto pancreatico o “pancreas duct-oriented”: in casi con dotto pancreatico3 mm è raccomandata una anastomosi di tipo SJI, viceversa, se il dotto è inferiore ai 3 mm è preferibile confezionare una anastomosi LJI. Concludendo, riteniamo che non sia più valido il vecchio paradigma secondo cui il chirurgo pancreatico debba eseguire ed affinare la tecnica ricostruttiva con cui egli è più confidente. I dati più recenti suggeriscono che ogni chirurgo, bensì, debba possedere nel proprio armamentario le diverse tecniche ricostruttive e, pertanto, adattarle alle caratteristiche locali del pancreas affinché si possa raggiungere un approccio “su misura” per ogni paziente.

BACKGROUND Although laparoscopic cholecystectomy (LC) is the gold standard for symptomatic gallbladder disease, a single-incision approach may be a new challenge in order to achieve minimization of surgical trauma. Single-site robotic cholecystectomy (SSRC) is able to offset the ergonomic limitation of laparoscopic single-site cholecystectomy and improves cosmesis. METHODS We present a single-institution initial experience of SSRC for cholecystolithiasis. Intra-operative and post-operative data of patients were reviewed to assess the technical feasibility and cosmetic outcome. RESULTS We evaluated a series of 27 consecutive patients retrospectively analyzed and prospectively collected who underwent SSRC. One patient was excluded from the final analysis because they converted to open procedure. The female/male ratio was 17/9, with mean age of 48 ± 12 years. The body mass index mean value was 26.0 ± 4.2. The mean operative time was 99.6 ± 21.5 minutes. No intra- or post-operative complications and readmissions were recorded. At 12 months follow up, every patient received the Body Image Questionnaire (BIQ) and a Photo Series Questionnaire. We recorded three patients (11.5%) with post-operative incisional hernia. Scores of the BIQ subscale for body image perception were 6 ± 1.2, while the scores of scar cosmesis were 21.1 ± 3.0. A statistically significant improvement in scar self-rating from T0 to T1 (P

Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180–390), mean tumor size was 2.3 cm (range 1.5–3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1–96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8–60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.

The cost effectiveness of the laparoscopic right hemicolectomy is still debated, and the current literature does not allow to be drawn certain conclusion. Our study compared direct clinical costs and outcomes for laparoscopic right hemicolectomy with the two most used type of anastomosis, such as ExtraCorporeal Anastomosis (ECA) and IntraCorporeal Anastomosis (ICA).In this retrospective study, all patients who underwent laparoscopic right hemicolectomy with intracorporeal and extracorporeal anastomosis between January 2016 and April 2018 were evaluated. Patients were divided into two groups according to the type of anastomosis: ECA or ICA.Thirty ECA and twenty-nine ICA patients were included in the study. Operative time was significantly longer in ICA group than ECA group (p0.001). No significant differences between the groups were seen in terms of timeto- first flatus, postoperative complications and re-admission rate. ICA group showed a shorter hospitalization (5 vs 6; p0.022). In the ICA group, considering only the surgical tools were more expensive than in ECA (1435.6 € vs 72 €). Nevertheless, the total cost of the two procedures in similar (14451.36 € in ECA group vs 14631.04 € in ICA group).ECA and ICA are comparable in terms of postoperative outcomes. ICA requires much more expensive charges, compared to a minor hospitalization. The ECA seems to be less expensive in terms of surgical supplies but the longer recovery determines an increase in the total cost resulting in a non-inferiority of one compared to the other technique.Cost-analysis, ExtraCorporeal Anastomosis, IntraCorporeal Anastomosis, Laparoscopy, Right Hemicolectomy.Il rapporto costo-efficacia dell’emicolectomia destra laparoscopica è tuttora oggetto di dibattito, ed un’analisi della letteratura attuale non consente di trarre conclusioni certe. Il nostro studio ha l’obiettivo di comparare i costi clinici diretti ed indiretti dell’emicolectomia destra laparoscopica mediante due tipologie di anastomosi: anastomosi extracorporea (Extra Corporeal Anastomosis) ed anastomosi intracorporea (Intra Corporeal Anastomosis).Retrospettivamente, dal Gennaio 2016 ad Aprile 2018, sono stati valutati tutti i pazienti sottoposti ad emicolectomia destra laparoscopica con anastomosi intracorporea ed extracorporea. In base al tipo di anastomosi utilizzata i pazienti sono stati divisi in due gruppi: gruppo ECA e gruppo ICA.Trenta ECA e venti-nove ICA sono stati inclusi nello studio. Il tempo operatorio è risultato significativamente più lungo nel gruppo ICA rispetto al gruppo ECA (p0.001). Non ci sono state significative differenze per quanto riguarda la prima canalizzazione, le complicanze post operatorie ed il tasso di riammissione. I pazienti sottoposti ad anastomosi intracorporea (ICA) hanno avuto tempi di degenza ospedaliera ridotti se comparati ai pazienti sottoposti ad anastomosi extracorporea (5 vs 6; p0.022). Considerando i costi diretti dei soli presidi chirurgici, il gruppo ICA è risultato più dispendioso rispetto al gruppo ECA (1435.6 € vs 72 €). Tuttavia, il costo totale delle due procedure, considerando anche i costi di degenza, (14451.36 € nel gruppo ECA versus 14631.04 € nel gruppo ICA) risultano equivalent.Le anastomosi extracorporea ed intracorporea risultano comparabili in termini di costi clinici ed outcome post-operatorio. L’anastomosi intracorporea (ICA) implica costi più elevati ma una ospedalizzazione minore. L’anastomosi extracorporea sembra essere meno costosa in termini di presidi utilizzati, ma la più lunga degenza ospedaliera media determina un’aumento dei costi totali risultando in una non-inferiorità dell’una o dell’altro tecnica.

