Differences in the learning curve of robotic transabdominal preperitoneal inguinal hernia repair according to surgeon's robotic experience.

PURPOSE: In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with the robotic platform but no experience with laparoscopic hernia repair. METHODS: Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure [the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4)]. Each intraoperative and postoperative outcome was compared according to surgeon's experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period. RESULTS: The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase. CONCLUSIONS: In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon's experience in robotic surgery.

Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome.

AIM: The study aimed to compare robotic rectal resection with laparoscopic rectal resection for cancer. Robotic surgery has been used successfully in many branches of surgery but there is little evidence in the literature on its use in rectal cancer. METHODS: We performed a systematic review of the available literature in order to evaluate the feasibility, safety and effectiveness of robotic versus laparoscopic surgery for rectal cancer. We compared robotic and laparoscopic surgery with respect to twelve end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing full-robotic or robot-assisted rectal resection and robotic total mesorectal excision was carried out. All aspects of Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement were followed to conduct this systematic review. Comprehensive electronic search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL. Randomized and nonrandomized clinical trials comparing robotic and laparoscopic resection for rectal cancer were included. No language or publication status restrictions were imposed. A data-extraction sheet was developed based on the data extraction template of the Cochrane Group. The statistical analysis was performed using the odd ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. RESULTS: Eight non randomized studies were identified that included 854 patients in total, 344 (40.2%) in the robotic group and 510 (59.7%) in the laparoscopic group. Meta-analysis suggested that the conversion rate to open surgery in the robotic group was significantly lower than that with laparoscopic surgery (OR = 0.26, 95% CI: 0.12-0.57, P = 0.0007). There were no significant differences in operation time, length of hospital stay, time to resume regular diet, postoperative morbidity and mortality, and the oncological accuracy of resection. CONCLUSION: Robotic surgery for rectal cancer has a lower conversion rate and a similar operative time compared with laparoscopic surgery, with no difference in recovery, oncological and postoperative outcomes.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials.

AIM: Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes. METHOD: We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes. CONCLUSION: The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Laparoscopic adhesiolysis: consensus conference guidelines.

AIM: Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. METHODS: A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. RESULTS: Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. CONCLUSION: Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

Expressional and functional analysis of the male-specific cluster mst36F during Drosophila spermatogenesis.

mst36Fa and mst36Fb are two male-specific genes that are part of a novel gene family recently characterized in Drosophila melanogaster. The genes are strictly clustered and show an identical tissue and temporal expression pattern limited to the male germline. Here we demonstrate that the transcription of these two genes, which is triggered by different cis regulatory elements, responds to the same testisspecific factors encoded by the aly and can class meiotic arrest genes. RNA interference was used to decrease expression of these two genes. We obtained a reduction of fertility in the transgenic adult males compared to the wild type. These data suggest that the Mst36Fa and Mst36Fb proteins may have an important role in the production of functional sperm.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

A study of rDNA magnification phenomenon in a repair-recombination deficient mutant of Drosophila melanogaster.

The rDNA magnification process consists of a rapid and inheritable rDNA increase occurring in bobbed males: in a few generations the bb loci acquire the wild-type rDNA value and reach a bb+ phenotype.--We have analyzed the rDNA magnification process in the repair-recombination-deficient mutant mei9a, both at the phenotypical and rDNA content levels. In mei9a bb double mutants the recovery of bb+ phenotype is strongly disturbed and the rDNA redundancy value fails to reach the wild-type level. The strong effect of this meiotic mutation on rDNA magnification suggests a close relationship between this phenomenon and the repair-recombination processes.

A comprehensive assessment of the avoidability of long-term complications of diabetes. A case-control study. SID-AMD Italian Study Group for the Implementation of the St. Vincent Declaration.

