Diverticulitis, surgery, evidence-based medicine, and the Steve Jobs' dots: a narrative review.

PURPOSE: Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. METHODS: Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. RESULTS: In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". CONCLUSIONS: Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management.

Inguinal hernia repair in a community hospital setting--have attitudes changed because of laparoscopy? A review of a general surgeon's experience over the last 5 years.

OBJECTIVES: The laparoscopic transabdominal preperitoneal (TAPP) approach for inguinal hernia repair is well documented in numerous studies as an excellent choice when performed by an experienced surgeon. In this report we wish to evaluate our experience of TAPP laparoscopic inguinal repair performed in a Community Hospital over the last 5 years, focusing on the feasibility of the technique and the incidence of complications when performed by general surgeons in this setting. We also wish to report and discuss how our attitudes concerning inguinal hernia repair have changed since we adopted the laparoscopic approach. MATERIALS AND METHODS: Between January 2003 and January 2008 a total of 193 patients, at "Civil Hospital" in Vittorio Veneto (TV), underwent TAPP laparoscopic inguinal hernia repair. The total hernias repaired were 362. RESULTS: The overall mean operative time was 45.58 min. (+/-15.2 min). All the procedures were performed in day surgery. There were no conversions to open repair or deaths in our series. We had 2 cases of small bowel occlusion and 5 relapsing hernias (1.3%), which we preferred to treat with an anterior approach. The mean follow-up was 30.4 (+/-5.6; range: 1 to 60 mo) months. No patients reported severe pain at 10 days, 7.2% (14 cases) reported mild pain at 3 months. There were no reports of night pain at 30 days. Approximately 90% of the patients had a return to physical-work capacity within 7 days, the remainder within 14 days. All patients were completely satisfied at 3 months. CONCLUSIONS: The analysis of the short-term postoperative outcomes of our experience enabled us to conclude that in the proper setting TAPP is feasible, effective, safe, and beneficial for patients and should be a routine part of any surgical practice providing adequate training has been undertaken and proper preparation observed.

Laparoscopic cholecystectomy with a three-trocar 5-mm instrument approach.

The natural evolution of laparoscopy seems to be the use of miniature instruments and, where possible, a reduction of the number of trocars used. We report the results of our experience with all 5-mm instrument three-trocar cholecystectomy vs. the conventional laparoscopy approach. From July 2002 to July 2005 a total of 518 patients underwent laparoscopic cholecystectomy: 268 of them (51.7%) were operated on with a 5-mm three-trocar approach. The primary end point was the feasibility rate of the technique. Secondary end points were safety and the impact of the technique on the duration of laparoscopy. There were two conversions to laparotomy--one in each group--while a conversion to the classical approach for the three-trocar group was registered in 9.3% of the cases. Occurrence of minor complications was 3.6% (9 cases) with the conventional approach as against 3.7% (10 cases) with the three-trocar approach. The present experience shows that 5-mm three-trocar cholecystectomy is a safe, easy, effective and reproducible approach for gallbladder disease. Such features make the technique a challenging alternative to conventional laparoscopy in the treatment of cholecystopathy, in both the acute and elective setting.

Preliminary experience using fibrin glue for mesh fixation in 250 patients undergoing minilaparoscopic transabdominal preperitoneal hernia repair.

PURPOSE: Fibrin glue for mesh fixation has been proposed to prevent the risk of nerve injury in inguinal hernia repair. We retrospectively evaluated a series of 250 patients who underwent minilaparoscopic transabdominal preperitorneal (miniTAPP) hernioplasty (using trocars, optics, and instruments <10 mm in diameter) in whom mesh fixation was achieved using 2 mL of fibrin glue. We considered the feasibility of the technique and the incidence of complications, especially those possibly related to mesh fixation. We also compared the results with an earlier series of 245 patients in whom tacks were used to fix the mesh. MATERIALS AND METHODS: Between April 2004 and November 2005, 250 patients underwent bilateral or unilateral miniTAPP hernioplasty with instruments, optics, and trocars smaller than 10 mm and meshes fixed by fibrin glue. RESULTS: The mean overall operative time was 52.25 +/- 15.2 min. All the procedures were done as day surgeries. We registered one intraoperative bladder lesion and 15 cases of seroma. There were no relapses, prosthesis rejection, or infection. The mean follow-up was 13.2 +/- 6.1 months (range, 5-24 months). CONCLUSION: On the basis of our initial experience, miniTAPP hernioplasty with a fibrin glue is feasible, effective, and easy to perform in experienced hands, with good results without higher risk of recurrence. In addition, the fibrin fixation method seems to decrease postoperative neuralgia and reduced the incidence of postoperative seromas and hematomas.

Peritonitis: laparoscopic approach.

BACKGROUND: Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment - exploration to identify the causative pathology and performance of an appropriate operation - can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution. METHODS: From January 1992 and January 2002 a total of 935 patients (mean age 42.3 +/- 17.2 years) underwent emergent and/or urgent surgery. Among them, 602 (64.3%) were operated on laparoscopically (of whom 112 -18.7% - with peritonitis), according to the presence of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than two previous major abdominal surgeries or massive bowel distension were not treated Laparoscopically. Peritonitis was not considered contraindication to Laparoscopy. RESULTS: The conversion rate was 23.2% in patients with peritonitis and was mainly due to the presence of dense intra-abdominal adhesions. Major complications ranged as high as 5.3% with a postoperative mortality of 1.7%. A definitive diagnosis was accomplished in 85.7% (96 pat.) of cases, and 90.6% (87) of these patients were treated successfully by Laparoscopy. CONCLUSION: Even if limited by its retrospective feature, the present experience let us to consider the Laparoscopic approach to abdominal peritonitis emergencies a safe and effective as conventional surgery, with a higher diagnostic yield and allows for lesser trauma and a more rapid postoperative recovery. Such features make Laparoscopy a challenging alternative to open surgery in the management algorithm for abdominal peritonitis emergencies.

The diagnosis of non-palpable lesions in laparoscopic surgery of the colon.

The identification of small neoplasms or areas presenting lesions associated with previous endoscopic polypectomy is one of the major problems in laparoscopic colonic resection. The aim of our study was to evaluate the effectiveness of tattooing with Indian ink to identify the area of the colon that is the site of the lesion in order to be able to perform colonic resections with oncologically correct margins. Eighty-four patients were observed with polypoid lesions or diagnosed as presenting lesions associated with endoscopic polypectomy for which colonic resection had been recommended. Marking was performed during preoperative colonoscopy by injecting 1 ml of Indian ink solution with a sclerotherapy needle into each of the four quadrants of the colon wall. This method, which is simple to execute, invariably allowed easy identification of the site of the neoplasm and laparoscopic colon resection with correct oncological margins. In the 84 cases, we recorded only one complication (1.1%) due to a paucisymptomatic microperforation discovered during the operation. The identification of small colon lesions can be performed easily using Indian ink. It is a simple, quick method which, if performed properly, always allows the site of the lesion to be identified and is associated with a negligible rate of complications.