Double traumatic diaphragmatic injury: A case report.

INTRODUCTION: Traumatic diaphragmatic injuries are rare complications resulting from a thoracic-abdominal blunt or penetrating trauma. Left-sided diaphragmatic injuries are more commonly reported in literature. Bilateral injuries are extremely rare, occurring in about 3% of the patients and just few cases reported in literature. Traumatic diaphragmatic hernias are definitely a marker of a severe trauma, in fact diaphragmatic injuries are often related to thoracic and abdominal organs injuries. Sometimes the classic clinical signs and symptoms of diaphragmatic injuries may initially not be present so that definitive evaluation is delayed or even missed. CASE REPORT: A 62-years old woman was admitted in Emergency Department after a pedestrian accident. A whole-body CT scan showed multiple fractures (ribs, pelvic and vertebral) but no organ injury. The next CT detected a left-sided posterior diaphragmatic hernia involving transverse colon. Thus we performed an explorative laparoscopy and found a double diaphragmatic injury. A primary repair with non-absorbable sutures and a prosthetic titanized patch was performed.

Robotic-assisted repair of iatrogenic common bile duct injury after laparoscopic cholecystectomy: Surgical technique and outcomes.

BACKGROUND: Bile duct injury after cholecystectomy can be a life-threatening complication. Use of robotic approach to manage a complex biliary injury is in an early phase. METHODS: We have performed an analysis of our prospectively maintained database that included 12 patients who underwent robotic-assisted repair of bile duct injury after laparoscopic cholecystectomy between 2014 and 2017. RESULTS: All patients underwent robotic biliary repair within 2 weeks after primary injury. No conversion to open surgery was necessary, the estimated mean blood loss was 252 mL, and the mean operative time was 260 minutes. The mean length of stay was 9.4 days. The 30-day complication events were a subhepatic abscess and a recurrent episode of cholangitis. One patient underwent the reoperation. The mortality was null. CONCLUSION: Robotic-assisted bile duct injury repair seems to be safe and feasible. It offers promising results, thus potentially capable of modifying the management of biliary injury.

Laparoscopy is an available alternative to open surgery in the treatment of perforated peptic ulcers: a retrospective multicenter study.

BACKGROUND: Perforated peptic ulcers (PPU) remain one of the most frequent causes of death. Their incidence are largely unchanged accounting for 2-4% of peptic ulcers and remain the second most frequent abdominal cause of perforation and of indication for gastric emergency surgery. The minimally invasive approach has been proposed to treat PPU however some concerns on the offered advantages remain. METHODS: Data on 184 consecutive patients undergoing surgery for PPU were collected. Likewise, perioperative data including shock at admission and interval between admission and surgery to evaluate the Boey's score. It was recorded the laparoscopic or open treatments, the type of surgical procedure, the length of the operation, the intensive care needed, and the length of hospital stay. Post-operative morbidity and mortality relation with patient's age, surgical technique and Boey's score were evaluated. RESULTS: The relationship between laparoscopic or open treatment and the Boey's score was statistically significant (p = 0.000) being the open technique used for the low-mid group in 41.1% and high score group in 100% and laparoscopy in 58.6% and 0%, respectively. Postoperative complications occurred in 9.7% of patients which were related to the patients' Boey's score, 4.7% in the low-mid score group and 21.4% in the high risk score group (p = 0.000). In contrast morbidity was not related to the chosen technique being 12.8% in open technique and 5.3% in laparoscopic one (p = 0.092, p > 0.05). 30-day post-operative mortality was 3.8% and occurred in the 0.8% of low-mid Boey's score group and in the 10.7% of the high Boey's score group (p = 0.001). In respect to the surgical technique it occurred in 6.4% of open procedures and in any case in the Lap one (p = 0.043). Finally, there was a statistically significant difference in morbidity and mortality between patients < 70 and > 70 years old (p = 0.000; p = 0.002). CONCLUSIONS: Laparoscopy tends to be an alternative method to open surgery in the treatment of perforated peptic ulcer. Morbidity and mortality were essentially related to Boey's score. In our series laparoscopy was not used in high risk Boey's score patients and it will be interesting to evaluate its usefulness in high risk patients in large randomized controlled trials.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES).

BACKGROUND: In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases. METHODS: Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011. RESULTS: A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer). CONCLUSIONS: Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery.

BACKGROUND: There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications. METHODS: A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus. RECOMMENDATIONS: In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.