Laparoscopic cholecystectomy: technical compromise between French and American approach. Presentation of an original technique.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is a well standardized technique. There are two main approaches, proposed by French and American Schools. They have similar operative times, but different arrangements for site ports insertions and for patients and operators' position at operative bed. Although we can foresee new scenarios for the next future (robotics, SILS, NOTES, minilaparoscopy), it seemed interesting to describe a simple variation to LC introduced in the last years in our experience relative to the positioning of operators and patient during standard American technique. METHODS: In a retrospective analysis of 140 patients operated on for LC in the last two years (70 with French technique and 70 with "American modified" technique) we compared the following parameters: laparotomic conversion, duration of operation, hospital stay, morbidity and mortality rates. RESULTS: Conversion to laparotomy, length of operative time and hospital stay were similar. Morbidity rates were slightly different, but it did not show statistically significant differences between the two groups. Mortality was nil. CONSIDERATIONS: Our variant to LC seems to be almost a compromise between the two main techniques. Our operators' arrangement gave a greater comfort for surgeons during LC and our results were similar to those reported with adoption of French and American approaches. These considerations led us to judge our variation safe and reliable.

[Our experience in the management of patients with Mirizzi syndrome]. / Orlentamenti attuali nel trattamento della sindrome di Mirizzi. Nostra esperienza.

The authors report their experience in the management of patients with Mirizzi Syndrome (MS) admitted, over a period of 15 years, at the General Surgery of Emergency Department of Cardarelli Hospital, Naples, Italy. All patients were admitted and surgically treated in emergency save for one. Out of 12 patients, cholecystectomy was performed in 7 cases. In others 5 patients, with cholecystocholedochal fistula, cholecystectomy with positionig of T-Tube was performed in 4 cases (MS-II); finally, 1 patient with MS type III undewrwent choledochojejunostomy. According to literature, the diagnostic protocol included abdominal ultrasonography and CT scan of the abdomen for all patients; in one case, a cholangio-MRI was performed to clarify the diagnosis. The preoperative diagnosis is essential to reduce risk of iatrogenic injuries. The cholangio-MRI, used to this extent, clarifies the site of obstruction, shows the anatomy of the biliary tree and allows to make all the possible differential diagnoses in order to exclude the presence of biliary tumors before surgery. The intraoperative cholangiography remains mandatory to clarify the anatomy of the biliary tree. In the cases we have treated, ERCP was never performed. We believe that ERCP has limited indications and unsatisfactory outcomes for both diagnosis and treatment of MS. Pathological examination of the fresh-frozen surgical specimens was always performed intraoperatively to exclude the presence of concomitant cancer of the gallbladder. The traditional treatment of patients with MS is surgery, as confirmed by our experience. We perform cholecystectomy for MS type I and cholecystectomy with direct repair of the biliary fistula over aT tube for MS type II. Patients with MS type III usually undergo a tailored operation based on the intraoperative findings, while choledochojejunostomy is mandatory for patients with MS type IV. Laparoscopic surgery is indicated only for MS type I and II. It seems to carry a higher risk for the patient and we do not use this approach in the emergency settings.

[Mainly abdominal "complex" polytrauma. Considerations on surgical strategy and clinical case report]. / Politraumatismo "complesso" a prevalenza addominale. Considerazioni sulla strategia chirurgica e presentazione di un caso clinico.

The Authors want to present un uncommon case of polytrauma managed with surgical treatment at the Trauma Center of the A. Cardarelli Hospital in Naples. Chest, abdomen, pelvis, and left lower limb have been severely injured. This case is so interesting because of the rareness of some lesions (i.e. diaphragm rupture) and the numerous lesions of internal organs (i.e. lungs, spleen, liver, pancreas, mesenterium) and of the bones (i.e. thigh-bone and pelvis). A very good outcome has been obtained for survival as well as for functionality and quality of life since we have strictly applied the rules for the management of the "complex" polytrauma.

[Conservative treatment of the digestive fistulas: personal experience]. / Trattamento conservativo delle fistole digestive: nostra esperienza.

OBJECTIVE: The authors, thanks to experience obtained in an Unit for the treatment of digestive fistulas, discuss the possibility of a conservative treatment for the anastomotic fistulas. MATERIAL AND METHODS: From 2000 to 2003 were treated thirty-five patients with post-anastomotic gastroenteric fistulas marked according to their localization, way end output (51.5% high, 42.8% moderate and 5.7% low). The treatment is based on an aspiration system, sometimes integrated with an irrigation system. A semi-permeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic, polymer covered with a self-adherent surgical sheet. This system create a vacuum chamber equipped with a subathmospheric pressures between 262.2 and 337.5 mmHg (350-450 mmbar), integrated with a continuous irrigation using antibiotic solutions or 3% lactic acid. RESULTS: The AA. obtained the resolution in 30 patients (85.7%), 3 patients needs the surgery (8.6%), 2 died, one for sepsis and the other one for malnutrition. The mean time for the closure was 45 days (from 20 to 90). A part of digestive external fistulas goes to spontaneous resolution so comes the idea that the creation of particular condition is the basis of their closure.

[Anterior jugular vein cavernoma in a forthcoming rupture stage: a case report]. / Cavernoma fissurato della vena giugulare anteriore. presentazione di un caso clinico.

The Authors present a very rare case of left anterior jugular vein cavernoma anterior jugular vein cavernoma in an over-seventy-year-old woman. The patient was visited already in a complicated status occurring as an increasing lateral neck mass. The case is so interesting for several reasons: for the peculiar lesion that belongs, in fact, to the uncommon group of the cavernous hemangiomas; for the exceptional localization on the anterior jugular vein; for the old age of the patient; last, but not least, for the unusual presentation of the forthcoming rupture. A speed healing without complications has been achieved thanks to the immediate diagnosis (it is important to suspect the lesion!), to the imaging techniques and to the surgical approach performed in emergency.

[The congenital cystic dilatation of the liver and bile ducts (CDB): our experience]. / La dilatazione congenita delle vie biliari: la nostra esperienza.

The congenital cystic dilatation of the liver and bile ducts (CDB) is a very uncommon disease. It often appears in females and most frequently in paediatric patients. Its etiopathogenesis is not yet completely defined. Its evolution includes, together with several complications, the malignant transformation. The Authors present the outcomes of their experience based on a series of 5 patients observed from 1991 till today. Apart from the rarity of this disease, their series is so interesting because 4 out of 5 are adult patients and the fifth one is over 15. In addition, differentiating from the literature trend, the group included only male patients. Are also discussed the most important aspects referring to nosology, epidemiology, etiopathogenesis, clinical pattern and its evolution of CDB, looking over a wide review too. The Authors extensively examine the diagnostic problems; owing to that the patients were observed in the period 1991-1999 it is necessary to clarify that some imaging methods, i.e. CSTscan and the bile duct MNR, were not yet introduced. The surgical treatment has been investigated as well, developed during its historical evolution until nowadays and our solutions for the 5 cases have been presented and discussed. In their series the Authors haven't ever observed during hospitalisation a malignant transformation.