Laparoscopic adrenalectomy for large adrenal tumor guided by a 3D anatomic model. New frontiers in abdominal surgery.

If until few years ago the surgeon could study a complex surgery only on the basis of two-dimensional images, today can use 3D physical models on a scale of 1 to 1 of an organ. We report the case of a 53 years old woman with Cushing's syndrome and a giant right adrenal tumor. To better define the relationship between the neoplasm and inferior vena cava, the vascularization of the adrenal gland, any anatomical anomalies and the specific location of the middle adrenal vein, a 3D printed model was created in 1: 1 size based on the preoperative CT. A laparoscopic right adrenalectomy was performed. No intraoperative and postoperative complications were observed with resolution of the adrenal disorder. This case highlights the feasibility and clinical effectiveness of 3D anatomical models for correct preoperative planning, the surgeon's intraoperative guidance to reduce possible errors and therefore improve the patient's postoperative outcome.

Fluorescent lymphography for thoracic duct identification: Initial experience of a simplified and feasible ICG administration.

INTRODUCTION: Indocyanine green (ICG) lymphography can be performed to obtain realtime fluorescent images of the thoracic duct (TD). The injection of ICG into the inguinal nodes usually is ultrasound-guided. Our hypothesis was to simplify the ICG administration until making it executable by unqualified personnel without ultrasound guidance. MATERIAL AND METHODS: From October 2019 to October 2021 we enroled 18 patients. ICG was injected with a 25 Gauge needle in the subcutaneous tissue of the inguinal region bilaterally 14-16 h before surgery. RESULTS: The TD was visualised in every case considered. The easy switching between fluorescence and white light visualization facilitated the identification and dissection of the TD avoiding involuntary injuries. CONCLUSIONS: The simplified ICG administration to identify TD during oesophagectomy is easy to perform, does not require specifically trained staff, is not time demanding and has comparable results to the procedure performed under ultrasound guide.

Outpatient treatment of abdominal wall hernia. A strategy to reduce the impact of the COVID-19 pandemic.

AIM: The aim of this study is to demonstrate the feasibility and efficacy of the treatment of abdominal wall hernias in ambulatory setting in selected patients to break down long waiting lists due to the COVID 19 pandemic. METHODS: From February to June 2021, we performed 120 hernia repair operations with local anesthesia in ambulatory settings without anesthetists. (105 inguinal hernia, 6 femoral hernia and 9 umbilical hernia). All patients were selected from our waiting lists first through a telephone interview through an adequate collection of the anamnesis and then clinically (LEE index and ASA score) and based on the characteristics of the hernia. RESULTS: For all patients, the operation was performed under local anesthesia with lidocaine and naropine. Lichtenstein tension-free mesh repair were performed for all patients with inguinal hernia; polypropylene mesh-plug was the technique used to repair the crural hernias while a direct plastic was performed for the treatment of umbilical hernias.. The mean age was 58 years. We did not observe any intraoperative complications and patients were discharged after 4 hours of operation. There was no case of readmission. Only 3 (2.5%) patients developed scrotal bruising. We did not observe any other complications or recurrence at 30 days and 6 months. Most patients (97.5%) expressed satisfaction for local anesthesia and for the path created. CONCLUSION: Hernia pathologies could be treated in ambulatory setting with good results in selected patients and could represent an alternative to face the limitations imposed by the COVID pandemic on daily surgical activities. KEY WORDS: Ambulatory surgery Cocid-19 Epidemic,Wall hernia.

Emergency duodenal resection for giant GIST with acute gastrointestinal bleeding A case report.

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, which cover about 1-2% of gastrointestinal neoplasms. They are more common in the stomach (40-60%) while a minor part in jejunum/ileus (25- 30%), duodenum (<5%), colorectal (5-15%) and esophagus (<1%). The clinical presentation depends on the primary localization of the neoplasma and tumor size, however in 18% it is asymptomatic. Gastrointestinal bleeding is the most dangerous complication, often necessitating emergency surgery and represents a common symptom of duodenal GIST. We present a case of a 82-year-old male presented with abdominal pain, asthenia and melena with haemodynamically stable. The patient underwent a recent coronary angioplasty and currently on double antiplatelet therapy. During observation a palpable mass was detected in the periumbilical region and right hypochondrium. A superior digestive endoscopy was performed which revealed an ab estrinseco compression of second duodenal segment and bleeding of third duodenal mucosa segment. No local haemostasis could be accomplished. An Angio-CT showed a large exophytic tumor arising from the 3th duodenal segment with approximately 13x9 cm, with apparent intratumoral bleeding. No indication for possible angioembolization. Due to gradual modification of the haemodynamic , the patient was submitted to emergency laparotomy. A segmental enterectomy was performed and the post-operative period ran without complications. The histopathologic exam showed a gastro-intestinal stromal tumor of epithelioid cell nature with low mitotic count (2 per 50HPF). The immunohistochemical analysis revealed positivity for CD117 (c-Kit) and DOG1 with Ki67<1%. KEY WORDS: Bleeding, Duodenal GIST, Gastrointestinal, Gastrointestinal stromal tumor.

Case Report: Management of Malignancy-Exacerbated Pemphigus Vulgaris During COVID-19 Pandemic.

Pemphigus vulgaris is an intraepidermal autoimmune mucocutaneous blistering disease whose etiopathogenesis includes various trigger factors, i.e., drugs and malignancies. We present a case of malignancy-exacerbated pemphigus vulgaris which required a careful diagnostic process in order to rule out paraneoplastic pemphigus, along with the challenges posed by the need of treating both cutaneous and oncologic diseases. Possible post-operative complications post-poned the start of first-line immunosuppressive treatment of pemphigus. Moreover, the infective risks had to be minimized during the peak of the COVID-19 pandemic in Italy. Intravenous immunoglobulins were chosen as "bridge" therapy before the tumor surgical excision, followed by rituximab in post-operative phase.

Robotic gastric surgery: a monocentric case series and review of the literature.

INTRODUCTION: The technical complexity of D2 lymphadenectomy and esophago-jejunal anastomosis are the main factors that limit the application of laparoscopic surgery in the treatment of gastric cancer. Robotic assisted gastric surgery provides potential technical advantages over conventional laparoscopy but an improvement in clinical outcomes after robotic surgery has not been demonstrated yet. EVIDENCE ACQUISITION: Data from 128 consecutive patients who had undergone robotic gastrectomy for gastric cancer at our center institution from April 2017 to June 2020 where retrospectively reviewed from a prospectively updated database. A narrative review was then carried out on PubMed, Embase and Scopus using the following keywords: "gastric cancer," "robotic surgery," "robotic gastrectomy" and "robotic gastric surgery". EVIDENCE SYNTHESIS: Ninety-eight patients underwent robotic distal gastrectomy and 30 underwent robotic total gastrectomy. The mean value of estimated blood loss was 99.5 ml. No patients required conversion to laparoscopy or open surgery. The median number of retrieved lymph nodes was 42. No tumor involvement of the proximal or distal margin was found in any patient. The median time to first flatus and first oral feeding was on postoperative day 3 and 5, respectively. We registered 6 leakages (4.6%), namely, 1 duodenal stump leakage and 5 anastomotic leakages. No 30-day surgical related mortality was recorded. The median length of hospital stay was 10.5 days (range 4-37). CONCLUSIONS: Published data and our experience suggest that the robotic approach for gastric cancer is safe and feasible with potential advantages over conventional laparoscopy.