[Identification of an objective reference parameter for the reconstruction of a large incisional hernia following physiological principles]. / Identificazione di un parametro obiettivo di riferimento per la ricostruzione secondo criteri fisiologici del grande laparocele.

Repairing a parietal defect of a large incisional hernia should not be limited to the closure of the breach by means of the modern biocompatible prosthetic sheets, but must also be able to restore a correct intra abdominal pressure, otherwise the derangement from the normal respiratory dynamics and the circulatory stasis in the abdominal veins and in those of the lower limbs remain unaltered. Over-correcting the parietal abdominal tension on the contrary can cause a dangerous compartmental syndrome. The attempts of an intraoperative measurement of the correct intra abdominal pressure restoration has been generally hampered from the condition of curarization of the patient during the operation. Using the automatic mechanical ventilator fixed at volume and not at pressure priority, as usual, can offer the possibility to calibrate, following objective parameters, the propriety of the surgical repair still during the final phases of the reparative operation. The simplicity and ingenuity of the here proposed method and the normal availability in every operative theatre of the necessary means for this measurements described, requires attention among the surgeons and a large diffusions of its simple use.

A new surgical tool facilitating the low colo-rectal anastomosis. The original "grasping tie".

A new surgical tool is here proposed to be used together with a circular stapler to help performing a mechanical anastomosis of the low rectum after a sigma or rectum resection. Its name, grasping tie, indicates its main function to fix from outside the rectal stump to the axle of the stapler anvil by means of a nylon ribbon slipping knot before the connection of the two parts of the stapler. The small dimensions of the operative end of the tool make easy to operate in the narrow space of the deep pelvis.

[Experimental study of the effect of the Argon Beam Coagulator on organic tissues from the viewpoint of surgical utilization]. / Studio sperimentale dell'effetto dell'Argon Beam Coagulator su tessuti organici in vista dell'impiego in chirurgia.

The Argon Beam Coagulator has gained his space in surgery thanks to its operative characteristics, that are very useful in sealing the bleeding parenchymal tissue with minimal injury to the surroundings. The aim of the present study is that of evaluate the physical properties of the instrument in its coagulation action. The experimental study with the Birtcher 6000 Argon Beam Coagulator has been designed to measure the top temperature that develops right where the Argon beam meets the tissue, while operating. Using a laser guided telethermometer, the searching of that temperature was uneasy right on the operatory field because of the unwilling movements of the operator hand and those of the patient himself. Therefore a similar protocol was made on a piece of meat coming from the butcher. At the longest application of the beam coagulation on the same point the developed temperature was never higher than 100 degrees C whilst a complete coagulation effects. The advantage of the Argon Beam coagulation are therefore to seal the diffuse bleeding without injury to this adjacent tissues, never exposed to a temperature higher than that of boiling water. The advantages are also evident in comparison with the more usual spray electrosurgery that is instead characterized by a wide carbonisation also with this spray option.

[Complicated colon cancer: the experience at an Operative Surgery Unit]. / Il cancro del colon complicato: esperienza di una Unità Operativa Chirurgica.

INTRODUCTION: Prognosis of colon cancer is worse if complications are present at the moment of diagnosis. The high mortality rate with surgery in emergency in such cases needs a careful reflection about the best suitable operation to perform. MATERIALS AND METHODS: 107 consecutive patients observed along a 9 year-period for colon-rectal cancer are retrospectively analysed. 27 of them were complicated at the presentation for obstruction (19 patients), colon perforation (6 patients) or rectal hemorrhage (2 patients). In the whole experience 5 patients underwent primary resection of the tumour and direct anastomosis; 5 only a decompressive colostomy; 6 were primarily resected and anastomized under the protection of a cecostomy; 6 other patients underwent a Hartmann procedure; 2 were treated with only an intestinal by-pass; 1 was treated with Miles procedure; 1 with an anterior rectal section and the last one was resected-anastomosed in two steps, after a temporary decompressive colostomy. RESULTS: Intraoperative mortality was of 11.1% (3 patients) and morbidity 18.5% (5 patients). General 5 years survival was 62.1% among the cases complicated at presentation. The recurrence rate was 8.45%. Both these figures are below a statistical significance (p = 0.57). CONCLUSIONS: The necessity to treat in emergency the colon cancers reduces the possibility to adopt the best rules of modern programmed oncologic surgery giving up the chemotherapy w/o neoadjuvant radiotherapy with which a preoperative down-staging of the tumour were possible. For these reasons in emergency not only mortality and morbidity are higher than in case of elective surgery, but also metastasization and recurrence are worse because of a more difficult radicality in surgery.

