Laparoscopic cholecystectomy in the obese: results with the traditional and fundus-first technique.

INTRODUCTION: The aim of this study was to assess retrospectively the results of laparoscopic cholecystectomy (LC) performed in obese patients at our institution with the traditional technique and with the fundus-first (FF) technique. PATIENTS AND METHODS: We performed a retrospective analysis of 194 obese patients that underwent LC between 1994 and December 2007 at our institution. Surgical techniques were compared with respect to operative times, conversion to open cholecystectomy, postoperative complications, mortality, and length of postoperative stay. RESULTS: In the reviewed period, LC was performed in 113 (58.2%) patients with obesity type I (OTI), 55 (28.3%) patients with obesity type II (OTII), and 26 (13.5%) patients with obesity type III (OTIII). None of the differences among obese groups treated with the two techniques were statistically significant, with the exception of the lower operative times in the OTIII patients treated with the FFLC. The median operating time in the OTIII group was, respectively, 90 minutes for traditional LC and 65 (range, 45-130) for FFLC (P < 0.05). DISCUSSION AND CONCLUSIONS: This study achieved to conclude that LC in the obese is a safe, feasible, and efficient operation, but remains a demanding procedure even in experienced hands. FFLC can support the traditional LC in the treatment of obese patients, yielding a complication rate comparable with the traditional technique. In our study, it significantly reduced the operative time in OTIII patients, simplifying all the intra-abdominal maneuvers and the gallbladder dissection.

Ultrasonographic venous anatomy at the popliteal fossa in relation to tibial nerve course in normal and varicose limbs.

The aim of this study was to investigate the ultrasonographic venous anatomy at the popliteal fossa in relation to tibial nerve course in normal and varicose limbs in order to detect anatomical abnormalities suggesting the potential risk of tibial nerve damage during surgery. Ninety-seven consecutive patients (194 limbs) were investigated by duplex ultrasound examination of the popliteal fossa. Forty-seven patients (48%) were candidates for surgery due to small saphenous vein (SSV) reflux. The tibial nerve course and its relation to the SSV were investigated in healthy and diseased patients. The tibial nerve ran along the medial edge of the SSV in 171 (88%) of the examined limbs. It ran behind the vein in 7 limbs (4%) and laterally in 16 limbs (8%). In this particular anatomical arrangement the SSV ends in the popliteal vein, running horizontally behind or wrapped around the tibial nerve for a distance of several centimetres. The median distance of the tibial nerve from the SSV was 0.2 cm (range: 0.1-0.3) in healthy limbs and 0.1 cm (range: 0.1-0.2) in varicose limbs, progressively diminishing as it proceeds upward. A posterior and lateral course of the tibial nerve (12%) would expose the nerve to potential damage during surgical procedures. Patient eligibility for treatment for SSV incompetence should always be based on a detailed ultrasonographic assessment of the course of the tibial nerve at the popliteal fossa in order to avoid the slightly higher risk of nerve damage due to particular anatomical abnormalities.

Use of biological material as an adjuvant in Bassini hernia repair: technical notes.

The aim of this study was to describe the feasibility and efficacy of a new operative technique using biological material as an adjuvant for the repair of inguinal hernia according to the original Bassini technique in an attempt to achieve complete restoration not only of the anatomical integrity but also of the physiological elasticity and flexibility of the inguinal canal. Between February and July 2008 a total of 12 patients underwent the original Bassini repair of primary and recurrent inguinal hernia. The biological material was used as an adjuvant to create a quadruple layer in the restoration of the posterior wall of the inguinal canal in order to further strengthen it. Fourteen procedures were performed on 12 adult male, unselected patients. Inguinal hernias were unilateral in 10 patients, bilateral in 2 patients, and recurrent in 3 patients. Mean operation time was 45 minutes (range: 30-70). No general or local intraoperative complications were registered. Mean postoperative pain was rated with the VAS pain score was 2.8 (range: 2-4) in the first 48 hours. No postoperative complications occurred. After a mean follow-up of 5 months (range: 3-6), there were no early recurrences nor persisting inguinal pain. The use of biological material as an adjunct to the Bassini procedure achieves four main objectives: two mechanical and two biological. The two mechanical aims include: further decrease of the tension of the suture line when anchored to the isolated posterior border of Poupart's ligament. The second mechanical objective is that the biological material acts as a binder that protects the suture line when the intra-abdominal pressure increases. The two biological objectives are regrowth of the fascia over the transversalis fascia, and increased production and deposition of collagen on the suture line ten times greater than that of the native fascia, thus improving the healing process.

Tension-free hernioplasty of recurrent inguinal hernia under local anaesthesia: a 5-year review.

