Remote mentoring in laparotomic and laparoscopic cancer surgery during Covid-19 pandemic: an experimental setup based on mixed reality.

In this paper, Mixed Reality (MR) has been exploited in the operating rooms to perform laparoscopic and open surgery with the aim of providing remote mentoring to the medical doctors under training during the Covid-19 pandemic. The employed architecture, which has put together MR smartglasses, a Digital Imaging Player, and a Mixed Reality Toolkit, has been used for cancer surgery at the IRCCS Hospital 'Giovanni Paolo II' in southern Italy. The feasibility of using the conceived platform for real-time remote mentoring has been assessed on the basis of surveys distributed to the trainees after each surgery.

An Intrapancreatic accessory spleen presenting as a neuroendocrine tumor.

Although the second most common site of the accessory spleen is the tail of the pancreas, intrapancreatic accessory spleens (IPAS) are rarely recognized radiologically. When an accessory spleen is located in the pancreas, it may mimic a hypervascular pancreatic tumor. We report a case of intrapancreatic accessory spleen which radiologically (on TC) mimicked a neuroendocrine pancreatic tumor (PNET). It was not possible to be sure that the pancreatic nodule had no malignant potential; because of the close proximity to splenic vessel we performed en bloc resection of the spleen and distal pancreas. Postoperative course was uneventful. IPAS must be considered in the differential diagnosis of pancreatic tail tumors, particulary an asymptomatic small PNET; new and adequate diagnostic studies have demonstrated utility in defining these lesions. We review pertinent literature. KEY WORD: Intrapancreatic accessory spleen, Pancreatic neuroendocrine tumor.

Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform.

BACKGROUND: Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy. METHODS: We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter). RESULTS: Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy. CONCLUSIONS: Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial. TRIAL REGISTRATION: Retrospectively registered on 20 july 2018 . TRIAL REGISTRATION NUMBER: researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

Incidental thyroid carcinoma in patients with TIR1, TIR2 and TIR3 FNA.

AIM: The aim of our study was to evaluate the presence of incidental differentiated thyroid carcinomas, at final histological examination, in patients undergoing thyroidectomy or lobectomy for presumed benign pathology or in those with cytological diagnosis of indeterminate nodules (TIR3). MATERIAL OF STUDY: 457 patients who underwent surgery for benign disease and 179 patients with indeterminate FNA were included in our study. RESULTS: 77 out of 457 patients had the diagnosis of differentiated thyroid carcinoma. 29 out of 179 patients had the same diagnosis as previous ones, but not on the undetermined FNA nodule. In the most of the cases, the istotype was follicular variant of papillary carcinoma. DISCUSSION: The incidence of incidental carcinomas, approximately the same in the two groups of patients, respectively 16.8% and 16.2%, shows that there is still a group of patients with benign thyroid disease escaping a careful ultrasound evaluation and therefore a targeted FNA. Even in patients with indeterminate cytology, the presence of an incidental carcinoma suggests that on the one hand there has been an overestimation and on the other a non-recognition of the really suspect nodule. Although in most cases it is a microcarcinoma, we must not overlook the presence of many tumors at stage T3. CONCLUSIONS: Surely the analysis of the set of risk factors with a wider application of molecular biology surveys will in the future lead to better selection of patients to undergo surgery sooner than those that can be followed in follow up even for a longer period of time. KEY WORDS: Differentiated thyroid carcinoma, Fine needle aspiration, Incidental carcinoma.

Incidental carcinoma of the thyroid.

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 455 patients submitted to surgical intervention in order to establish the incidence of this kind of carcinoma. Two hundred fifty-six patients (56%) were affected by benign disease (176 multinodular goiter, 12 uninodular goiter, 1 Plummer disease and 67 Basedow disease) and 202 (44%) by carcinoma. In 28 of 256 patients (11%), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (10 papillary carcinoma, 1 follicular carcinoma, 29 papillary carcinoma follicular variant). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent Fine Needle Aspiration (FNA) and there were no suspicious features in all exams that may suggest the presence of carcinoma. Twenty-three of the 40 incidental carcinoma (57.5%) were microcarcinomas. Ten patients had a sincronous carcinoma. Actually, these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could identify the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNA, but in most cases it's not really biologically aggressive.

[Laparoscopic cholecystectomy for acute cholecystitis in pregnancy: a case report in woman with situs viscerum inversus]. / Colecistectomia laparoscopica per colecistite acuta in gravidanza: il caso di una portatrice di situs viscerum inversus.

