[Laparoscopic sigmoid resection]. / Resezione del sigma per via laparoscopica.

AIM: The possibility of treating lesions of the colon by laparoscopic surgery dates back to the early 90s. In spite of the remarkable spread of the techniques in the last 10 years, are there still some problems related to the laparoscopic approach of malignant lesions of the colon: does it increase the risk of metastasis spread? which are the real advantages for the patient? does it increase the costs and are the benefits comparable? The authors present their experience on the resection of the sigmoid by laparoscopic approach. METHODS: From September 1998 to August 2002, in the General Surgery Unit and Center of Laparoscopic Surgery of the Monaldi Hospital in Naples, 193 laparoscopic resections of the colon-rectum have been performed, which of 101 were resections of the sigmoid for benign and malignant pathologies. The patients were 54 males and 47 females, with an age range between 34 and 86 years. RESULTS: The average operating time has been of 130 minutes (range 80-210). The average post-operative stay in hospital has been of 10.2 days (range 6-25). Three conversions in the first 30 cases have been necessary; the transit resumed within the first 24-48 hours and feeding was possible after 3 days. CONCLUSION: The postoperative follow-up has been achieved in all the patients up to 3-6 months, in 60 patients up to 2 years and in 35 patients up to 3 years. Two ventral hernias in the site of the supra-pubic incision, 1 metastasis on Trocar site, 2 local relapses and 1 parietal metastasis have been observed. The laparoscopic resection of the colon, either for malignant or for benign disease, can be performed with acceptable morbidity and mortality.

Laparoscopic partial splenectomy for a splenic pseudocyst.

We describe a laparoscopic hemisplenectomy that was performed to treat a 21-year-old patient with a large splenic pseudocyst located in the upper splenic pole. The diagnosis was made by computed tomography and ultrasound, and surgery was performed with ultrasound scalpel, clips, and fibrin glue. Surgery lasted 70 min and did not require blood transfusions. The patient was discharged on postoperative day 3, and at 28-month follow-up there were no sequelae or recurrences. The laparoscopic approach is a valid alternative to laparotomy because the integrated magnified view enables the surgical team to perform surgery in a much shorter time and with greater hemostatic accuracy than the traditional technique.

Vena cava injury. A serious complication during laparoscopic right adrenalectomy.

We report our experience with a case of vena cava injury during laparoscopic right adrenalectomy. A laparoscopic right adrenalectomy was performed in a 22-year-old woman who suffered from a right surrenalian adenoma. Four trocars were used for the transperitoneal laparoscopic approach with the patient in the lateral decubitus position. After isolation of the medial margin of the gland and clipping and sectioning of the main adrenal vein, the right side of the vena cava was injured during dissection of the right upper pole, due to the use of monopolar scissors. The hemorrhage was managed immediately with the aid of fenestrated atraumatic forceps and an aspiration probe. A fifth trocar was inserted to evaluate the size of the lesion, which was then sutured laparoscopically with croised 5/0 nonresorbable stitches. No transfusion was needed. Operating time was 210 min. The post-operative course was uneventful. Hospital stay was 7 days. At 10-month follow-up, the patient had no problems related to the intraoperative complication. Our preliminary experience shows that the laparoscopic approach enables safer management of lesions involving large abdominal vessels. We believe that the transperitoneal approach is the preferential route for laparoscopic adrenalectomies. Monopolar coagulation can be dangerous and must be avoided when dissecting large vessels.

Laparoscopic orchiopexy without division of the spermatic vessels: can it be considered the procedure of choice in cases of intraabdominal testis?

BACKGROUND: Several surgical procedures have been described for the management of nonpalpable testis. Following a vast experience with a complete laparoscopic two-stage Fowler-Stephens procedure, we report our experience with laparoscopic orchiopexy performed without dividing the spermatic vessels. METHODS: Over a 24-month period, 70 boys with nonpalpable testes (72 overall) underwent laparoscopic diagnostic exploration. Twenty patients (27.8%) of this series who showed an intraabdominal testis underwent laparoscopic orchiopexy without sectioning the spermatic vessels. In seven cases, the testis was just proximal to the internal inguinal ring; in 13, it was in the high intraabdominal position. The technique consisted in sectioning the gubernaculum (when present), opening the peritoneum laterally to the spermatic vessels, and mobilizing the testicular vessels and the vas deferens in a retroperitoneal position for 8-10 cm. The testis was then brought down into the scrotum through the internal inguinal ring (11 cases), if this was open, or through a neo-inguinal ring (nine cases) created medially to the epigastric vessels. In every case, we closed the inguinal ring at the end of the operation using one or two detached sutures. RESULTS: Operating time ranged between 40 and 75 min (median, 55). All the testes were successfully brought down into the scrotum. We had only one (5%) intraoperative complication. In the second patient treated with this procedure, there was an iatrogenic rupture of the spermatic vessels due to excessive traction. CONCLUSION: On the basis of our experience, we believe that laparoscopic orchiopexy without division of the spermatic vessels should be the treatment of choice in the management of nonpalpable testes, because it does not affect normal testicular vascularization and is minimally invasive. A blunt dissection and a delicate manipulation of the testis without excessive traction are the best ways to avoid any kind of complication.

Identification of the immediate-early transcripts of Kaposi's sarcoma-associated herpesvirus.

In the immediate-early phase of reactivation or primary infection, herpesviruses express a small number of genes without requiring prior viral protein synthesis. Immediate-early genes usually encode regulatory proteins critical for the viral life cycle. Kaposi's sarcoma-associated herpesvirus (KSHV) gene transcription in the immediate-early stage of viral reactivation was examined by using a chemical induction combined with a gene expression screening method. RNA transcripts from at least four KSHV genomic loci accumulate when latently infected B-lymphoma cells are induced for reactivation in the presence of an inhibitor of protein synthesis (cycloheximide) and thus represent immediate-early class transcripts. Among them, a 3.6-kb mRNA encodes three putative open reading frames (ORFs), namely, ORF50, K8, and K8.2. ORF50 is a homologue of Rta, a transcription activator encoded by Epstein-Barr virus (EBV). The K8 gene codes for a 237-amino-acid protein with a basic-leucine zipper domain near its C terminus and an acidic domain near its N terminus and which closely resembles the ZEBRA protein of EBV and Jun/Fos family proteins. Other immediate-early mRNAs of KSHV include a 1. 7-kb mRNA encoding ORF45, a 2.0-kb mRNA encoding ORF K4.2, and a 4. 5-kb mRNA. Functional roles of products of these KSHV immediate-early transcripts remain to be studied.

[Impairment of diuresis in surgical intervention. Role of urinary prostaglandins]. / Contrazione della diuresi in corso di intervento chirurgico. Ruolo delle prostaglandine urinarie.

In 8 patients who underwent abdominal surgery for non-neoplastic reasons, we have evaluated some parameters of renal function (PRP, NaU, GFR and diuresis) plasma levels of PRA and ADH and urinary prostaglandins PGE2 and 6-keto-PGF1 alpha. In 4 patients we found that surgery per se was associated with enhancements of PRA, ADH and 6-keto-PGF1 alpha. In other 4 patients, Indomethacin, a specific inhibitor of prostaglandin synthesis was given and this was followed by impairment of natriuresis and RPF. These data confirm the central role of prostaglandins in the control of diuresis and natriuresis and suggest that use of drugs affecting prostaglandin synthesis should be avoided in patients who are undergoing surgery.