[The treatment of inguinal hernia: experience of a Operative Surgery Unit]. / Il trattamento dell'ernia inguinale: esperienza di una Unità Operativa Chirurgica.

INTRODUCTION: 550 patients submitted to surgical hernia reparation are reviewed for a retrospective analysis. PERSONAL EXPERIENCE: The case report shows a predominance of prosthesis reconstruction according to Trabucco (254 patients) and of the surgical technique of Shouldice (191 patients). Other procedures of the experience refer to the surgical techniques of Bassini (46 patients), Lichtenstein (46 patients), Mugnai/Ferrari (7 patients), Postenski (3 patients), Rives (2 patients), and Stoppa (1 patient). RESULTS: The reconstruction procedure was performed from a number of surgeons, all let free to choice the kind of operation following his personal skill and preference, but always in the most correct technique way. The results were satisfying in terms of short hospital stay, both precocious and late low complications, and always without failure. DISCUSSION: A first consideration is that there is no data from the literature that any prosthesis procedure offers a lower postoperative complication incidence than the Shouldice's technique, and our experience confirms this option. CONCLUSIONS: A surgeon can nowadays freely cultivate his preference for any of the possible procedures in reconstructing an inguinal hernia, but it is highly advisable that all the possibilities, also the pure surgical ones, remain in the surgeon's possibility of choice not to waste a precious previous surgical culture.

[Monitoring sheet for the management of the diabetic patient in preparation for elective surgery]. / Scheda gestionale del paziente diabetico per la preparazione all'intervento chirurgico di elezione.

Diabetes represents a risk factor for patients undergoing surgery, not only in emergency but also in elective situations. All efforts in such patients are addressed to the restoration of the most physiologic conditions in respect for glucose balance and glucose metabolism since the preoperative phase, and during all the perioperative period. As these patients have to observe a more or less long period of preoperative and perioperative fasting since the day preceding the operation, any oral anti-diabetic regimen has to be timely discontinued, and the use of insulin is necessary. The doses of insulin have to be defined preoperatively with respect of the metabolic needs of the patients in the days preceding the operation, and must be able meanwhile to reduce blood glucose among the physiologic values, in absence on any urinary glucose, to restore a correct metabolism. The simple management form introduced in the paper for this purpose, and in use in our department through many years, makes easier getting and keeping all this aim and is extremely useful not only for the residents but also for the nurse staff. Its main characteristic is to offer daily, and for the single meal, a direct visual comparison of insulin dose and blood glucose level, in respect of a correct and constant caloric alimentation.

Simulated use of the "grasping tie" as for colo-rectostomy after low rectal resection.

Simulated test of effectiveness of the original tool grasping tie, technically already illustrated in two previous papers listed in bibliography, for fixing a spongy rubber tube, simulating a rectal stump on the anvil's axle of a circular stapler, by tightening over it a nylon ribbon slip-knot (the tie). After connecting the anvil to the stapler head through an other spongy rubber tube simulating a colonic loop, and the firing of the stapler, it is demonstrated the correct circular anastomosis achievable.

[Critical update on the no-touch technique in colonic cancer using the grasping tie]. / Aggiornamento critico della tecnica del "no-touch" per il cancro del colon con l'uso del "Grasping tie".

The time honoured strategy of "no-touch" in the surgery of colon cancer does not stand an anatomical and patho-physiological criticism, also on the basis of some results of the literature. The personal experience of the problem leads to the proposal of an alternative realization of the procedure, that is an up-to-date of the classic method, and is really worth and easy to be overall adopted. The suggestion is to seal bipolarly the colon tract with the tumour by mean of the original grasping tie from the very beginning of the operation, and then to temporarily clamp the mesocolon close to the gut, before going on with the surgical dissection, lymphectomy and exeresis as usual. This procedure is able to completely isolate from the first steps of the operation the affected tract of the colon, so opposing the possible spreading of tumour cells in the portal and in the systemic venous stream during the following surgical manipulations. The rationale of the proposal is that of a more efficacy of the "no-touch" strategy based on strict anatomical and patho-physiological considerations.

Study of the antireflux function of the Roux-en-y jejunal loop in reconstruction following gastrectomy.