We report a case of a three month young pregnant woman (In Vitro Fertilization and Embryo Transfer - IVF-ET - twin pregnancy) with situs viscerum inversus totalis affected by acute cholecystitis. As already happened in other pregnant women, we use laparoscopic approach and cholecystectomy is performed successfully without any morbidity for mother and fetuses.

[Laparoscopic appendectomy. Our experience]. / Appendicectomia laparoscopica. Esperienza personale.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. Our study examined 150 patients, 67 males and 83 females. They underwent surgery for acute appendicitis in emergency. The choice between open or laparoscopic tecnique was due to patient's clinical conditions and surgeon's experience. Two of these patients had no infiammatory process. Eleven patients were affected by gynaecological diseases. The last 137 patients underwent surgery for acute appendicitis and the diagnosis was confirmed. Among them, 35 (25%) were affected by a complicated appendicitis with diffuse or clearly defined peritonitis. In 134 patients the surgery was completed laparoscopically. The conversion rate was 2%. Morbility rate was 3%, due to intra abdominal abscesses secondary to acute complicated appendicitis. The mean operative time was 76 min and the mean hospital stay was 4.8 days. The death rate was 0%. In our experience, laparoscopic appendectomy has significant advantages over traditional open surgery in both acute and complicated appendicitis, especially in young women. In this way, we can diagnose pelvic disease that could be characterized by the same symptoms of acute appendicitis, then we suggest laparoscopic appendectomy even just to complete the diagnostic iter. Laparoscopy is useful in terms of convalescence, postoperative pain, hospital stay, aesthetic outcome and an easier exploration of the peritoneal cavity.

[Incidental carcinoma in thyroid pathology: our experience and review of the literature]. / Il carcinoma incidentale nella patologia tiroidea. La nostra esperienza e revisione della letteratura.

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 240 patients submitted to surgical intervention in order to establish the incidence of the carcinoma. One hundred sixty five patients (68.75%) were affected by benign disease (132 multinodular goiter, 30 uninodular goiter, 2 Plummer and 1 Basedow) and 75 (31.25%) by carcinoma. In 30 of 165 patients (18.2 %), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (18 papillary carcinoma, 6 follicular carcinoma, 5 papillary carcinoma follicular variant and 1 oncocytic carcinoma). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent FNA and there were no suspicious features in all exams that may suggest the presence of carcinoma. Fifteen of the 30 incidental carcinoma (50%) were microcarcinomas; in the other 13, dimensions were more than 1 cm, but less than 2 cm in 9 cases. Two patients had a synchronous carcinoma. Actually these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could let think about the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNAB, but in must cases it's not really biologically aggressive.

[Role of laparoscopy in acute obstruction of the small bowel: personal experience and analysis of the literature]. / Ruolo della laparoscopia nelle occlusioni acute del tenue: esperienza personale e analisi della letteratura.

Small bowel obstruction is caused by postoperative adhesions in most patients. The traditional surgical treatment has been laparotomy with adhesiolysis and possible resection of the ischaemic intestine. The laparoscopic approach has proved feasible but not without risks. We analysed our experience in the management of acute small bowel obstruction and then reviewed the literature in an attempt to identify the real role of laparoscopy. From January 2003 to June 2008, 19 patients operated on for small bowel obstruction were identified. We evaluated our performance in terms of the aetiology of the obstruction, operative time, length of postoperative hospital stay, conversion rate, and major morbidity and mortality. Postoperative adhesions were responsible for the occlusion in 13 cases; a single band was identified in 47% of patients (9 cases). Neoplastic disease (3 cases), a gallstone ileus, Crohn's disease and an internal hernia were the remaining cases. Laparoscopic treatment was only possible in 7 patients with single adhesions (77%), and a conversion was carried out in the remaining 12 cases (63%), including "laparoscopy-assisted" cases (6 cases). The duration of the intervention (89 +/- 21 min vs 135 +/- 27.5 min) and postoperative hospitalisation (3.6 +/- 1 days vs 6.25 +/- 1.6 days) were in favour of the completely laparoscopic group as compared to the laparoscopy-assisted group. A case of postoperative peritonitis due to bowel perforation required a second intervention. With an appropriate selection of patients, confirming the high incidence of the single adhesions responsible for the occlusion and the resulting high success rate of laparoscopy, we believe that only an initial laparoscopic approach can help identify such favourable situations.