Splenic flexure (SF) cancer is not a common condition and its treatment is still under discussion. Although laparoscopic surgery is well accepted for the treatment of colon cancer at any stage, complete mesocolon excision (CME) with selective vascular ligation using the laparoscopic approach for SF cancer remains technically demanding and represents a real challenge for surgeons. We present a single-institution experience of laparoscopic CME for SF cancer. Intra-operative, pathologic, and post-operative data of patients who underwent laparoscopic SF resection were reviewed to assess the technical feasibility and oncologic safety. Technical features, histopathology, morbidity, and mortality were evaluated. From February 2015 to October 2017, a minimally invasive approach was proposed to 17 patients (M/F 14/3) affected by splenic flexure cancer. In all patients, the procedure was completed by laparoscopy. The anastomosis was completed intra-corporeally in 89% of cases. The distal margin was 3.1 ± 2.6 cm and the proximal margin was 6.5 ± 3.3 cm from the tumor site. The number of mean harvested nodes was 13.9 ± 7. The mean operative time was 215.5 ± 65 min, and blood loss was 80 ± 27. In one case, a laparoscopic partial gastrectomy was associated due to tumor invasion. The mean post-operative stay was 6.7 ± 3.3 days. Readmission was necessary for two patients. No major morbidity was recorded. Despite the wide spread and increasing confidence in laparoscopic colectomy, SF resection remains one of the most challenging procedures in colorectal surgery with a complex learning curve. SF resection with CME and CVL is feasible and safe for the treatment of early-stage and locally advanced SF cancer.

Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.

