Gut microbiota and pediatric patients with spina bifida and neurogenic bowel dysfunction.

PURPOSE: Gut microbiota has recently been recognized to be influenced by a broad range of pathologies. Alterations of gut microbiota are known as dysbiosis and have found to be related to chronic constipation, a condition which affects also pediatric patients with spina bifida (SB). METHODS: In this study, gut microbiota richness and composition were investigated by 16S rRNA sequencing and bioinformatic analysis in 48 SB patients (mean age, 11.9 ± 4.8 years) with secondary neurogenic constipation and 32 healthy controls (mean age, 18.0 ± 9.6 years). The study also aimed at exploring eventual effects of laxatives and transanal irrigation (TAI) adopted by SB subjects to get relief from the symptoms of neurogenic constipation. RESULTS: Collected data demonstrated that the microbiota richness of SB patients was significantly increased compared to healthy controls, with a higher number of dominant bacteria rather than rare species. The absence of SB condition was associated with taxa Coprococcus 2, with the species C. eutactus and Roseburia, Dialister, and the [Eubacterium] coprostanoligenes group. On the other hand, the SB patients displayed a different group of positively associated taxa, namely, Blautia, Collinsella, Intestinibacter, and Romboutsia genera, the [Clostridium] innocuum group, and Clostridium sensu stricto 1. Bifidobacterium and the [Eubacterium] hallii group were also found to be positively associated with SB gut microbiome. CONCLUSIONS: Among SB patients, the administration of laxatives and TAI did not negatively affect gut microbiota diversity and composition, even considering long-term use (up to 5 years) of TAI device.

Staghorn stone in megapolycalicosis in a child: Still the case for open surgery? Case report.

We here report a rare case of congenital megapolycalicosis in a 14-year-old girl complicated by a 24-mm staghorn stone and numerous calculi at the level of all caliceal groups that had become symptomatic in recent weeks with malaise, hematuria, and urinary tract infection. Among the various therapeutic options, we opted for open surgery. The staghorn stone was removed by pyelotomy, and washout of the caliceal cavities released numerous microcalculi of 1.5-9 mm in size that were then removed. To our knowledge, this is the first case of pediatric megacapolycalicosis complicated by staghorn stone, which presents complex problems for the diagnosis and therapy.

The history of the pediatric inguinal hernia repair.

The history of inguinal hernia repair is a rich one. For centuries, hernia healers, doctors, anatomists, surgeons and quacks have been devoted to this pathology that has afflicted mankind throughout its evolution. The development of surgical correction mainly focused on adult pathology, with treatments that often involved the loss of the testis. Hernia management in children, however, also dates from antiquity. Described as a swelling on the surface of the belly in ancient papyri, it was treated with tight bandages by the early physicians of Alexandria. For centuries, conservative treatment had been used for the child using primordial trussess, many prayers, and often pagan rituals as the arboreal passage of children described by Marcello of Bordeaux, doctor of the Emperor Theodosius I (347-395 AD), reserving medical intervention only for cases of strangulation in which only reduction was attempted. The middle ages were characterized by an increase in cultural and scientific exchange, during which the first comprehensive surgical textbooks and atlases were written. Different approaches to the inguinal hernia were not taught and passed down through generations of surgeons. The modern era brought a better understanding of the inguinal anatomy, which led to surgical techniques associated with less post-operative complications. Today, the pediatric inguinal hernia repair is one of the most common pediatric operations performed. It is considered a safe procedure with very low complication rate.

Transanal irrigation (TAI) in the paediatric population: Literature review and consensus of an Italian multicentre working group.

Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients' selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.

Toward sutureless laparoscopic inguinal hernia repair in children?

We report our experience with a sutureless technique for laparoscopic inguinal hernia repair in children. Twenty-eight children, 12 girls and 16 boys, aged 3 months to 7 years, underwent sutureless laparoscopic inguinal hernia repair. In girls, we utilized simple cauterization of the internal inguinal ring with a single trocar technique. In boys denudation of the peritoneum was obtained utilizing a three-trocar technique. The peritoneum around the internal inguinal ring was peeled off and detached from the vas and the vessels, and then wrapped around the grasper, resulting in a large area of denudation. No perioperative complications were observed. No recurrences nor testicular damage were noted after a mean follow-up of 18 months (range 6-35 months). The mean operative time was 12 min (range 7-20 min) for girls and 19 min (range 15-30 min) for boys. A 6-year-old girl exhibited a lymphocele. The sutureless technique appears to be easy, safe, and effective, provided that the patients are carefully selected. In boys, special attention needs to be paid to preservation of the vas and the testicular vessels.

