Emergency laparoscopic ileocecal resection for Crohn's acute obstruction.

INTRODUCTION: Emergency surgery for Crohn's disease (CD) is a rare entity, and its indications are scant in the published literature. Emergency laparoscopy for small bowel obstruction has gained wide dissemination with the spread of advanced laparoscopic skills within surgical practice. Therefore, incidental terminal ileitis after exploration might be a more-common finding in the near future, and further studies are needed to better ascertain proper surgical treatment. CASE DESCRIPTION: We report on a case of acute obstruction caused by undiagnosed terminal ileitis associated with CD. DISCUSSION AND CONCLUSION: The patient underwent explorative laparoscopy and subsequent video-assisted ileocecal resection with an optimal outcome.

Lesson learned from 10 years' experience in laparoscopic appendectomy in a community hospital.

The debate between open and laparoscopic appendectomy is now overtook by the need of a standardized technique, as laparoscopy, in the elective and emergency setting, is widely disseminated thorough surgical practices. A retrospective review of a 10 years' case history (838 laparoscopic appendectomies) is analyzed, and the last 5 years experience (300 cases) compared to the previous experience after the adoption of a standardized technique, which comprehends an all-comers policy without patients' selection prior to explorative laparoscopy. No post-operative infections have been recorded, neither intra-abdominal abscesses nor wound infections, in the laparoscopic group. Significant differences (p < 0.05) have been found between the rate of peritonitis and male sex, elderly patients, and the use of stapler for the treatment of the appendiceal stump. Also conversion to laparotomy has been associated with complicated appendicitis, while associated diseases are found more frequently in fertile women. No differences in the operating time have been evidenced between laparoscopic, open or converted appendectomy. We sustain that every patient with a suspect of appendicitis should have a laparoscopic chance, indeed maintaining a low threshold for conversion; and that surgical indication should be anticipated for male and elderly patients, in order to lower the rate of complicated appendicitis.

Critical view of safety during laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder hilar dissection since the introduction of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is therefore ideal for a safe dissection, even in less experienced hands. MATERIALS AND METHODS: We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times were examined with univariate analysis (Student t test). RESULTS: No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases. CONCLUSION: We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.

Granular cell tumor of the male breast.

A 54-year-old male presented with a painless, hard, irregular lump in his right breast, with fixation to the pectoralis muscle. Mammography and ultrasound showed a 2.5-cm mass suspicious of malignancy. The patient underwent a wide local excision. A 2.5-cm hard, stellate lump was found and sent to the pathologist, which revealed this to be a benign granular cell tumor. Granular cell tumor of the breast is a rare neoplasm, of unknown etiology, which is benign in 98% of cases, but mimics breast cancer, causing challenging diagnostic and therapeutic dilemmas. Traditional imaging techniques do not recognize any feature specific for this tumor. Only excisional biopsy allows the detection of the distinct histological and immunohistochemical profile of the lesion (granular cytoplasm and staining for the S-100 protein). Only local surgical excision is indicated. General and senologist surgeons must be aware of this entity to avoid unnecessary mastectomy or lymphadenectomy.

Transvaginal evisceration after laparoscopic adrenalectomy in neurofibromatosis.

Transvaginal evisceration is a rare complication of hysterectomy. We describe this event following adrenalectomy for pheochromocytoma in a patient affected by neurofibromatosis. This is the first case reported in the literature following laparoscopic surgery. Prompt emergency intestinal reduction and vaginal cuff repair is required to prevent ischemia of the eviscerated bowel. Pneumoperitoneum, passage of stools, or an unknown connective tissue dysplasia due to genetic abnormalities might have contributed to this unpredictable event. The general surgeon must be aware of this rare but challenging gynecological complication.

Rare cause of biliary obstruction by ascariasis associated with choledocholithiasis.

Ascariasis, the most common parasitic infestation of the gastrointestinal tract, is typical of tropical and subtropical countries. Migration of the worm to the bile ducts is rare and has been exceptionally observed in developed countries. This study reports a case of biliary ascariasis associated with gallbladder and common bile duct lithiasis observed in Italy in a 60-year-old woman originating from Senegal. The patient was treated with endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy, and antihelminthic therapy. In particular, ERCP allowed the diagnosis and the extraction of the parasite from the papilla of Vater. After a 6-month follow-up, the patient is in good condition, without signs of cholestasis in laboratory values and no dilatation of the biliary tree at abdominal ultrasound. Although biliary ascariasis is rare in Western countries, the increase in population migration makes it necessary for clinicians world-wide to consider this difficult diagnosis and to determine how to treat it in the most conservative way.