Describtion of a rare case of intestinal obstruction due to peritoneal sarcoidosis mimicking peritoneal carcinomatosis, and of the literature review about its surgical management.A 69 year-old woman was referred to our emergency department with diffuse abdominal pain, enteric vomiting and constipation. Abdominal CT showed a dilatated small bowel loops extended to the jejunum with a mechanical obstruction. Given the failure of a non operative management, an explorative laparotomy was performed.Intraoperative evaluation showed an omental cake with extensive adhesions between small bowel and abdominal wall. The adhesion band determining occlusion was identified and cut. Furthermore, several peritoneal and omental biopsies were performed. Postoperative period was uneventful. Unfortunately, one month later, the patient died following an episode of spontaneous pneumothorax and respiratory complications.Sarcoidosis is a chronic multisystemic disorder of unknown aetiology with granulomatous inflammation. Peritoneal involvement is a rare presentation of sarcoidosis. Clinical presentation depends on the extent of organ involvement. In some cases,symptoms are no specific and uncommon findings have been reported so far.Despite a peritoneal carcinomatosis was suspeted, this case shows that abdominal sarcoidosis might be considered as a differential diagnosis when a lesion suspected of being peritoneal carcinomatosis shows non-typical clinical presentations.Peritoneal sarcoidosis, Small bowel obstruction.La sarcoidosi è una malattia multiorgano caratterizzata dalla presenza di granulomi non caseosi. L’interessamento polmonare con dispnea e tosse è presente in circa il 90% dei pazienti e rappresenta pertanto la principale causa di mortalità e morbidità. L’interessamento gastrointestinale è raro e rappresenta circa l’1% di tutti i casi di sarcoidosis, ma il coinvolgimento subclinico sembra essere molto più frequente. La sarcoidosi peritoneale è stata raramente descritta ed il primo caso risale al 1954. Le manifestazioni cliniche principali sono il dolore addominale, l’occlusione intestinale con o senza essudazione ascitica. Riportiamo il caso di una donna di 69 anni, con anamnesi patologica remota e prossima silente per patologie polmonari, che giunge alla nostra osservazione con un quadro di addome acuto, diffusa dolenzia e alvo chiuso a feci e gas. Il quadro TC addome ha messo in evidenza la presenta di anse digiunali distese e con livelli idroaerei in assenza di masse pelviche o fluido libero in cavità peritoneale. L’esame TC del torace ha segnalato la presenza di alcune aree di consolidazione, talune escavate, e multiple nodularità con adenopatia mediastinica. A causa del fallimento del trattamento conservativo, la paziente è stata sottoposta ad una laparotomia esplorativa che ha evidenziato un quadro occlusivo sostenuto da sindrome aderenziale complessa e dalla presenza di multiple nodularità peritoneali sulla parete addominale e sul grembiule omentale che si è provveduto a bioptizzare. Il decorso post operatorio è risultato regolare con la dimissione della paziente in buone condizioni cliniche. Sfortunatamente la paziente è deceduta a distanza di un mese per le sopraggiunte complicanze respiratorie dopo un episodio di pneumotorace spontaneo. La tipizzazione istopatologica ha messo in evidenza la presenza di granulomi non caseosi a componente epitelioide compatibile con sarcoidosi. In considerazione dell’aspetto intraoperatorio sospetto per carcinosi peritoneale a partenza da organi pelvici o extrapelvici, la sarcoidosi peritoneale dovrebbe essere sempre posta in diagnosi differenziale e pertanto considerata nel workup diagnostico della carcinosi peritoneale.