Laparoscopic treatment of symptomatic simple renal cysts in children: single-center experience.

Simple renal cysts, although common in adults, are rare in children. They are usually discovered incidentally in the course of the study of other urinary tract symptoms, although they are not always asymptomatic. Renal cysts can be classified as being either simple or complex. The purpose of this review is to present our case series of simple symptomatic renal cysts treated with laparoscopy. Nineteen patients with symptomatic renal cysts (6 to 13.5 cm) were referred to our institution between January 2006 and January 2017. They comprised 12 (40.5%) females and seven (59.5%) males, aged 8 to 15, with a mean age of 12.2 years. Of these patients, nine had previously been treated unsuccessfully by ultrasound-guided aspiration/alcoholization with 95%-ethanol, between 9 and 13 months prior to the laparoscopy. Five patients had undergone one treatment and four had undergone two treatments. All of the patients were treated by laparoscopic threetrocar deroofing. The cysts were opened and the wall excised using scissors and a monopolar hook. In most cases, to better handle the edges of the cyst and obtain a better grip, a needle was used to aspirate a small amount of fluid (used for cytological examination). The wall of the cyst was excised, the cyst edges were sealed, and the perirenal fat was placed on the bottom of the cyst (wadding technique). The mean operating time was 95 minutes (range 50- 150). The postoperative course was uneventful for all of the patients. The hospital stay ranged from one to three days. All of the patients were asymptomatic following the treatment. At a mean follow-up time of 3.6 years, none of the patients had experienced a recurrence. Renal function, as assessed by a MAG3 renal scintigraphy scan, was well-preserved in all of the patients, and all of them undergo an annual ultrasound scan.

The history of varicocele: from antiquity to the modern ERA

ABSTRACT Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

The history of varicocele: from antiquity to the modern ERA.

Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes culminated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772- 1832). Although some questions regarding the etiopathology and treatment of varicocele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

Laparoscopic Finding of Ectopic Adrenocortical Tissue in a 2-Year-Old Boy with Vanishing Testis.

Ectopic adrenocortical tissue (EAT) along the spermatic cord is an unusual condition in children. The author reports on a 2-year-old boy with impalpable testis. On laparoscopy, EAT was detected along the hypotrophic spermatic vessels and excised. These remnants should be removed to prevent hormone production or malignant transformation.

Adolescence transitional care in neurogenic detrusor overactivity and the use of OnabotulinumtoxinA: A clinical algorithm from an Italian consensus statement.

AIMS: OnabotulinumtoxinA (onaBNTa) for treating neurogenic detrusor overactivity (NDO) is widely used after its regulatory approval in adults. Although the administration of onaBNTa is still considered off-label in children, data have already been reported on its efficacy and safety. Nowadays, there is a lack of standardized protocols for treatment of NDO with onaBNTa in adolescent patients in their transition from the childhood to the adult age. With the aim to address this issue a consensus panel was obtained. METHODS: A panel of leading urologists and urogynaecologists skilled in functional urology, neuro-urology, urogynaecology, and pediatric urology participated in a consensus-forming project using a Delphi method to reach national consensus on NDO-onaBNTa treatment in adolescence transitional care. RESULTS: In total, 11 experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥70% of the experts agreed on recommendations. To facilitate a common understanding among all experts, a face-to-face consensus meeting was held in Rome in march 2015 and then with a follow-up teleconference in march 2017. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed. CONCLUSIONS: This manuscript represents the first report on the onaBNTa in adolescents. Young adults should be treated as a distinct sub-population in policy, planning, programming, and research, as strongly sustained by national public health care. This consensus and the algorithm could support multidisciplinary communication, reduce the extent of variations in clinical practice and optimize clinical decision making.

Tubularized proximally-incised plate in distal/midshaft hypospadias repair.

The aim of this study was to verify the validity, feasibility, and the functional results, by uroflowmetry, of Tubularized proximallyincised plate technique in selected case of distal/midshaft hypospadias. Out of 120 patients scheduled to undergo TIP (or Snodgrass) procedure, 23 were selected between January 2013 and January 2016 (19.1%). This case series comprised 16 patients with distal and 7 with midshaft hypospadias. Mean age at surgery was 2.9 years. The inclusion criteria were a deep and wide glandular groove and a proximal narrow urethral plate. The procedure was carried out as described by Snodgrass but the incision of the urethral plate, including the mucosal and submucosal tissue, was made only proximally, between the original meatus and the glandular groove in no case extending to the entire length of the plate. Postoperatively a foley catheter was left in place from 4 to 7 days. Uroflowmetry was performed when the patients age ranged from 2.5 to 5.7 years (mean age 3.11 years and mean follow-up 1.8 years, body surface 2). No patient presented fistulas nor perioperative complications. At uroflowmetry, eighteen patients presented values above the 25th percentile and 5 showed a borderline flow. All patients in this group remained stable without urinary symptoms. In selected cases, the tubularized proximally-incised plate yields satisfactory cosmetic and functional results for the treatment of midshaft proximal hypospadias. A long-term follow-up study is needed for further evaluation. Patient selection is crucial for the success of this technique.

