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.

Hybrid endovascular/surgical Kommerrell's diverticulum treatment.

Kommerrell's diverticulum of the right aberrant subclavian artery is a rare disease, its treatment is still controversial. We report the case of a patient with a six cm aneurysmal dilation successfully treated in a hybrid surgical/endovascular way.

Optional caval filter in kidney cancer patients with tumor thrombus level I and II.

BACKGROUND: Kidney diseases requiring a radical surgical approach can come up complicated by the presence of a thrombus of the renal vein or the inferior vena cava (IVC). The overwhelming majority of these cases concern the presence of a kidney tumor, especially renal cell carcinoma (RCC). Kidney tumor presenting with thrombus extension into the IVC represents a difficult operative challenge, especially for the risk of thrombus dislocation due to the manipulation of the IVC during tumor isolation, which may result in pulmonary embolism (PE). METHODS: We propose a retrospective cohort study regarding 10 patients (thrombus level I or II) operated in our center from 2010 to 2015. All of them had a renal tumor. In 8 patients TC proved tumor thrombus extended into the IVC<2 cm above the renal vein (level I), in the remaining patients the thrombus entered the IVC>2 cm above the renal vein but below the hepatic veins (level 2). All the patients underwent an IVC temporary/optional filter placement as a preoperative maneuver before radical nephrectomy. RESULTS: The efficacy of the procedure is confirmed by the absence of any inter- or postsurgical thromboembolic event in all patients; filter was removed in 3 patients, moreover, concerning the long-term information we obtained about the patients, none of them has showed complete occlusion of IVC. CONCLUSIONS: The results of the study support effectiveness of preoperative temporary IVC placement to prevent thrombosis embolism shedding and to improve surgical safety.

Adrenal Schwannomas: Rare Tumor of the Retroperitoneum.

Schwannoma is a benign neurogenic tumor originating from Schwann cells. These produce the myelin sheath that covers peripheral nerves that are often affected. This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors. These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients. Diagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis. We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland.

A case of myxoid liposarcoma of the retroperitoneum: a challenging tumour for diagnosis and treatment.

Retroperitoneal sarcomas are rare neoplasms that account for only 1%-2% of all solid tumors and liposarcomas represent the most frequent histological type. We describe the case of a 44-year-old female with a retroperitoneal myxoid liposarcoma of 22 × 19 × 8 cm in size. The only symptoms were persistent pain and progressive tenderness of the abdomen lasting for two months. The mass was radically excised during laparotomy. CT and MRI were useful to clarify the site of origin of the tumor, relationships with other organs, and planning surgery but final diagnosis was based on histological findings. Here we review the literature about the challenging diagnosis, treatment, and prognostic factors of this disease.

Spontaneous perforation of Meckel's diverticulum: case report and review of literature.

AIMS: Meckel's diverticulum is a congenital anomaly found in approximately 2% of the general population. The complications caused by Meckel's diverticulum include intussusception, volvulus in adolescents and acute bleeding in adults 3. This is an interesting and unusual case of spontaneous perforation of Meckel's diverticulum, in a Caucasian woman. METHODS: A 46-year-old Caucasian woman was admitted because of severe abdominal pain and diarrhoea. A CT (Fig. 1) scan of the abdomen and pelvis was obtained, which demonstrated free air and a moderate amount of free fluid in the pelvis tracking up the gutters. The patient was consented and taken to theatre for diagnostic laparoscopy. A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum (Fig. 2). Wedge resection of the perforated Meckel's diverticulum was performed with endoGIA stapler fired at the base of diverticulum. Histopathology showed heterotopic gastric mucosa within the diverticulum and evidence of acute inflammation with perforation. The patient was followed up for two years and is symptom-free. DISCUSSION: The total lifetime rate of complications is widely accepted at 4%, with a male-to female ratio ranging from 1.8:1 to 3:1 4,5. Hemorrhage is the most common presentation in children and is reported in over 50% of cases 10. In adults, hemorrhage occurs often but only in 11.8% is present 5. 90% of bleeding diverticula contain heterotropic mucosa, most often gastric mucosa 13. In one study, 11% of children with complicated Meckel's diverticulum (MD) were initially diagnosed with appendicitis.8 CONCLUSIONS: The diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis. Laparoscopy has a definite role in patients with symptomatic Meckel's diverticulum, especially when the diagnosis is in doubt and it has proved definitive in facilitating diagnosis.

Giant submucosal lipoma cause colo-colonic intussusception. A case report and review of literature.