Describe a rare case of intestinal obstruction due to sigmoid colon incarceration into a right Spigelian hernia and provide a literature review about its surgical management.An 88 year-old man presented with a 3-day history of right lower quadrant pain and abdominal distension. Clinical examination revealed a not reducible palpable mass on right side of the anterior abdominal wall. Computed tomography shown signs of intestinal obstruction and a Spigelian hernia of about 3 cm.Sigmoid colon was incarcerated in the defect but no signs of intestinal ischemia was found during the surgical exploration. The hernia content was reduced and the defect was repaired with a polypropylene mesh placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fourth postoperative day.Spigelian hernia occurs through congenital or acquired defects in the Spigelian fascia at the level of the semicircular line. Clinical presentation depends on the size and the pattern of the hernia defect. In some cases, symptoms are no specific and uncommon findings have been reported so far. Preoperative establishment of the hernia content and the location of the sac is mandatory to plan a correct surgical strategy. Intestinal incarceration often occurs and suggests a prompt surgical exploration.Colonic obstruction secondary to an incarcerated Spigelian hernia is a rare but dangerous occurrence. Surgical approach is selected based on patient's conditions and surgeon's expertise. In a non-contaminated surgical field, the use of prosthesis is recommended.Intestinal obstruction, Mesh repair, Spigelian hernia.L’ernia di Spigelio è un raro difetto della parete addominale anteriore che insorge a livello della fascia omonima, situata lateralmente al margine del muscolo retto dell’addome. Il punto di maggior debolezza è rappresentato dalla linea arcuata di Douglas o linea semicircolare, che segna la scomparsa della lamina posteriore della guaina dei muscoli retti. La presentazione clinica dipende dal contenuto del sacco erniario e dalla posizione che assume attraverso i differenti strati muscolari. L’ernia di Spigelio si presenta spesso in modo acuto e complicato. Riportiamo il caso di un paziente di 88 anni, cardiopatico ed in trattamento con anticoagulanti orali, giunto alla nostra osservazione per l’insorgenza acuta di dolore addominale associato a distensione ed alvo chiuso a feci e gas. L’esame fisico ha rilevato una dolorabilità diffusa nei quadranti inferiori e la presenza di una massa di circa 3 cm a livello della fossa iliaca destra, molto dolente alla palpazione e non riducibile alla compressione. La TC dell’addome ha messo in evidenza la dilatazione delle anse ileali e del colon fino al sigma che appare stirato ed impegnato in un sacco erniario compatibile con un’ernia di Spigelio del lato destro. All’esplorazione chirurgica, il colon è risultato costretto nel colletto erniario ma senza presentare segni di ischemia. Per tale motivo è stato ridotto in addome ed il difetto di parete riparato con una rete di polipropilene posizionata nello spazio extraperitoneale. L’incarceramento di un ansa intestinale in un’ernia di Spigelio rappresenta un evento estremamente grave che si presenta nel 20% dei casi, di cui la metà richiede un intervento chirurgico. Il decorso intraparietale del sacco erniario rende spesso difficile una corretta diagnosi clinica ed il ricorso alla tomografia computerizzata risulta obbligatorio sia per una corretta definizione diagnostica che per pianificare la strategia chirurgica. Sebbene la laparoscopia sia stata dimostrata utile e sicura nel trattamento dell’ernia di Spigelio, non ne è stata ancora riconosciuta la superiorità rispetto all’approccio tradizionale. In emergenza, la laparotomia viene preferita anche rispettando lo status fisico del paziente e l’esperienza dell’operatore.

Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.

Hypocalcemia is the most frequent major complication following total thyroidectomy (TT), delaying timely hospital demission. We prospectively evaluated the diagnostic utility of parathyroid hormone (PTH) measured one hour after TT and the delta (post-minus pre-surgery) PTH in order to determine which biomarker best predicted post-surgery hypocalcemia.Ninety-six consecutive patients, with either plurinodular goiter, Graves' disease or cervico-mediastinal goiter (22 (23%) men and 74 (77%) women, mean age 48.5 ± 15.2 and 47.9 ± 13.2 years, respectively), scheduled to undergo TT were enrolled. PTH was measured prior and one hour after surgery. Delta PTH was defined as one-hour post-surgery values minus pre-surgery PTH level. Hypocalcemia was defined as a calcemia under 8.0 mg/dL. Receiver operating characteristic (ROC) analysis was used to evaluate the Area Under Curve (AUC), sensibility and specificity of the two biomarkers for the occurrence of hypocalcemia. Forty-nine (51%) patients presented biochemical values under the cut-off but only 17 (18%) had clinical symptoms.Both variables yielded statistically significant AUC (PTH one-hour post surgery: 0.654; p = 0.0403; 95%CI: 0.519–0.773 and delta PTH: 0.659; p = 0.0263; 95%CI: 0.527–0.776). Although comparison of the two ROC curves did not yield significant differences, delta PTH yielded a better sensitivity and PTH one-hour post-TT yielded a marginally better specificity (sensitivity of 50% and 87% and specificity of 76% and 67% for cut-offs of