OBJECTIVE: To identify and quantify risk factors for the development of long-term diabetic complications (i.e., critical limb ischemia, amputation, chronic renal failure [creatinine > 3 mg/dl], dialysis treatment, proliferative retinopathy, blindness), with particular emphasis on those variables that, being related to quality of care, can be considered avoidable. RESEARCH DESIGN AND METHODS: We designed a case-control study that enrolled 886 patients with long-term diabetic complications and 1,888 control subjects without complications from 35 diabetic outpatient clinics and 49 general practitioners offices during a 6-month period. Selected socioeconomic, pathophysiologic, self-care, health care, and lifestyle information were collected for all patients. RESULTS: A logistic regression analysis showed that several factors are related to the development of major diabetic complications. Among patient characteristics, male sex (odds ratio [OR] = 1.8, 95% CI 1.4-2.3) and age (OR = 1.7, 95% Cl 1.2-2.4 for patients between 50 and 69 years of age as opposed to those younger than 50 years of age) were associated with an increased risk of complication. Among clinical variables, the type and the duration of diabetes were the most important predictors of diabetic complications. The presence of hypertension was also associated with the development of diabetic complications, particularly when it was poorly controlled by treatment (OR = 3.1, 95% CI 2.3-4.3). Patients who needed help to reach a health care facility and those who did not regularly attend such a facility were at higher risk of developing complications (OR = 1.5, 95% CI 1.2-1.9; OR = 1.7, 95% CI 1.3-2.2, respectively). Educational aspects were also related to the outcome: patients who did not receive any kind of educational intervention had an increased risk of developing complications (OR = 4.1, 95% CI 1.7-9.7), while self-management of insulin therapy had a protective effect (OR = 0.6, 95% CI 0.5-0.8). The summary attributable risk related to avoidable risk factors (i.e., uncontrolled hypertension, poor compliance with visit scheduling, inadequate diabetes education, no self-management of insulin treatment) was 0.39. CONCLUSIONS: Our data suggest that, by removing avoidable risk factors, the number of diabetic complications considered could be reduced by more than one-third. The case-control methodology represents an efficient way of monitoring clinical practice and relating it to important outcomes. It can be of help for policy makers in identifying the more effective strategies and in tailoring specific interventions aimed at improving the quality of the care delivered to diabetic patients.

The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies.

OBJECTIVE: The role of self-monitoring of blood glucose (SMBG) in type 2 diabetes is still a matter of debate. In the framework of a nationwide outcomes research program, we investigated the frequency of SMBG and its association with metabolic control and quality of life (QoL). RESEARCH DESIGN AND METHODS: The study involved 3,567 patients with type 2 diabetes who were recruited by 101 outpatient diabetes clinics and 103 general practitioners. Patients completed a questionnaire investigating SMBG practice and QoL (diabetes-related stress, diabetes health distress, diabetes-related worries, and Centers for Epidemiologic Studies-Depression scale). RESULTS: Data on SMBG were available for 2,855 subjects (80% of the entire study population). Overall, 471 patients (17%) stated that they tested their blood glucose levels at home > or =1 time per day, 899 patients (31%) tested their blood glucose levels > or =1 time per week, and 414 patients (14%) tested their blood glucose levels <1 time per week, whereas 1,071 patients (38%) stated that they never practiced SMBG. A higher frequency of SMBG was associated with better metabolic control among subjects who were able to adjust insulin doses, whereas no relationship was found in all other patients, irrespective of the kind of treatment. Multivariate analyses showed that an SMBG frequency > or =1 time per day was significantly related to higher levels of distress, worries, and depressive symptoms in non-insulin-treated patients. CONCLUSIONS: Our findings suggest that SMBG can have an important role in improving metabolic control if it is an integral part of a wider educational strategy devoted to the promotion of patient autonomy. In patients not treated with insulin, self-monitoring is associated with higher HbA(1c) levels and psychological burden. Our data do not support the extension of SMBG to this group.

The relationship between physicians' self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes. The QuED Study Group--quality of care and outcomes in type 2 diabetes.