Persistence of global orthograde peristaltic propulsion in the Y jejunal loop according to Roux makes this latter adequate for reconstruction of digestive transit after gastric resection or total gastrectomy, simultaneously avoiding reflux. Ectopic pacemakers can set in its proximal tract and favor intestinal and bile juice reflux in the gastric stump or esophagus, especially if the loop is too short and the new pacemaker is far from its superior margin. Moreover, the slower peristaltic waves can favor a relative stasis and, thus, a containing function, which could represent an element of morbidity over a certain limit. If the Y loop is not too long, but long enough to include the higher frequency ectopic pacemaker, which overcomes the lower frequency ones located distally, the positive aspects of both these characteristics can be exploited for satisfying and free of morbidity results. We believe that the best length is 35-40 cm, with positive clinical results. 99Tc-HIDA sequential scintigraphy clearly shows the absence of bile material reflux in the digestive tract proximal to the anastomosis.

Surgical conservative treatment for Bauhin's syndrome.

BACKGROUND AND STUDY AIMS: Hypertrophy of ileocaecal sphincter seems to be the basic etiological factor of Bauhin's valve syndrome (BVS). In the rare literature all cases are treated by means of an hemicolectomy. A patient with Bauhin's valve syndrome is described, whose pathologic characteristics were hypertrophy of ileocaecal sphincter and a circular submucosal lipoma on the caecal side of the valve. Lipomata, although uncommon, may arise throughout the whole gastrointestinal tract, mostly asymptomatic, and submucosal layer is most frequently involved than subserosal one. More than two-thirds of gut lipoma are found in the large bowel, where they represent the most common benign lesion after adenoma. PATIENTS AND METHODS: A 36 year old woman suffering from periodic upper abdominal pain, nausea and diarrhea, was submitted to an explorative surgical procedure, after imaging study of the bowel showed only an indistict mass in the caecum. Though a caecotomy a dissection of an hypertrophic and swollen portion of the ileocaecal valve was performed, saving the ileo-caecal sphincter. The residual mucosal margins were sutured, the last tract of the ileum was fixed to the caecum, completing with a caecorrhaphy and appendectomy. RESULTS: Normal post-operative period, discharging the patient after few days. Since the operation all symptoms disappeared, and after four years there is a total well-being of the patient with complete disappearance of the former symptoms. CONCLUSIONS: If the BVS is only due to a lipomatous hypertrophy of the mucosa and submucosa of ileo-caecal valve, hemicholectomy seems to be not justified: it is an exceedingly invasive procedure for a non-malignant disease. It is important a throughout radiological diagnosis and a caecotomy direct control during an operative exploration for a correct surgical choice.

[The "grasping tie". I. Introduction to and technical notes of an innovative mechanical tool aimed at formation of "purse string" in digestive surgery]. / "Grasping tie"--I. Presentazione e note tecniche di un innovativo strumento meccanico per la confezione della "borsa di tabacco" in chirurgia digestiva.

The grasping tie is an original and mechanical tool, conceived and planned to be used in digestive surgery, to temporary grasp and fasten at the axis of the head or the anvil of a circular stapler the tract of the gut chosen for anastomosis. Its use permit to fix the lower oesophageal stump in total gastrectomy, or that of the rectal stump in the lower rectal resection, respectively to the axis of the circular stapler component for the time necessary to perform the mechanical anastomosis. That is performed by the employment of a thin nylon ribbon, which will be progressively tightened as requested like a one way running knot about the tract of the gut and at the axis of the part of the stapler. The device will be repeatedly activated by an handle located at one of its ends, tightening progressively at the other end a thin nylon ribbon preventively put and laced around the chosen point of the digestive tract to grasp firmly and irreversibly the gut to the axis of the stapler, and then cut away by a trigger of the device in the same end of the handle. The nylon ring will be extracted together with the muscle-mucosal rings once completed the stapler suture, so that nothing of the ribbon remains in the patient. Its function is alternative to the classical tool used to prepare a purse-string suture on a segment of the digestive tract. Its advantages in front of that tool is the minimal space it requires for its use, therefore with operative advantages in fixing the head of the circular stapler in the oesophagus during the reconstructive steps after a total gastrectomy, and in fixing the lower rectum to the axis of anvil of a circular stapler preventively introduced in the anus and extruded. Moreover its employment is advantageous in closing from the outside the two ends of a tract of the gut where a tumour is located, so allowing a safe subsequent manipulation of the gut without oncologic prejudice.

[Contribution to the knowledge on natural history of giant hepatic angioma]. / Contributo alla conoscenza della storia naturale dell'angioma epatico permagno.

Hepatic haemangiomas are mostly discovered by chance because of their limited dimensions. Their treatment is optional and very often an observing conservative strategy is adopted whilst a danger is foreseeing from different facts. Very different is the case of giant haemangiomas discovered because their bulk and discomfort coming from the compression exerted on near structures. In this cases a surgical treatment, segmentectomy or hemiepatectomy, are the current demanding choices. But if the volume of haemangioma is too bulky and occupies most hepatic parenchyma the necessary resection may be too extended and possibly dangerous. The two observations of the paper refer to two patients followed conservatively for over 20 years. In fact the volume of the haemangiomas in both patients was too large, the symptoms were only related to the weight of the mass and therefore a surgical solution was deferred to a possible worsening of the symptomatology. Such worsening didn't happen in the time for both the patients, demonstrating that the natural history of such lesion can also be very benign over many years.

[Digestive system neoplasms originating from the autonomic nervous system. Diagnostic, therapeutic and prognostic issues]. / Tumori del canale digerente derivati dal sistema nervoso autonomo. Problematiche diagnostiche terapeutiche e prognostiche.

The gastrointestinal autonomic nerve tumors (GAN tumor) are uncommon stromal tumors of the intestinal tract and retroperitoneum. The distinction of GAN tumors from other gastrointestinal stromal tumors is based on electron microscopic findings. However further study of additional cases is needed to fully characterize both their gross and microscopic features and to further characterize the natural history of such tumors. In the present study we report two cases of GAN tumor that arose from the stomach and small intestinal with different prognostic evolution in two patients of 73 and 65 years old. They were both treated by surgery, but only one case was successful. In addition patient 1 aged 73, died 11 months after surgical treatment with liver metastases on CT. scan. Patient 2, is clinically well five years after surgical treatment.

[The radical treatment of hepatic hydatidosis with deep and multiple locations. The role of new technologies particularly in the case of multiple locations]. / Sul trattamento radicale dell'idatidosi epatica a localizzazione profonda e multipla. Ruolo delle nuove tecnologie, specie in caso di localizzazioni multiple.

Advanced technologies (intraoperative ultrasonography, CT scan, argon coagulator ...) have changed the surgical approach of liver hydatid disease, allowing even multiple or deeply located cysts to be detected and treated successfully. Authors report a series of 4 patients with single (3) or multiple (1) unilocular hepatic cysts; and 1 patient with thoraco-pulmonary hydatid recurrent disease. Treatments of choice and surgical techniques are described. No infective compliances occurred. The mean period of hospitalization was 19 days (ranging between 10 days and 4 weeks). The longest hospitalization was observed in a patient with a post-operative biliary fistula at low out put. Total cysto-pericystectomy is emphasized as the gold standard procedure in the treatment of non complicated unilocular hydatid cysts of the liver. Modern means of investigation and technical equipment make it feasible and safe even in unfavorable localizations, allowing radical removal of the cysts preserving in the meantime all the surrounding liver parenchyma.

[The scientific videotape with digital processing in surgery. The new opportunities offered surgery for videotape recording and postprocessing with the use of information and digital technologies]. / Il videotape scientifico ad elaborazione digitale in chirurgia. Le nuove opportunità offerte alla chirurgia dalle registrazioni in video-tape e dalla post-produzione con l'impiego delle tecnologie informatiche e digitali.

The facility of the tape recording of a surgical operation, by means of simple manageable apparatuses and at low costs, especially in comparison with the former cinematography, makes it possible for all surgeons to record their own operative activity. Therefore at present the demonstration in video of surgical interventions is very common, but very often the video-tapes show surgical events only in straight chronological succession, as for facts of chronicle news. The simplification of the otherwise sophisticated digital technology of informatics elaboration of images makes more convenient and advisable to assemble the more meaningful sequences for a final product of higher scientific value. The digital technology gives at the best its contribution during the phase of post-production of the video-tape, where the surgeon himself can assemble an end product of more value because aimed to a scientific and rational communication. Thanks to such an elaboration the video-tape can aim not simply to become a good documentary, but also to achieve an educational purpose or becomes a truly scientific film. The initial video will be recorded following a specific project, the script, foreseeing and programming what has to be demonstrated of the surgical operation, establishing therefore in advance the most important steps of the intervention. The sequences recorded will then be assembled not necessarily in a chronological succession but integrating the moving images with static pictures, as drawings, schemes, tables, aside the picture-in picture technique, and besides the vocal descriptive comment. The cinema language has accustomed us to a series of passages among the different sequences as fading, cross-over, "flash-back", aiming to stimulate the psychological associative powers and encourage those critical. The video-tape can be opportunely shortened, paying attention to show only the essential phases of the operation for demonstrate only the core of the problem and utilize at the best the physiological period of active attention of the observer. The informatic digital elaboration has become so easy that the surgeon himself can be able to elaborate personally on his personal computer, with professional and scientific attitude, the sequences of his surgical activity in a product of more general value. His personal engagement also in the phase of post-production gives him the possibility to demonstrate uprightly with images the complex surgical experience of science, skill and ability to communicate, perhaps better than he is able to do with words.

