[Ergonomic and cosmetic aspects of laparoscopic appendectomy: personal technique]. / Ergonomia ed estetica nell'intervento di appendicectomia laparoscopica: tecnica personale.

We analyzed our case series in order to evaluate the evolution of our laparoscopic technique in ergonomic and cosmetic terms, leading to the right compromise between these aspects. We retrospectively analyzed 136 diagnostic laparoscopies for suspected appendicitis, using scheme A in the first 98 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars placed above the pubis on the right and left side) and scheme B in the other 38 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars, one placed over the pubis and the other one on the right hip, just on the umbilical line). The diagnosis of appendicitis was confirmed in 117 patients, while other diseases were present in 19 patients. There were no differences between the two groups in mean operative time (45 min), postoperative complications (0.7%) and clinical course (hospital stay: 36 hours on average). We believe that the right compromise between ergonomic and cosmetic considerations is the one shown in scheme B. In this way it is possible to perform all diagnostic and therapeutic manoeuvres such as pulling the appendix out through the umbilical trocar and using suprapubic trocars as an access route for a possible drainage.

["Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA III and IV): our experience]. / La colecistectomia laparoscopica a "bassa pressione" nei pazienti ad alto rischio (ASA III ed ASA IV) nella nostra esperienza.

The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation.