Minilaparotomic incision for haemorrhagic corpus luteum: a case report.

Corpus luteum cyst rupture with consequent hemoperitoneum is a common cause of admission to the emergency room. This condition is frequently misdiagnosed because of overlapping of clinical findings in acute gynecologic diseases. However, an incorrect identification may lead to delay in surgical treatment, which can Romabe a life-threatening condition. Ultrasound (US) is the first technique used for diagnosis that can confirm or dismiss the presence of intraperitoneal fluid. Secondly, the contrast-enhanced computed tomography (CT) is the quickest way to identify the site of active bleeding and to establish the correct management of the clinical condition. Herein, we report a case of a 19-years-old girl with acute abdominal pain correctly identified by diagnostic images and treated with mini-invasive surgery techniques in order to quickly act without clinic and aesthetic sequelae.

Intracesarean removal of two huge fibroids occupying the whole uterine fundus: a case report.

Uterine fibroid is an estrogen-dependent mass growing during pregnancy. Caesarean myomectomy (CM) is a controversial procedure. A 35-year-old obese (106 Kg) patient gravida 2 para1 (caesarean section), undergoing caesarean section, had two myomas occupying the whole uterine fundus (104.2 mm and 50 mm respectively). Intracesarean myomectomy was carried out after extraction foetus (Apgar score: 9/10). Postoperative course was uneventful and patient was discharged after four days.

Observational study: the use of the Ventralight Echo PS (positioning system) prosthesis in the treatment of incisional hernia.

The treatment of incisional hernias, especially those that are multiple or recurring, has always represented important challenges for surgeons. An incisional hernia is a mechanical damage of the abdominal wall that can result in respiratory problems and alterations of splanchnic circulation, especially when in large size hernias. The increasing availability of prostheses with greater resistance Romato infections and tension, lightness, biocompatibility, and reduced visceral adhesions has improved outcomes and minimized relapses. It is still important, however, to carefully choose the type of prosthesis and surgical technique, whether laparotomic or laparoscopic, correlated to the positioning site of the prosthesis. In this observational study we report the results and outcomes of 50 patients surgically treated for incisional hernia in our hospital. The surgical technique used to repair the hernias was laparoscopic with the use of the Ventralight Echo PS. This prosthesis is equipped with a comfortable and innovative pneumatic system that facilitates its positioning during surgery. In our experience, it has brought undeniable advantages for the treatment of incisional hernias and for all patients with parietal defects who could benefit from laparoscopic treatment.

Nuck canal cyst involving right femoral vein: management and therapy of a rare clinical case.

We present a very rare case of a 49-year old woman suffering from Nuck canal cyst reaching and compressing femoral vein. Nuck canal cyst is very uncommon event because the pouch accompanying the gubernaculum during intrauterine descent of ovaries usually obliterates, whereas when it persists a cystic cavity containing citrine fluid develops. A gravid 0 para 0 49 old woman was admitted to Catania University Surgery Department owing to suspected lymphatic tumor compressing right femoral vein and causing groin pain with ipsilateral leg partial stasis. Patient believed right venous stasis was due to fibromatous uterus. Ultrasounds and computed tomography (CT) scan defined size (7.1 × 4.2 × 1.5 cm), structure (cystic) of mass and its relation with femoral vein, although they were not diriment for diagnosing its nature. Color Doppler detected circulatory function of compressed femoral vein. Surgery was challenging and Nuck cyst was removed after accurate separation from the right femoral venous walls. A case of Nuck cyst involving femoral vein has never been reported so far.

A rare case of trichilemmal ovarian carcinoma. Case report and review of the literature.

Trichilemmal ovarian carcinoma is very rare. A 52-years-old woman was admitted to University Hospital Department suffering from pain in the left iliaca fossa lasting for three months. Uterus was normal in size, painless as well as right adnexum. On the left site ovary was increased in volume and slightly sore. Transvaginal ultrasounds showed a 97x65x86 mm mixed vascularized unilocular mass. CT scan detected a pelvic expansion with a heterogeneous density due to the presence of different structures varying from fat to bone tissue. A proper informed consent was obtained and a suprapubic transversal laparotomy according to Pfannenstiel was carried out. Ovarian mass and ipsilateral tube were removed with no rupture. The anatomical extemporaneous result was of benign dermoid cyst. The postoperative course was uneventful and after three days the patient was discharged in regular conditions and was recommended to come for final anatomical result. Following a month, the final histological answer was of 15 mm trichilemmal malignant tumor in a context of a large benign dermoid cyst. The neoplastic lesion appears to be entirely contained within the limits of the swollen mass. The outer surface was with no lesions. A case of trichilemmal malignant tumor involving ovary has not been published so far.

CT-guided drainage with percutaneous approach as treatment of E. Faecalis post caesarean section severe abscess: case report and literature review.