Use of LigaSure™ on bile duct in rats: an experimental study.

BACKGROUND: The closure of a cystic duct during cholecystectomy by means of radiofrequency is still controversial. We report our preliminary experimental results with the use of LigaSure™ on common bile duct in rats. METHODS: Thirty Wistar rats weighing 70 to 120 g were employed for this study. The animals were all anesthetized with intraperitoneal ketamine and then divided into three groups. The first group (10 rats, Group C) underwent only laparotomy and isolation of the common bile duct. The second (10 rats, Group M) underwent laparotomy and closure of the common bile duct (CBD) with monopolar coagulation. The third group (10 rats, Group L) underwent laparotomy and sealing of the common bile duct with two application of LigaSureTM. Afterwards, all rats were kept in comfortable cages and were administered dibenzamine for five days. They were all sacrificed on day 20. Through a laparotomy, the liver and bile duct were removed for histological examination. Blood samples were obtained to dose bilirubin, amylase and transaminase levels. RESULTS: Mortality rate was 0 in the control group (C), 3/10 rats in group M and 0 in group L. In group L, the macroscopic examination showed a large choledochocele (3-3.5 × 1.5 cm) with few adhesions. At the histological examination there was optimal sealing of the common bile duct in 9/10 rats. In group M, 2/10 rats had liver abscesses, 3/10 rats had choledochocele and 5/10 rats, biliary peritonitis. There was intense tissue inflammation and the dissection was difficult. Analyses of blood samples showed an increase in total bilirubin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in groups M and L. CONCLUSIONS: The preliminary results of our study confirm that radiofrequency can be safely used for the closure of the common bile duct. The choledochocele obtained with this technique could represent a good experimental model. These results could be a further step for using the LigaSureTM in clipless cholecystectomy.

Long-Term Follow-Up of Testicular Microlithiasis in Children and Adolescents: Multicenter Prospective Cohort Study of the Italian Society of Pediatric Urology.

Introduction Testicular microlithiasis (TM), characterized by the presence of intratubular calcifications in a single or both the gonads, is an uncommon entity with unknown etiology and outcome in pediatric and adolescent age. In this study, the results of a multicenter long-term survey are presented. Materials and Methods From 11 units of pediatric urology/surgery, patients with TM were identified and yearly, followed up in a 7-year period, adopting a specific database. The recorded items were: age at diagnosis, presenting symptoms/associated abnormalities, ultrasonographic finding, surgery and histology at biopsy, if performed. Results Out of 85 patients, 81 were evaluated yearly (4 patients lost to follow-up). TM was bilateral in 66.6% of the patients. Associate genital abnormalities were present in 90%, more frequently undescended/retractile testis (23.4%) and varicocele (22.2%). TM remained unchanged at 4.7 years follow-up in 77 patients (93.8%) and was reduced in 4 patients after 1 to 5 years of inguinoscrotal surgery. Orchiectomy was performed in three patients (3.7%), one for severe testicular hypoplasia and two for seminoma (2.5%), respectively, concurrent and metachronous to diagnosis of TM. Tumorectomy with parenchymal sparing surgery was performed in a teratoma associated with TM. Conclusion TM is a controversial entity, often associated with several inguinogenital features, which rarely can recover. Testicular malignancy, although present in TM, has not proven definitively associated to microliths. Proper counseling, yearly ultrasound, and self-examination are long-term recommended.

Vesicoscopic Treatment of Symptomatic Congenital Bladder Diverticula in Children: A 7-Year Experience.