[Guideline concepts of the present-day surgery in breast cancer]. / Concetti informatori la moderna chirurgia del cancro mammario.

The more important trends of nowadays surgery for breast cancer are those of an advanced rationalization of combined strategies in a multidisciplinary view. Moreover it takes advantages from the availability of an extremely modern diagnostic instrumentation used in search of a truly early diagnosis, based on scheduled screening and surveillance criteria both for general population and particularly for that at risk. In this way it is easier and possible to adopt less radical and more conservative surgical techniques, whose effectiveness is well demonstrated in association with adjuvant treatment thanks to the convergence of multiple competences. The better results of the last years are certainly related to the collaboration of surgeons with oncologists, thanks to the ever more effectiveness of adjuvant chemo- and radiotherapy, that make more acceptable the attitude for the reconstructive and the conservative surgery whenever possible. This interpretation of the actual positive results of breast cancer surgery point the way to follow, and are the basis for hoping further improvement in the treatment of this disease, ever more efficacious whilst that diagnosis precocious be more and more.

Perspectives of scientific publications of surgery in Italy. Perspectives on the article of M. Rubino and Al. "Types of surgical articles. Comparative analysis of three Italian and three foreign journals".

The globalization of the information and the wide use of the English language in the scientific world impose a not avoidable comparison to the scientific Italian journals, but with value indicators that if accepted without criticism could humble the undeniable internal values. In fact such comparison is based certainly on the quality of the contents, but it has already as background parameter the language of publication if the aim is that of an adequate diffusion. The questions that rise from the analysis of the problem are essentially two: if there is still room nowadays for surgical scientific publications in Italian language and if it is correct to accept in a closed box the indicator of international comparison conditioned by the English language, with the consequence that the definite value judgement is entrusted to external opinions. Certainly the Italian journals of surgery must aim both to quality and to their diffusion for reaffirm and validate their cultural rights. The quality depends on the authors and on the surgical environment in which they operate, beyond the engagement of the scientific direction of the journal; the diffusion on the correct employment of the English language, at last of the abstracts, and on the general editorial strategy pointing to encourage and promote the widest coverage of critique. It remains but to bravely loose the knot represented from the proposal of a uncritical acceptance of the indicator of the IMPACT FACTOR with the consequent absolute judge of quality, that fatally depends from an egemonic Anglo-Saxon filter, not exempt from an unavoidable lobbystic imprint.

[Transclavicular approach for delivery of intrathoracic giant goiter. An alternative surgical option]. / L'accesso trans-clavicolare per la liberazione del gozzo immerso permagno. Una proposta chirurgica alternativa.

To remove the immerse portion of a cervical goitre it is necessary to treat preventively the cervical thyroid arteries. In most cases it is afterwards it is easy the blunt finger dissection of the mediastinal bulk following the correct cleavage plane and its dislodging in the cervical area. But in very rare instances, according also to the personal experience, remains some difficulty for the passage of a too bulky and hard mediastinal mass through the rigid limits of the upper thoracic outlet, or the immerse struma is too fragile for pulling it by transfixion threads. Therefore, traditionally arises the opportunity of an additional surgical access, through the breastbone or through the thoracic wall, according to the circumstances. Our experience, completely occasional but extremely positive of two of such cases, induces us to advance a proved alternative surgical proposal. When the difficulty of the removal of the immerse portion of the goitre comes only from the incongruence of the immerse volume and the rigid limits of the upper thoracic outlet, our proposal is that to obtain an amplification of the narrow passage breaking the continuity of the clavicle, by its section beneath the periostium near the breastbone and removing this sternal stump from the joint. The result is that of an widening of the upper thoracic outlet, no more rigid, and making easy the transit of the immerse portion from anterior mediastinum so dislodged in the neck. The rationale of this choice is that all is requested in such cases is only to overcome the obstacle of the incongruence among volume and bulk of the immerse portion and the bone limits fixed from the narrow upper thoracic outlet. Both the traditional sternotomy and the thoracotomy seems disproportional for this purpose, moreover with additional problems during the operation. The true advantage of these classical solutions is in treating under direct vision the anomalous arteries of the mediastinal goitre in cases of ectopic localization. But this is not the case of an immerse cervical goitre. It is therefore essential to note that this proposal applies only to the migrated goitre and not to the ectopic ones. The recovery is extremely simple, and both the aesthetics and the static of the scapular joint are not substantially compromised.