We report a case of a 32-year old woman with severe pelvic abscess formation who was readmitted to the hospital after ten days of postoperative caesarean course. The patient had undergone emergency caesarean section (CS) for acute foetal sufferance during expulsive period and following three days had been discharged regularly. Enterococcus Faecalis was isolated from purulent material. A prompt antibiotic therapy was carried out, therefore clinic condition did not improve. A percutaneous Computed Tomography (CT)-guided drainage of the abscess was planned. Under local anesthesia abscess was drained. The hospitalization stay allowed monitoring the patient's clinical condition and laboratory blood panel until normalization of all parameters.

Neoplastic sigmoid-uterine fistula. An exceptional complication of large intestine cancer.

Neoplastic sigmoid-uterine fistula is an extremely rare condition because the uterus is a thick and muscular organ. A 74-year-old woman was admitted to the First Aid Station suffering from abdominal pain and foul smelling vaginal discharge. Gynaecological examination showed fecal drainage from the cervical orifice, while the uterus was regular in size but very firm and painful. Ovaries and fallopian tubes were not palpable owing to abdominal tenderness. Ultrasounds reveled inhomogeneous thickening of uterine cavity, without detecting fistula. Contrast Medium CT (CMCT) showed Douglas' recto-uterine pouch occluded. The sigmoid wall was very thin exception a site where a fistula was suspected. At the surgery severe adhesions of the sigma-rectum with the posterior uterine wall were observed. After adhesiolysis, 18 cm colon-sigma-rectum was removed. Total hysterectomy with salpingooophorectomy was performed. Lymphadenectomy ended the procedure. Anatomical specimen confirmed sigmoid-uterine fistula. At histology a mildly differentiated adenocarcinoma of sigma-rectum was shown. Postoperative course was uneventful. Such a case of neoplastic sigmoiduterine fistula has not been reported so far.

Colorectal cancer in aged patients. Toward the routine treatment through laparoscopic surgical approach.

AIM: Colorectal cancer is one of the most common malignancies in general population. The incidence seems to be higher in older age. Surgery remains the treatment of choice and laparoscopic approach offers numerous benefits. We report our personal experience in elderly patients operated on for colorectal cancer with laparoscopic resection. PATIENTS AND METHODS: From January 2003 to September 2013, out of 160 patients aged 65 years or older and operated with minimally invasive techniques, 30 cases affected by colorectal cancer and operated on with laparoscopic approach were analyzed in this study. RESULTS: Male/female ratio was 1.35 and mean age 72 years. Constipation, weight loss, anemia and rectal bleeding were the most commonly reported symptoms. Lesions involved descending-sigmoid colon in 53% of cases, rectum in 37% and ascending colon in 10%. Among laparoscopic colo-rectal operations laparoscopic left colectomy was the most frequently performed, followed by right colectomy, abdominoperineal resection and Hartmann procedure. Operative times ranged from 3 to 5 hours depending on surgical procedure performed. Mean hospital stay was 6 days (range 4-9). Conversion to open approach occurred only in a case of laparoscopic right colectomy (3%) for uncontrolled bleeding. A single case of mortality was reported. In two cases (7%) anastomotic leakage was observed, conservatively treated in one patient and requiring reoperation in the other one. CONCLUSIONS: Laparoscopic colorectal surgery is feasible and effective for malignancies in elderly population offering several advantages including immunologic and oncologic ones. However an experienced surgical team is essential in reducing risks and complications.

Surgical removal of multiple mesenteric fibroids (Kg 4,500) by abdominal spread of previous laparoscopic uterine myomectomy.

INTRODUCTION: Huge and multiple mesenteric fibroids (4,500 Kg weight) are very unusual. In many cases they are mistaken for subserosal fibroids of the womb due to the proximity with uterine walls. When they have a rapid growth, the risk of becoming malignant (sarcoma) has not to be underestimated. Surgery is challenging to remove abdominal nodes. CASE REPORT: A case of a 40-year old woman, admitted to the hospital with abdominal masses occupying the entire cavity was reported. Both computerized tomography (CT) and ultrasounds (US) were not diriment for belonging of tumours. Clinical history of patient reports a laparoscopic removal of uterine fibroids, using the morcellator. Laparoscopy was performed four years before. Open surgery by means of a large transversal suprapubic laparotomy according to Pfannestiel was carried out. Multiple and huge mesenteric, peritoneal and intestinal tumours spread in the whole abdominal cavity were found, removed and examined by frozen section histology; in addition a series of small conglomerated myomas in the site of previous laparoscopic transumbilical route was taken away as well (the largest fibroid weighed Kg 3.500 and the all tumors removed 4,500 Kg); the result was benign (fibroids) and genital apparatus was preserved. Operation was challenging. Postoperative course was uneventful; after five days patient was discharged. CONCLUSIONS: This case is very interesting for many factors: A) many extra-uterine fibroids spread throughout abdominal cavity; B) considerable weight of the masses C) intraoperative and postoperative danger. Finally, due to involvement of previous laparoscopic transumbilical incision together with other findings, the hypothesis of post laparoscopic dissemination has to be considered. A case of so large extragenital abdominal fibroids following laparoscopic uterine myomectomy has never been published so far.