The aim of this study was to describe the tension-free hernioplasty of recurrent inguinal hernia under local anaesthesia via the anterior approach, in order to evaluate the feasibility, safety and effectiveness of local anaesthesia and its outcome in terms of hernia recurrence and chronic inguinal pain. The effects of hernia type, type of anaesthesia, comorbid disease and complications on recurrence and chronic inguinal pain were analysed. Fifty-nine procedures were performed electively on 56 adult patients. Local anaesthesia was used in all patients. In 4 patients (7%) a shift from local to general anaesthesia became necessary to conclude the procedure due to intra-operative pain. Three cases (5%) with a bilateral inguinal hernia were treated at the same time. Thirty-five (59%) recurrences were repaired with the technique proposed by Lichtenstein, 13 cases (22%) with the dynamic self-regulating (P.A.D.) system, and 11 cases (19%) with a plug repair. After a median follow-up of 96 months there was only 1 recurrence (1.6%) and 1 case of chronic inguinal pain (1.6%). We conclude that use of local anaesthesia is indicated in recurrent inguinal hernia not only for its simplicity, safety and lasting postoperative analgesia, but especially for the lack of potentially detrimental cardiovascular effects observed with general anaesthesia.

Inguinal hernia repair with the dynamic self-regulating prosthesis (PAD system). Recurrence and complications in 236 consecutive patients.

We retrospectively analysed 236 consecutive patients with primary and recurrent inguinal hernia treated with the dynamic self-regulating prosthesis (PAD system). Parameters such as hernia type, operation time, type of anaesthesia, complications, hospital stay and recurrence were evaluated. Recurrence rates were determined by clinical examination. 254 PAD procedures were performed on 236 adult male patients. Inguinal hernias were unilateral in 218 patients, bilateral in 18 patients, and recurrent in 22 patients. There were 101 patients (43%) with Nyhus type II hernia, 113 (48%) with Nyhus type III hernia, and 22 (9%) with Nyhus type IV hernia; local anaesthesia was used in 149 (63%) patients, and epidural anaesthesia in the others. Haemorrhage occurred in 2 patients (0.8%) and required re-operation. After a median follow-up of 40 months (range: 21-56), there were only 2 (0.8%) recurrences, both in the same patient. Persistent inguinal pain at 1 year occurred in 3 patients (1.2%). There was no statistical correlation between preoperative comorbid disease, Nyhus type of hernia, operative time and recurrence (p < 0.2). We conclude that the PAD system is as effective as mesh repair with an acceptable recurrence rate and fewer complications.

Gastric antral vascular ectasia--an unusual cause of gastric outlet obstruction: report of a case.

Gastric antral vascular ectasia is an important cause of gastric bleeding. We herein report a case of gastric outlet syndrome due to a gastric antral vascular ectasia in a patient with a negative history for anemia or gastric bleeding. The patient underwent an antral resection. The specimen showed vascular ectasia, fibromuscular hyperplasia, and fibrin thrombosis, especially localized in the submucosa. The pathogenesis of this syndrome remains unclear. Surgery in cases of gastric outlet obstruction is the only reliable method to cure the patient. An antrectomy has been shown to be the procedure of choice. It carries a remarkably low rate of long-term sequelae and it can be performed in the majority of cases with low risk, especially in those patients not affected by cirrhosis or portal hypertension.

Atypical Mondor's disease mimicking a strangulated Spigelian hernia in a patient with a deep venous obstruction. A case report.

Mondor's disease is a rare entity characterised by thrombophlebitis of the subcutaneous veins of the anterolateral thoraco-abdominal wall. The condition is usually benign and self-limiting. We report on a case of an inguinal localization of the disease, occurring on a dilated superficial epigastric vein acting as a collateral pathway due to a left ilio-femoral venous obstruction. The patient was referred to our department with a diagnosis of strangulated Spigelian hernia. General physical examination and ultrasonographic studies ruled out a complicated abdominal hernia and the presence of malignant disorders. A diagnosis of inguinal Mondor's disease in association with a chronic deep venous obstruction of the left ilio-femoral venous axis was made. The patient was treated with conservative therapy. Warfarin was promptly started in order to impede progression of the thrombotic process to the ipsilateral great saphenous vein. Though atypical Mondor's disease is usually a benign, self-limiting process, it can cause unusual clinical patterns that might give rise to clinical dilemmas for the surgeon.

[Pneumoperitoneum: is exploratory laparotomy always indicated?]. / Pneumoperitoneo: è sempre indicata la laparotomia esplorativa?

Pneumoperitoneum usually indicates a surgical emergency because of visceral perforation in 85 to 95% of cases. Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma for the surgeon who is faced with this problem. Some cases of pneumoperitoneum can and should be managed conservatively. We report three cases of pneumoperitoneum and describe their outcomes. Two cases were treated conservatively, and one underwent laparotomy but no perforated viscus was found. We review the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. Furthermore, a compilation of other aetiologies of pneumoperitoneum without peritonitis as reported in the literature is presented. Pneumoperitoneum, preceded by a reasonable clinical history in a patient with an adequate abdominal examination, may warrant continued observation, thus avoiding an unnecessary laparotomy.