[Incisional hernia repair in the region of Brescia and in Lombardy: results of a survey and discussion]. / Il trattamento del laparocele in provincia di Brescia e in Lombardia. Risultati di un'inchiesta e loro discussione.

This paper reports the results of a survey on the surgical therapy of incisional ventral hernia in the county of Brescia (19 surgical wards) compared with the results in Lombardy. Using epidemiological data on open and laparoscopic surgery we investigated the recent trends in this kind of surgery, addressing aspects that are not yet supported by evidence-based data in the literature. Laparoscopic repair is performed in about half of the surgical wards, and in the majority (85%) of Lombardy hospitals that replied to the questionnaire. It is also performed in a small number of primitive ventral hernias. The creation of a pneumoperitoneum is accomplished both by the Verress and the Hasson techniques, without significant differences. Composite meshes have proved most interesting, and fixation by titanium spiral tacks is most commonly used. We found rapid discharge and low morbidity rates, similar to the published data. The preferred open technique is still the Rives-Stoppa submuscular mesh repair. It is generally agreed that there will presumably be a major diffusion of laparoscopic repair, in spite of the fact that it is nowadays performed only by surgeons familiar with advanced laparoscopic techniques and is still more expensive than open repair, which, however, is offset by the distinct benefit afforded by the patient.

Occasional finding of mesenteric lipodystrophy during laparoscopy: a difficult diagnosis.

Mesenteric lipodystrophy is a rare pathological condition affecting the mesentery. Its initial presentation is typically asymptomatic. Pathological characteristics are unspecific, and generally attributed to inflammation, unless the diagnosis is suspected. Laparoscopy done for other reasons has been, as in this case, unsuccessful in providing evidence for the correct diagnosis, thus requiring laparotomy due to lack of diagnostic tissue. After 6 mo no further medical therapy is required, as the patient remains asymptomatic. Discussion of this case and a brief review of the literature are presented in the following paragraphs.

Hemoperitoneum after percutaneous liver biopsy. Video-laparoscopic management.

BACKGROUND: Percutaneous liver biopsy is a safe procedure, with a low rate of major complications. Among these massive hemoperitoneum is the most life threatening, and its management sometimes leads to an emergency invasive surgical approach. CASE REPORT AND RESULTS: The following case highlights the possible role of laparoscopy in diagnosis and treatment of this condition. In this patient a significant intraperitoneal bleeding developed from a liver lesion 48 hours after needle-biopsy. Video-laparoscopic exploration evidenced a grade III laceration of the right lobe, successfully managed with coagulation and apposition of an absorbable haemostatic gauze. Peritoneal toilette and multiple drains completed the procedure. No surgical complications developed and the patient was discharged on 5th post-operative day. DISCUSSION: Minimally invasive surgery has been, in this case, an adequate alternative for the treatment of this bleeding complication of liver biopsy, offering advantages in terms of low morbidity, quick recovery and satisfying cosmetic results. CONCLUSIONS: Laparoscopy is gaining a prominent role in penetrating liver trauma, whenever conservative or angiographic management fails, and should be considered as the first surgical attempt especially in patients with stable hemodynamics despite active intraperitoneal bleeding.

Laparoscopy in afferent loop obstruction presenting as acute pancreatitis.

BACKGROUND: We describe an afferent loop obstruction caused by an adhesion band in a case of distal gastrectomy with Roux-en-Y end-to-side jejunal anastomosis for cancer. METHODS: An initial clinical presentation of acute pancreatitis was ruled out by a computed tomography scan, which revealed intestinal obstruction; it was then confirmed on laparoscopy. Definitive treatment was laparoscopic adhesiolysis. A complete review of the literature concerning afferent loop obstructions is presented. RESULTS: The treatment was successful, with minimal postoperative pain, and the 5-day hospital stay was uncomplicated. The patient remains asymptomatic at 1-year follow-up. CONCLUSIONS: The authors advocate minimally invasive surgery as a complete diagnostic and therapeutic alternative to emergency laparotomy in cases where afferent loop syndrome is suspected, and acknowledge that prompt surgery has a higher rate of success and reduces operative morbidity and mortality.

