The laparoscopic approach in abdominal emergencies: has the attitude changed? : A single-center review of a 15-year experience.

BACKGROUND: Laparoscopy has been practiced more and more in the management of abdominal emergencies. The aim of the present work was to illustrate retrospectively the results of a case-control 5-year experience of laparoscopic versus open surgery for abdominal emergencies carried out at our institution, especially with regard to whether our attitude toward use of this procedure has changed as compared with the beginning of our laparoscopic emergency experience (1991-2002). MATERIALS AND METHODS: From January 2002 to January 2007 a total of 670 patients underwent emergent and/or urgent laparoscopy (small bowel obstruction, 17; gastroduodenal ulcer disease, 16; biliary disease, 118; pelvic disease and non-specific abdominal pain (NSAP), 512; colonic perforations, 7) at the hands of a surgical team trained in laparoscopy RESULTS: The conversion rate was 0.15%. Major complications ranged as high as 1.9% with no postoperative mortality. A definitive diagnosis was accomplished in 98.3% of the cases, and all such patients were treated successfully by laparoscopy. CONCLUSIONS: We believe that laparoscopy is not an alternative to physical examination/good clinical judgment or to conventional noninvasive diagnostic methods in treating the patient with symptoms of an acute abdomen. However it must be considered an effective option in treating patients in whom these methods fail and as a challenging alternative to open surgery in the management algorithm for abdominal emergencies.

The misdiagnosis of ruptured abdominal aortic aneurysm: an ancient problem always present. Report of an atypical case.

The rupture of an abdominal aortic aneurysm is one of the most dramatic event in the daily clinical practice. It is often easily suspected when the classical signs of hemorrhagic shock are associated with an anterior (mesogastric) abdominal pain and an expanding mass, especially in the non-obese patients. Sometimes many of these signs can lack and, as a consequence, the diagnosis might be very difficult. This may cause a fatal delay for the patients. We describe a singular case in which the rupture of an abdominal aortic aneurysm was simulating an acute cholecystitis: the presented symptoms, together with a negative personal medical history, were so atypical that even four experienced practitioners misdiagnosed the vascular lesion and the diagnosis was possible only at autopsy.

Primary pulmonary nodular amyloidosis.

Primary nodular amyloidosis of the lung is an uncommon manifestation. The disease runs a benign course, but offers diagnostic problems due to non-specific radiological features entering the big field of the solitary nodule. We describe the case of a 60 year old man with multiple nodules on the left lung operated on diagnostic and therapeutic video-assisted thoracoscopy and discuss the possibilities, if any, of suspecting such a disease through radiologic characteristics along with findings from the patient's history, physical examination and laboratory tests.

Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single-center study.

BACKGROUND: Nonobese patients undergoing laparoscopic procedures present a dilemma as to the correct mode of entry into the abdominal cavity because the Veress needle (VN) technique seems to be associated with a high risk of vascular and visceral injuries. Direct trocar insertion (DTI) has been reported as an alternative to the VN for creation of the pneumoperitoneum. METHODS: An open comparative randomized prospective study was conducted on the feasibility and safety of DTI vs the VN technique in nonobese patients of any age category referred for urgent or scheduled laparoscopic procedures. Exclusion criteria were obesity (defined as a body mass index [BMI] > 27 kg/m(2)), major abdominal distension, and two or more previous abdominal operations. The study endpoints were the feasibility and safety of the DTI and VN techniques. Results were evaluated on an intention-to-treat basis. Statistical analysis was carried out with the t-test for independent samples, the chi-square tests, and the Fisher's exact tests, as appropriate. The level of significance was 0.01. RESULTS: Since January 2002, a total of 598 nonobese patients have been entered into the current trial; 46% (mean BMI 21.6 A+/- 4.4 kg/m(2)) were randomly allocated to DTI, whereas 54% (BMI 21.1 A+/- 5.3 kg/m(2)) were allocated to the VN techniques. Demographic features and type of procedures were similar for the two groups. DTI was feasible in 100% of patients vs 98.7% in the VN group (p = NS). Minor complications were nil in the DTI group and 5.9% in the VN group (p < 0.01). The latter group consisted of 11 cases (3.4%) of subcutaneous emphysema and eight cases (2.5%) of extraperitoneal insufflation. Major complications were nil in the DTI group and 1.3% among VN patients (p = NS). These latter cases consisted of two (0.3%) hepatic lesions managed laparoscopically; one (0.3%) misdiagnosed ileal perforation requiring reintervention, and one (0.3%) mesenteric laceration treated conservatively. CONCLUSION: In thin and very thin patients of any age category with no more than one previous abdominal operation, DTI is a safe alternative to the VN technique and is associated with fewer minor complications. In terms of major complications, there is no difference between the two techniques. Either technique of access is acceptable Thin and very thin patients undergoing laparoscopy, on condition that the basic principles of laparoscopic surgery are complied with.

[Intestinal infarction in the elderly]. / L'infarto intestinale nell'anziano.

The bowel infarction is till affected by high mortality in spite of new diagnostic methods and therapy. In our experience was observed about 45 patients with bowel infarction by different etiology; fast diagnosis and therapy are necessary for a good prognosis. The arteriography, at the light of this experience, is the gold standard but it is still performed in a low number of patients. The laparoscopy, in the advanced pathologies, is able to avoid an ineffectual laparotomy and permits a better diagnosis in borderline cases.

Squamous cell liver cancer arising from an epidermoid cyst.

Squamous cell liver cancer (SCLC) arising from an epidermoid intestinal cyst is rare. Only 65 cases of this cyst have been reported since 1850, with 2 reported cases of squamous cell cancer. We describe here the case of a 21-year-old man who complained of mild pain, a feeling of fullness in the right upper quadrant of the abdomen, and fever and weight loss, who developed SCLC arising from an epidermoid intestinal cyst. The clinical presentation, management, and pathological findings are discussed.

[Physiopathology of intestinal anastomoses and dehiscences]. / Fisiopatologia delle anastomosi intestinali e delle deiscenze.

A lot of mechanisms of healing of intestinal anastomoses has been explained. A leading role in the intestinal wall is made by the submucosal tunica, where collagen synthesis and degradation process take place, but local and systemic factors are present by a definite causal action. Technique of suture, materials and surgeon's experience are of fundamental importance for the success of operation, even if in some cases it is important to take in consideration the clinical situation: emergency or not, the patient's state and age, concomitant diseases, pharmacological or radiotherapeutic treatments. Nowadays surgical research tends towards biochemical and molecular field to identify the factors, that speed up the healing process to use them in suturing materials getting a quick healing as soon as possible.

[Surgery of inguinal and femoral hernia in the elderly]. / La chirurgia dell'ernia inguinale e crurale nell'anziano.

Old people are continuously increasing in frequency but age is not a significant factor to value the operative risk in hernia surgery. From June 1985 to December 1996, 189 patients, aged > 80-year, were submitted to hernia surgery. No complications were noted when elective surgery was performed. Emergent procedure was undertaken in 7% of the patients major perioperative complications and one death were registered in this group of patients. Mean hospital stay has decreased in the period of the study: was 2.2 days in the last two years. Local anesthesia permitted a day surgery procedure in 60% of cases.