OBJECTIVE: To investigate the relationship between beliefs of physicians relative to intensive metabolic control in type 2 diabetes and levels of HbA1c obtained in a sample of their patients. RESEARCH DESIGN AND METHODS: Physicians' beliefs were investigated through a questionnaire sent to a sample of self-selected clinicians participating in a nationwide initiative aimed at assessing the relationship between the quality of care delivered to patients with type 2 diabetes and their outcomes. At the same time, physicians were asked to collect clinical data on a random sample of their patients, stratified by age (<65 vs. > or = 65 years). Mean HbA1c levels in the study population were thus evaluated according to target fasting blood glucose (FBG) used by their physicians. RESULTS: Of 456 physicians, 342 (75%) returned the questionnaire. Among the responders, 200 diabetologists and 99 general practitioners (GPs) recruited 3,297 patients; 2,003 of whom were always followed by the same physician and 1,294 of whom were seen by different physicians in the same structure on different occasions. Only 14% of the respondents used target FBG levels < or = 6.1 mmol/l, whereas 38% pursued values >7.8 mmol/l, with no statistically significant difference between diabetologists and GPs. The analysis of the relationship between FBG targets and metabolic control, restricted to those patients always seen by the same physician, showed a strong linear association, with mean HbA1c values of 7.0 +/- 1.6 for patients in the charge of physicians pursuing FBG levels < or = 6.1 mmol/l and 7.8 +/- 1.8 for those followed by physicians who used target values >7.8 mmol/l. After adjusting for patients' and physicians' characteristics, the risk of having HbA1c values > 7.0% was highly correlated with physicians' beliefs. Patients followed by different physicians in the same unit showed a risk of inadequate metabolic control similar to that of patients followed by physicians adopting a nonaggressive policy. CONCLUSIONS: Doctors adopt extremely heterogeneous target FBG levels in patients with type 2 diabetes, which in turn represent an important independent predictor of metabolic control. To improve patient outcomes, physicians-centered educational activities aimed at increasing the awareness of the potential benefits of a tight metabolic control in patients with type 2 diabetes are urgently needed.

Epidemiology and determinants of blood glucose self-monitoring in clinical practice.

The aim of this study was to describe the epidemiology of self-monitoring of blood glucose and to identify specific characteristics of those subgroups of diabetic patients treated with insulin that are most likely to monitor their blood glucose according to medical recommendations. Data were collected on 1384 insulin-treated patients, enrolled from 35 diabetic outpatient clinics and 49 general practitioners' offices between December 1993 and June 1994. Seventeen Italian regions out of 20 were included in the study. Our data show that 418 (31%) diabetic patients treated with insulin had never practised blood glucose self-monitoring. In addition, only 242 patients (18.2%) self-monitored their glycemia with a mean frequency of at least once a day (29.7% among insulin-dependent diabetes mellitus (IDDM) and 13.9%, among insulin-treated non-insulin-dependent diabetes mellitus (NIDDM-IT) patients). Patients' characteristics associated with a higher probability of practising blood glucose self-monitoring were age below 50 years, being treated at a diabetic outpatient clinic, hypertension, need of three or more insulin injections per day, history of hypoglycemic episodes, ability to self-manage insulin doses. Our study calls for vigorous efforts aimed at promoting the incorporation of clearly-defined educational programs at each level of care, in order to improve the motivation and self-care of diabetic patients. Furthermore, studies are necessary to identify subgroups of diabetic patients that truly need to self-monitor blood glycemia, and to assess the efficacy of the practice of self-monitoring of blood glucose in improving metabolic control and reducing acute and long-term diabetic complications.

Risk factors for lower limb complications in diabetic patients. The Italian Study Group for the Implementation of the St. Vincent Declaration.

Diabetic lower extremity complications may be influenced by a number of factors, including those related to the interaction between patients and the health-care system. Our objective is to identify risk factors for the development of lower limb complications, by looking for classical clinical variables and those related to quality of care. A case-control study was carried out between December 1993 and June 1994 by interviewing 348 patients with lower-limb diabetic complications and 1050 controls enrolled from 35 diabetes outpatient clinics and 49 general practitioner's offices in Italy. Among sociodemographic characteristics associated with increased risk of lower limb complications were male gender [odds ratio (OR) = 2.5, confidence interval (CI) 1.6-3.9], age between 50 and 70 years as opposed to younger than 50 (OR = 3.6, CI 2.1-6.3) and being single as opposed to married (OR = 1.4, CI 1.1-1.8). Among clinical variables, treatment with insulin for IDDM and NIDDM patients was an important predictor of lower extremity complications compared to NIDDM patients not being treated with insulin. Cardio-cerebrovascular disease and presence of diabetic neuropathy were associated with a higher risk of being a case (OR = 1.4, CI 1.2-1.8 and OR = 3.0, CI 2.1-4.2, respectively). Patients who needed help to reach the health facility before the onset of the complications and those who did not attend health facilities regularly were more liable to develop complications (OR = 1.5, CI 1.1-2.2 and OR = 2.0, CI 1.3-3.0, respectively). Patients who had never received educational intervention had a threefold risk of being a case as compared to those who received health information regularly. The study identifies factors most likely to be related to adverse outcome and permits to discriminate between avoidable and unavoidable factors.

Laparoscopic physiological hiatoplasty for hiatal hernia: new composite "A"-shaped mesh. Physical and geometrical analysis and preliminary clinical results.

BACKGROUND: We analyzed, using a theoretical model, the modality of recurrence after a simple cruroplasty for large hiatal hernias, and on the basis of physical and geometrical principles, we conceived a new shaped mesh for a "tension-free" repair. METHODS: We performed a physical and geometrical analysis of the hiatal region on a theoretical model. We also performed an anatomic study on 20 fresh cadavers to verify the reproducibility of the theoretical model and to study the most suitable shape for mesh and its adaptability to the hiatal region. Between September 2000 and October 2001, eight patients received laparoscopic reparation of large (type II or III) hiatal hernias by means of a composite "A"-shaped polytetrafluoroethylene (PTFE)-polypropylene mesh. There were two men and six women; mean age was 65 years (range, 35-78 years). Concomitant esophagitis was found in five patients and impaired esophageal peristalsis in two patients. A total or a partial fundoplication was associated in these cases. RESULTS: The physical and geometrical analysis of the hiatal region explained the reasons for the recurrence after hiatoplasty. The anatomical study on fresh cadavers resulted in a mesh tailored in an "A" shape and permitted to verify the adaptability of such a shaped mesh composed of two layers, polypropylene and PTFE. In the clinical series no conversions occurred; the mortality rate was null. Persistent dysphagia was present in two patients and disappeared after 3 months of treatment. No recurrence was observed at an 8-month average follow-up. CONCLUSION: The preliminary clinical study confirms the feasibility of this tension-free repair and the effectiveness of this composite A-shaped mesh.

Laparoscopic splenectomy for hematological diseases.

BACKGROUND: We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens. METHODS: Between June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n = 23), hemolytic anemia (HA) (n = 5), and hematological malignancy (HM) (n = 15). Statistical analyses were done to compare the three groups. RESULTS: LS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure. CONCLUSIONS: The statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.

[Multimodal treatment of liver metastases: our experience]. / Trattamento multimodale delle metastasi epatiche: nostra esperienza.

Our recent experience in multimodal treatment of liver metastases. Surgical treatment of liver metastases is increasing in these years regarding more and more patients, as well as more and more surgeons. In the same time the introduction of therapies allows today the integration of surgical treatment and also satisfactory palliation. Authors report their experience in these last 4 years and suggest interdisciplinary approach to get good results even in non dedicated centres.

[Surgical treatment of gastrointestinal stromal tumors: personal cases]. / Trattamento chirurgico dei tumori stromali gastrointestinali: casistica personale.

