[Surgical education: from teledidactics to virtual training]. / Dalla teledidattica alla realtà virtuale: come cambia la formazione del chirurgo.

The assessment of efficacy and quality of computer-assisted learning is today under evaluation. The Authors propose to use distant learning in the surgical knowledge teaching. In Italy, thanks to the Ministry of University and Scientific Research, a Master on distant learning in Medicine is now starting in 11 Italian Universities under the coordination of the second Faculty of Medicine of the University of Rome 'La Sapienza'. Thanks to the help of medicine and surgery teachers and informatics and telecommunication engineers, this Master is a first step to form and to license medical and surgical specialists experts in distant learning and videoconferencing telemedicine. Videoconferencing system can support Telementoring. Telementoring isn't an exclusive methodology but it is an additional methodology to tradictional didactic for clinicians and surgeons. It allows personal virtual trainings using computers and telecommunication systems.

The treatment of chronic intestinal ischemia.

BACKGROUND AND AIMS: Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. PATIENTS AND METHODS: Eleven patients, of a mean age of 57 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up length was 31 months. RESULTS: There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). CONCLUSIONS: Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patients status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

The surgical treatment of ilio-femoral venous obstruction.

METHODS: A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis. RESULTS: There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months. CONCLUSION: The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

Use of mesh to repair the submuscolar pocket in breast reconstruction: a new possible technique.

The reconstruction of the female breast after mastectomy has become a crucial part of primary breast cancer therapy. Setting of an implant is possible only in case of locally abounding soft tissue coverage and when no radiation has before performed. It is necessary a complete integrity of the submuscolar pocket and good blood supply of the skin to avoid failure of the procedure. In Author's experience, started since 1994, an immediate breast reconstruction after mastectomy is performed using gel-silicon implants directly when it was possible or setting first an expander. In six cases the condition of major pectoralis muscle after mastectomy was so foul that an immediate breast reconstruction with prosthesis was not realizable. However, the Authors tried a new technique using polypropylene mesh sutured on the major pectoralis muscle to cover the muscle partially destroyed. Preliminary data from the 6 pts seems to be encouraging.

[Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery]. / Quadrantectomia sottocutanea per via periareolare: un nuovo approccio nella chirurgia del cancro della mammella.

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.

[Remote teaching in surgery: problem-based learning, telementoring, and evaluation tests]. / La didattica remota in chirurgia: apprendimento per problemi, telementoring e test di valutazione.

The authors propose the use of distant learning in the surgical knowledge teaching. The problem based learning methodology can support this new didactic approach. Telementoring is an interactive experimental methodology that allows young surgeons education by distant learning tutoring of an expert surgeon. The problem about assessment of efficacy and quality of computer-assisted instruction is to day under evaluation.

Distal polytetrafluoroethylene bypasses in patients older than 75 years.

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.

Robotics and telecommunication systems to provide better access to ultrasound expertise in the OR.

Surgery has begun to evolve as a result of the intense use of technological innovations. The result of this is better services for patients and enormous opportunities for the producers of biomedical instruments. The surgeon and the technologist are fast becoming allies in applying the latest developments of robotics, image treatment, simulation, sensors and telecommunications to surgery, in particular to the emerging field of minimally-invasive surgery. Ultrasonography is at present utilised both for diagnostic and therapeutic purposes in various fields. Intraoperative US examination can be of primary importance, especially when dealing with space-occupying lesions. The widening use of minimally-invasive surgery has furthered the development of US for use during this type of surgery. The success of a US examination requires not only a correct execution of the procedure, but also a correct interpretation of the images. We describe two projects that combine robotics and telecommunication systems to provide better access to US expertise in the operating room. The Midstep project has as its object the realisation of two robotic arms, one for the distant control of the US probe during laparoscopic surgery and the second to perform tele-interventional US. The second project, part of the Strategic CNR Project-'Robotics in Surgery', involves the realisation of a common platform for tracking and targeting surgical instruments in video-assisted surgery.

Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery.

BACKGROUND: Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used. METHODS: A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases. RESULTS: The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma). CONCLUSIONS: The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.

[Intestinal perforation caused by a chicken bone: apropos of a clinical case]. / Perforazione intestinale da osso di pollo: a proposito di un caso clinico.

Ingestion of foreign bodies (FB) seems to be a relatively common occurrence in certain classes of people. The majority of ingested objects reach the stomach end 80% of these pass spontaneously without complications. However nearly 20% of FB that pass from the stomach result in complication distally such to required a surgical operation. The authors report a case of chicken bone perforation of the ileus, which was diagnosed by surgical operation. The case reported is of interest for several reason. The lack of condition that can predispose patients to accidental ingestion of FB, no specific history of FB ingestion and the impossibility to detect chicken bones on plain radiography.

[Non visible carcinoma of the gallbladder. A strategic problem after video laparoscopic cholecystectomy]. / Il carcinoma non visibile della cistifellea. Un problema strategico dopo videolaparocolecistectomia.

A formal contraindication to laparoscopic cholecystectomy is gallbladder cancer. Sometimes its first appearance is intraoperative finding or microscopic examination of gallbladder removed for presumed benign disease. These patients with "inapparent carcinoma" may be long-term survivors if definitive and curative therapy is performed. We present the case of 56 y. woman which presented a T2 unsuspected carcinoma that was reoperated and cured by wedge liver resection, extended lymph node dissection and large excision of tissue of trocar wounds.