Introduction The objective of this study was to report on the use of vesicoscopy in the treatment of symptomatic congenital bladder diverticula (CBD) in children. Material and Methods In this study, 16 males, aged 4 to 12 years (median age, 6.25 years), were treated for symptomatic CBD; 3 patients presented double diverticulum and 13 presented single diverticulum. The presenting symptoms were recurrent urinary tract infection, hematuria, lower abdominal pain, and voiding dysfunctions as urgency, frequency alone, or in association. A first midline 5-mm trocar was introduced for a 0-degree telescope at the dome of the bladder, and two left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The bladder was then insufflated with carbon dioxide to 10 to 12 mm Hg pressure. The diverticula were inverted into the bladder and the mucosa around the neck was circumcised by using scissors and hook. The defect was sutured and the bladder was drained. Vesicoureteral reflux (VUR) of third grade or higher was treated endoscopically. Results Mean operative time was 90 minutes for procedures. At 6-month follow-up, ultrasound and voiding cystourethrogram (VCUG) showed the disappearance of the diverticulum in 15 out of the 16 patients. The patient, with huge double diverticulum and fourth grade right VUR, presented recurrence of a small left diverticulum. Patients with voiding disorders presented a gradual improvement of their urgency. VUR disappeared at VCUG in all patients. Conclusion Vesicoscopic diverticulectomy resulted a safe and effective procedure and can be considered a valid alternative to the open or laparoscopic procedures. In our opinion, routine use of vesicoscopy could become the gold standard for the treatment of CBD in children.

Laparoscopic upper pole heminephroureterectomy in children: Seven-year experience.

BACKGROUND: Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach. MATERIALS AND METHODS: From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain. RESULTS: The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2 nd to 4 th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously. CONCLUSION: The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.

One-trocar-assisted pyeloplasty: An attractive alternative to open pyeloplasty.

BACKGROUND: To survey the effects of one-trocar-assisted pyeloplasty (OTAP) in the treatment of ureteropelvic junction obstruction (UPJO) in kids. MATERIALS AND METHODS: Forty-four children (±3.5 years) were submitted to OTAP procedure. A flank incision under the XII rib was made, the Gerota's fascia was achieved and a balloon Hasson trocar with an operative telescope inserted for retroperitoneal access. The renal pelvis and ureter were isolated and exteriorised. Forty-two patients underwent Anderson-Hynes dismembered and one Fenger pyeloplasty . One patient was converted to an open procedure. Two patients presented an aberrant crossing vessel. In all patients, a double J stent was positioned. The operative time and length of stay (LOS) were evaluated. Renal scan and ultrasound (US) were utilised to evaluate the results from 6 to 12 months. RESULTS: OTAP was successful in all but 1 patient. Mean operative time and LOS were 128 min and 3,5 days. We had four operative complications (9.09%). The US and a nuclear scan confirmed the resolution of the UPJO in all patients except one with the Fenger pyeloplasty who had an open Anderson-Hynes. CONCLUSIONS: The combination of retroperitoneoscopic and open procedures for dismembered pyeloplasty offers a simple, time-saving method in a minimally invasive fashion with low morbidity for patients with UPJO.

Single-incision laparoscopic surgery and conventional laparoscopic treatment of varicocele in adolescents: Comparison between two techniques.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has gained great popularity in paediatric surgery due to its minimally invasive approach and improved cosmetic results. Notwithstanding, reports describing its adoption in children are still fragmentary and some perplexities have been raised by some surgeons. We reviewed our experience with the SILS Palomo varicocelectomy procedure (SIL-V) in children and adolescents, comparing this group with a similar series operated using conventional laparoscopic varicocelectomy (CL-V). PATIENTS AND METHODS: A total of 69 Palomo laparoscopic varicocelectomies were performed in patients aged 11-17 years from January 2011 to January 2013. Indications for surgery included grades II-III varicocele or ipsilateral testicular hypotrophy. The SIL-V procedure was performed in 44 patients with roticulating and conventional 5 mm instruments. Testicular vessels were isolated "en bloc," clipped and cut. Operating time, visual analogue scale and post-operative results were compared to a similar group of 25 patients operated with CL-V. RESULTS: No patient of the SIL-V group required conversion to conventional laparoscopy, none to open surgery. Mean operative time was 22 min (range: 19-28) in the SIL-V group, not significantly different compared with CL-V (mean 21 min, range: 18-25). All patients experienced a smooth recovery from surgery without any complications, and were discharged on day 1. No difficulties were found in the SIL-V group. The post-operative pain score was significantly better in SIL-V. CONCLUSION: The SIL-V procedure is safe and effective and allows a fast and efficient isolation of the vascular bundle. The use of conventional instruments is technically feasible in SIL-V.

Laparoscopic approach to Meckel's diverticulum.

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers. METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients' demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed. RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years). CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel's diverticulectomy is safe and effective in the treatment of MD, with excellent results.

Work-related upper limb musculoskeletal disorders in pediatric minimally invasive surgery: a multicentric survey comparing laparoscopic and sils ergonomy.

PURPOSE: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons. METHODS: A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ(2) test. RESULTS: Results indicated a similar incidence of WMS with shoulder symptoms (>75%) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ(2) = 0.001). CONCLUSIONS: This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.