Surgical management of gastrointestinal stromal tumors: our experience. Gastrointestinal stromal tumors (GIST) are rare neoplasm even if they are the most common mesenchimal malignancies of the gastrointestinal tract. GIST have long been a source of confusion and controversy, in particular to define their pathological classification, preoperative diagnosis, management strategies, and prognosis. A radical resection of the tumor is often possible and always recommended. Recent studies have identified its principal pathogenic defect. An effective adjuvant therapy treatment (STI571) have been found for advanced and metastatic GIST.

[Factors related to the uptake of breast cancer screening (mammography and breast ultrasound): a retrospective survey on a sample of resident women, 50-70 years aged, from Abruzzo region]. / Fattori predittivi dell'utilizzo di metodiche preventive per il tumore del seno (mammografia ed ecografia mammaria): indagine retrospettiva su un campione di donne abruzzesi, di età compresa tra 50 e 70 anni.

Within the context of a large breast cancer screening program we conducted a retrospective survey to identify the personal, socioeconomic and behavioural characteristics associated with previous use of mammograms (Ma) and breast ultrasound examination (US). Contact was made with a sample of more than 10,000 resident women who were asked to complete three questionnaires. Achieving an answer rate of 86%, we collected data from 9,087 women, 50-70 years aged, coming from Abruzzo, a central Italian region. 61% of the participants performed Ma, while US was performed by 34%, and 67% of women attended at least one of those examinations. Multiple logistic regression results indicated that older age, low level of education, not performing diets and breast self examination were significant predictors of a lower use of both examinations. Women that were married, mothers, on menopause, with a family history of cancer, uterine fibroma, past users of oral contraceptives were more likely to having performed Ma, but not US. Age at menarche, BMI and smoking were found not to be significant in predicting attendance for both screening examinations, with the exception of ex-smokers for US. Our findings represent an important contribution to the development of the needed tailored interventions to increase breast screening participation.

[Deep venous thrombosis after leg amputation. Review of the argument]. / La trombosi venosa profonda dopo amputazione degli arti inferiori. Review sull'argomento.

Patients undergoing lower extremity amputation are perceived to be at high risk for deep vein thrombosis (DVT). DVT can cause micro or macro pulmonary embolism and often the post-thrombophlebitic syndrome. The chronic condition can affect patient quality of life and his residual working capacity. Usually the echo-Doppler or the color-Doppler is used as a prevention and diagnostic method, identifying patients at high risk. Following the Authors examine and report the Literature opinion about the topics.

[Richter's hernia: a clinical case and the clinico-therapeutic considerations]. / Ernia di Richter: caso clinico e considerazioni clinico-terapeutiche.

The authors report a case of Richter's hernia. They underline main clinical and therapeutic patterns, emphasizing the need of an early diagnosis and surgery. This is a hernia of abdominal wall with partial entrapment of bowel wall (antimesenteric site) through a small ring. The incidence increased in the last years because of diffusion of laparoscopic techniques. Richter's hernia could be asymptomatic for a long time or show vanish sign. Sometimes this hernia can be diagnosed during surgery. The clinical signs are conclamated if hernia is complicated by strangulation. High mortality is justified by performing too late diagnosis and operation.

[Total splenectomy for a recurrent giant splenic cyst]. / Splenectomia totale per voluminosa cisti splenica recidiva.

Primary splenic cysts are a rare finding. Some are large and require surgical removal. The Authors report a case of a recurrent huge splenic cyst in a 41-year-old female patient. A marsupialization was performed at another hospital 6 years before. Ultrasonography and computed tomography imaging revealed a cystic lesion in the spleen measuring approximately 20 cm in diameter. A total open splenectomy was performed. Postoperative course was uneventful. The histologic diagnosis was an epithelial cyst of the spleen with no atypical cells in the cyst wall, as previously found at the first operation. The epidermoid cysts have an epidermal lining, and prevention of recurrence is dependent on complete resection of the cyst wall preserving, whenever possible, the splenic tissue. Recurrence can be avoided with partial splenectomy in polar localization of the cyst, or complete removal of the cyst by "peeling" it off the splenic parenchyma. Marsupialization of the cyst, either via a laparoscopic or an open approach, is often ineffective.