BACKGROUND: Lipoma of the large intestine is rare, with a reported incidence ranging between 0.2% and 4.4%. We present a case of a giant colonic lipoma causing descending-colonic intussusception. AIMS: A 54-year-old woman visited our emergency room with sudden onset of intermittent abdominal cramps. She was nauseous and had rectal blood loss for three days. Physical examination showed a tender palpable mass in the left lower abdominal quadrant. Rectal examination showed little blood on the glove. A CT scan demonstrated a clear intussusception of the descending-colonic (Fig. 1). Since the clinical presentation was that of an imminent ileus a laparotomy was performed. The intussusception was found in the descending coloni (Fig. 2), en-bloc resection with left hemicolectomy and was performed with end-to-end anastomosis. DISCUSSION: Lipomas of the gastrointestinal tract are rare conditions first described by Baurer in 1757. Lipomas in the intestinal tract are still relatively rare, however, being present in only 0.2% of a large autopsy series of 60 000 cases reported in 1955. In 90% of cases, lipoma of the colon are localized at submucous level. Submucosal lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain. Accurate preoperative diagnosis is difficult and lipoma is often mistaken for adenomatous polyp or carcinoma. CONCLUSION: Differential diagnosis includes malignancy, diverticulosis, adenomatous polyps and previous anastomosis. CT is the examination of choice. Surgical approach remains the treatment of choice for large colon lipoma.

Spontaneus small bowel volvulus in an adult. Case report and review of the literature.

BACKGROUND: We present a case of spontaneus small bowel volvulus in an adult patients who presented to the emergency department. In this case we had no obvious precipitating factors. AIMS: A man of 72 years, was transferred to our hospital after being examined and diagnosed with acute pain. Over the past two years has had four episodes of sharp epigastric pain radiating to the back half with associated nausea and vomiting. He is an alcoholic and heavy smoker. His medical history, blood, urine and biochemical data were all non-cotributory. An abdominal CT angiography, we noticed a swirling mass of mesenteric and small bowel with adjacent around the superior mesenteric artery. METHODS: A case of spontaneus volvulus of the small intestine in an adult with a review of the literature is reported. CONCLUSIONS: SBV is an uncommon but potentially serious cause of small bowel obstruction in Western countries, carrying an overall mortality rate of 10% to 35%. In the presence of gangrene, mortality is usually 40% or greater. Physicians should consider, in patients with obstruction of the small intestine where their pain is excessive and does not respond to treatment with narcotics analgesic the possibility of volvulus of the mesentery. If the diagnosis is suspected emergency surgical is necessary, conservation measures usually result in a higher rate of gangrene. Although no studies have identified an optimal surgical treatment, resection and primary anastomosis has been recommended in all cases.

[Complicated duodeno-biliary fistula in bleeding duodenal ulcer: case report an literature review]. / La fistola duodeno-biliare complicata nell'ulcera duodenale sanguinante: caso clinico e revisione della letteratura.

Upper gastrointestinal tract bleedings may represent the first clinical evidence of peptic ulcer and the related surgical emergency is still characterized by a high mortality rate. The presence of multiple complications, rare but possible in case of duodenal ulcer, such as the fistulization in the common bile duct alone or associated to others, can significantly increase the difficulty in the treatment. The Authors report a particularly complex case of a 77 years old male diabetic patient, with chronic bronchopaty, urgently admitted to our department for hematemesis. Soon after his hemodynamic stabilization, the patient was submitted to surgery which showed a duodenal ulcer with penetration/fistulization in the common bile duct associated to a perforation of the gallbladder with intra-hepatic abscess and erosion of the gastro-duodenal artery. Despite unfavourable outcome the case gave us the starting point for a review of the literature primarily related to the rarer biliary complications of duodenal ulcer. Bleeding ulcers today are usually treated by an interdisciplinary approach comprehensive of endoscopy, interventional radiology and, only rarely, surgery. The choice among the available options depends on the clinical presentation of the patient. Despite diagnostic and therapeutic progresses, peptic ulcer may still rarely have a dramatic presentation and be associated to uncommon and difficult anatomical aspects whose diagnosis and treatment may be not easy at all. The knowledge of all the aspects of peptic ulcer pathophysiology is therefore essential for the treatment of these patients.

Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device.

Colonic perforation during endoscopic diagnostic or therapeutic procedures, represents an uncommon occurrence even if, together with haemorrhage, it is still the most common complication of colonoscopy, with an incidence ranging between 0.1% and 2% of all colonoscopic procedures. The ideal treatment in these cases remains elusive as the endoscopist and the surgeon have to make a choice case by case, depending on many factors such as how promptly the rupture is identified, the condition of the patient, the degree of contamination and the evidence of peritoneal irritation. Surgical interventions both laparotomic and laparoscopic, and other medical non-operative solutions are described in the literature. Only three cases have been reported in the literature in which the endoscopic apposition of endoclips was used to repair a colonic perforation during colonoscopy. Ours is the first case that the perforation itself was caused by the improper functioning of a therapeutic device.

Isolated injury of the superior mesenteric artery caused by a lap belt in a child.

Isolated vascular injuries are rare in cases of blunt abdominal trauma, and superior mesenteric artery injury is extremely rare but potentially lethal. The incidence of this kind of life-threatening injury has increased in recent years. The diagnosis of these isolated injuries is difficult, and its delay is associated with a higher morbidity and mortality. The authors report on the case of a child with an isolated injury of the superior mesenteric artery caused by a lap belt, during a motor-vehicle crash which was successfully managed. Correct use of all types of restraints is to be recommended. The diagnosis of this rare intraabdominal vascular injury is possible especially when the major signs are evident, but an awareness of this rare possibility is essential for the outcome.