Gasless laparoscopic treatment of perforated duodenal ulcer: a case report.

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases. Its emergency treatment is based on surgery, namely, simple closure or more definitive ulcer surgery. Laparoscopic repair of perforated duodenal ulcer with classic insufflation of CO2 is quick, simple, and technically feasible in most patients. We describe herein the operative treatment of a perforated duodenal ulcer in a 33-year-old man who presented to our Hospital with acute onset of severe abdominal pain. Wide peritoneal lavage and suture of the perforation was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. This new approach enables the use of conventional instruments and provides a clear field of vision in the abdomen equal to that created by the traditional CO2 technique. Because there is not a pneumoperitoneum to maintain, the gasless technique permits a constant irrigation and suction of the abdominal cavity, a wide peritoneal lavage, and the continuous suction of fluid, blood, smoke, and humidity without losing the camera set. If indicated, it permits the laparoscopic repair of the perforation combined with the laparoscopic vagotomy in the same emergency setting. The present case proved it to be another abdominal procedure that can be carried out with all the technical and anesthesiological advantages of gasless minimally invasive surgery.

Re-exploration of the saphenofemoral junction in the treatment of recurrent varicose veins.

A retrospective study of 61 patients (61 legs) with recurrent varicose veins (RVV) and saphenofemoral junction (SFJ) incompetence was set up to assess the efficacy of re-exploration of the SFJ through a lateral approach. All the patients underwent re-exploration of the SFJ by a single surgeon (MPV) through a lateral approach. Thirty-one patients (50.8%) presented an intact SFJ. Twenty-seven patients (44.2%) presented intact major tributaries emerging from the stump of SFJ. In 2 patients (3.2%) the recurrence was related to neovascularization and in 1 case (1.6%) to cross groin venous connection. Follow-up averaged 2.81 years. Three (4.9%) patients were lost, 56 out of 58 patients (96.55%) were asymptomatic, 2 out of 58 (3.4%) presented a new recurrence in the groin. Complete isolation of the FV to identify every tributary and ligation of the SFJ flush with the FV are essential to avoid further recurrences.

Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis.

Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function. Laparoscopy for surgical treatment of hepatic diseases is at an early stage. Laparoscopy has been often proposed for diagnosis, staging of hepatic malignancy, treatment of hepatic cyst or benign tumors, but very few laparoscopic treatments of hepatic malignancies have been reported at present and always using conventional CO2 laparoscopy. We describe herein the operative treatment of a single subglissonian HCC of segment III in a child, HCV (hepatitis C virus)-related cirrhosis. A nonanatomical wedge resection was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. The technique, in selected cases, is a simple, safe, and effective surgical method. The gasless technique guarantees a clear vision, it makes possible the continuous suction of smoke and fluids, it allows the use of conventional instruments for classic maneuvers of the liver surgery (Pringle maneuver), and the easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless minimally invasive surgery.

Gasless laparoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. Laparoscopic gastrostomy is usually performed when PEG is contraindicated, for example, in patients with esophageal strictures, large gastric tumors, or a history of multiple abdominal surgery. We report herein a case of gasless laparoscopic gastrostomy performed for carcinoma associated with a severe respiratory distress syndrome in a malnourished patient with a tight esophageal stricture. The gasless technique uses the Laparolift System (Laparolift, Origin Medsystem, Inc.), a device composed of a fan-shaped retractor and a mechanical lifting arm that produces an abdominal wall distention resembling a truncated pyramid. Gasless laparoscopy was a safe alternative approach to CO2 pneumoperitoneum in this patient.

Gasless laparoscopic removal of retroperitoneal leiomyosarcoma.

Leiomyosarcoma is a rare malignant tumor originating from the smooth muscular tissue in any part of the organism. The only therapy is its complete removal. We describe herein the operative treatment of a retroperitoneal leiomyosarcoma with gasless laparoscopic complete removal. The procedure was successfully performed in a consenting woman with an abdominal mass. Gasless laparoscopic removal was performed with a mechanical retractor (Laparolift, Origin Medsystem Inc.), obviating the creation of the pneumoperitoneum and of the sealed environment. The technique is a simple, safe, and effective surgical method. Gasless technique guarantees a clear vision, makes possible continuous suction of smoke and fluids, and allows the use of conventional instruments and easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless miniinvasive surgery.

Surgical treatment of substernal goiters.

Fifty-one patients (4.6%) underwent resection of a substernal goiter in a fifteen-year period during the course of 1103 thyroidectomies. Forty-eight (94.2%) goiters were benign and three (5.8%) malignant. Mean age was 55 years. Female:male ratio was 2:1. Four patients (7.8%) had undergone prior thyroid surgery. Most had long-standing goiters (mean duration: 15 years). The most common symptoms included airway compression (56.8%), hoarseness (13.7%), dysphagia (11.7%), superior vena cava syndrome (9.8%). Twelve patients (23.5%) were asymptomatic. Chest X-rays showed a tracheal deviation and/or a mediastinal mass in 43 patients (84.3%). Goiter extended into the right mediastinum in 28 patients (54.9%), into the left in 19 (37.2%), and bilaterally in three (5.8%). A cervical collar incision provided adequate exposure in 42 cases (82.3%). Five patients (9.8%) required a cervical incision plus partial median sternotomy and one (1.9%) a cervical incision plus a right postero-lateral thoracotomy. In three asymptomatic patients (5.8%) thoracotomy was followed by cervical incision due to a preoperative incorrect diagnosis. Major postoperative complications included two cervico-mediastinal hematoma with one subsequent death and four (7.8%) recurrent laryngeal nerve palsy. This series showed that: (1) Standard chest roetgenogram with esophagogram is still the most useful investigation, although CAT scan can help in planning the operation. (2) Cervical collar incision provides adequate exposure in nearly all cases. (3) When goiter enucleation is difficult or at risk, a complementary median sternotomy is indicated in right retrovascular goiters. (4) Operation should be recommended in all but the highest-risk patients. (5) Tracheal intubation with small caliber tubes is nearly always possible in patients with acute tracheal compression.

[Systems analysis in hospital management]. / L'analisi sistemica nella gestione ospedaliera.

Organization is one of the most important concepts for contemporary society. Whereas in recent years industry and the private services field have adopted management criteria to establish aims and methods, and to manage their organizations, the same is not true for public services. So in this area, particularly in health services, the need for a managerial type of organization is particularly evident. The basic change in the approach to the solution of organization problems, in accordance with a management type criterion, is the substitution of the traditional analytical approach with an assessment of systemic type that examines relations and interactions between the various components of an organization. Of the various methods proposed, one conceptual instrument that permits a management-type analysis of an organization is the "7S" method. An approach of this type may be particularly useful for the evaluation of an extremely complex structure like that of a hospital. According to this method, the interactions between strategy, structure, systems, staff, style, skills, and system of prevalent values of the hospital's organization structure are analysed with the purpose of improving their management.

Contusive trauma of the popliteal artery.

The writers have reviewed thirteen cases of contusive trauma of the popliteal artery which came under their observation. The incidence of such lesions in arterial trauma is 22 per cent. The limb was saved in 76 per cent; but the result was only functionally good in only 46 per cent. The fundamental factors for successful revascularization are early diagnosis and precise technique. The operation of choice is a by-pass using the saphenous vein from the contralateral limb; this "jumps" right over the focus of arterial contusion.