[Multilevel atherosclerotic lesions of the lower limbs. Simultaneous surgical and endovascular approach. A case report]. / Lesioni aterosclerotiche "multi-level" dell'arto inferiore. Approccio terapeutico simultaneo, chirurgico ed endovascolare. Caso clinico.

Surgical treatment of femoro-popliteal atherosclerotic occlusion usually consists in a femoro-distal bypass. However, the associated presence of proximal lesions that reduce prosthesis inflow, or of distal lesions that increase resistances may be decisive factors in determining the outcome of the revascularisation. Frequently, an iliac or common femoral artery stenosis can be treated with an endovascular technique prior to surgery, thus increasing the bypass inflow that is going to be created. On the contrary, in the case described here, the stenosis was distal to the femoropopliteal bypass and was treated with PTA + stenting, thus increasing the run-off and the theoretical long-term patency. Therapeutic indications and technical options are discussed in the light of the recent international literature and the new achievements in terms of endovascular technique.

Blind pouch syndrome secondary to gastrojejunostomy. Report of a case.

A case of blind pouch syndrome following a Roux-en-Y reconstruction after gastrectomy is presented. The patient had a history of pain, anaemia and weight loss and the diagnosis was made on the basis of upper gastrointestinal barium contrast radiography. The surgical procedure was an entero-entero anastomosis between the blind loop and the efferent loop. The postoperative course was uneventful. No symptomatic recurrence was found at one-year follow-up. We advocate this procedure as a valid alternative to resection in cases where the blind loop is not damaged by chronic dilatation. The aim of this operation is to maintain the preferential gastric emptying route via the blind loop in order to prevent recurrence on the stump, and reduce loop isolation in order to minimise ischemic or stenotic damage to the anastomosis.

Comparison between laparoscopic and open repair for perforated peptic ulcer. A retrospective study.

The aim of the study was to assess the differences in postoperative outcome in two well-matched groups of patients undergoing suture of a perforated peptic ulcer. The first 10 patients were treated laparoscopically, and the second group of 10 in a traditional manner through a midline xipho-umbilical incision. Operative technique was the same, only via a different access. Variables influencing outcome were matched for comparison of the influence of the technique. All patients underwent operation within 24 hours from onset of symptoms. Analysis of pre-, intra- and postoperative factors was done for the two groups. A significant difference was found only in the percentage of wound infections (0% vs 40%) in favour of the laparoscopic group. Surgical time, postoperative pain, resumption of feeding and discharge from hospital were similar in the two groups. As in other larger studies, our findings confirm the indication for laparoscopy in acute abdomen. The suture technique is feasible and safe and is to be considered as the gold standard when used with the same indications as in open surgery.

Introduction of laparoscopic appendectomy: a retrospective comparison with the open technique.

Laparoscopic appendectomy (LA) is gaining favour as an alternative to the traditional laparotomic technique (OA) despite the persistence of controversy regarding indications, morbidity, hospital stay, costs and surgical time. We present a retrospective analysis of our first three years of experience with the procedure. During this period we performed 235 appendectomies (102 laparoscopic and 133 laparotomic). The conversion rate was 9.7%, due to severe peritonitis, high-grade inflammation and an unfavorable position of the appendix; we found a significantly higher percentage of difficulty due to these factors in the laparotomic procedures. Operating time was similar in the two groups. The rate of associated pathology was higher (22.5% vs 6%) after laparoscopy, but conversion to laparotomy was never necessary for treatment. Early morbidity was limited to 2 patients who underwent laparoscopic appendectomy (1 re-operation for a micro-abscess and 1 conservatively treated haemorrhage), while wound infections (13.5% vs 1.9%) and incisional hernias (0% vs 2.3%) were more frequent in the open procedures. Hospital stay was slightly less in the laparoscopic group (4.0 vs 4.7 days). In our initial experience, laparoscopic appendectomy has shown significant advantages in terms of intraoperative diagnosis of associated diseases and diminished morbidity. We advocate a laparoscopic approach to appendicular disease, reserving conversion to laparotomy for selected cases after exploration.