How to prevent mesh erosion in transobturator Tension-Free Incontinence Cystocoele Treatment (TICT): a comparative survey.

BACKGROUND: Tension-Free Incontinence Cystocoele Treatment (TICT) was introduced by Leanza-Gasbarro-Caschetto in 2001, on the basis of experimental and clinical investigations to obtain a physiologic mechanism of closure and opening of the urethra in the event of genuine stress urinary incontinence (S.U.I.) and cistocoele. TICT took origin from the previous retropubic tension-free vaginal tape (TVT) based on the integral theory according which mid-urethra has a main role for urinary continence but differs in that the former restores the anatomy and physiology of the entire anterior compartment. Simultaneously Delorme in 2001 spread the TOT (Trans-Obturator Tape) technique, emphasizing the needle passage across the obturator foramen which represents a new and less invasive route in comparison with the retropubic one. Trans-obturator TICT exploits the advantages of TOT, adding the anatomical repair of bladder prolapse. Introduction of mesh for treatment of pelvic defects gives a lower rate of recurrence, but introduces new complications due to the extraneous materials, among which the most common is represented by mesh erosion. At present the rate of mesh erosion reported is 4.7% in the TOT. Aim of our survey was to verify a technique allowing post-operative erosion prevention. PATIENTS AND METHODS: 230 women with urodynamic stress incontinence and cystocoele after diagnostic phase were allocated to 2 treatment groups (A end B-group), with open alternative method. Agroup women underwent transobturator TICT procedure after preparation of anterior compartment by means of a transversal incision taking care to preserve the integrity of the vaginal skin in the site where the mesh would be allocated. Conversely, B-group transobturator TICT was carried out in a classical way, through a longitudinal incision of anterior vaginal skin and suturing after placing the mesh. Each of the two groups was initially constituted by 115 subjects. There were 14 preoperative dropouts among which 6 (115-6=109) in A-group and 8 (115-8=107) in B-group and, after, 16 postoperative dropouts including 7 (109-7=102) in the former and 9 (107-9=98) in the latter. Other pelvic defects were solved during the same operation for a complete repair of pelvic floor. RESULTS: A-group: subjectively SUI was cured in 87/102 (85.3%) objectively, SUI was cured in 88/102 (86.3%) of patients; cystocoele in 87/102 (85.3%). B-group: subjectively SUI was cured in 86/98 (87.7%) and objectively in 87/98 (88.8%) of patients; cystocoele was solved in 86/98 (87.7%). Between the two groups both anti-incontinence end cystocoele treatment was superimposable (p value > 0.05). Nevertheless regarding mesh erosion, a percentage of 5.1% (5/98) was found among B-group while none among A-group patients where integrity of vaginal skin beneath the mesh was preserved. CONCLUSION: Integrity of the vagina beneath the mesh is the right.key to prevent ad externum mesh erosion.

Single-Incision Laparoscopic Cholecystectomy: our experience and review of literature.

AIM: After the revolution in the surgery of gallbladder stones represented by the laparoscopic cholecystectomy, we tried a new technique that further maximize the aesthetic results and that at the same time is of easy learning for young surgeons. PATIENTS AND METHODS: From January 2011 to December 2012 we performed at our department 320 cholecystectomy: 27 in laparotomy and 293 in laparoscopy. Of these, 88 underwent to Single Incision Laparoscopic Surgery (SILS), namely the Single Incision Laparoscopic Cholecystectomy (SILC), in recruited patients aged between 19-65 years; 56 patients were females and 32 were males. RESULTS: The laparoscopic cholecystectomy with the SILS methodology is a safe technique. Respect to multi-port Laparoscopic Cholecystectomy (LC), we have cosmetic advances. The pain is less in extraumbilical sites, and the major umbilical pain can be prevented by local anaesthesia. The times are slightly longer, especially at the beginning of training, but after a few of operations it is reduced to about one hour. We didn't found any other difference in vantage and advantage between the two technics, only a case of postoperative umbilical hernia in SILS. CONCLUSION: We found the SILS a safe and effective technique for the cholecystectomy.

Hydronephrosis and utero-vaginal prolapse in postmenopausal women: management and treatment.

INTRODUCTION: Pelvic organ prolapse is a multifactorial disease. Aim was to evaluate the effect of the whole surgical correction of pelvic floor on hydronephrosis due to severe prolapse. PATIENTS AND METHODS: A retrospective case study on 250 patients presenting with severe uterovaginal prolapse was carried out. RESULTS: Hydronephrosis was found in 32/234 (13.7 %). All patients underwent hysterectomy, vaginal apex axial suspension, posterior and anterior repair, vaginally. Prepubic TICT (Tension free Incontinence Cystocoele Treatment) was done in 38 cases (3 with hydronephrosis). Of the 32/234 (13.7 %) patients with hydronephrosis, 18/32 (56.25%) had complete resolution of hydronephrosis after treatment, 14/32 (43.75%) had a reduction of calico-pyelic dilatation, among them 8 patients had a second degree and 6 a first degree of hydronephrosis. CONCLUSIONS: Vaginal-hysterectomy, axial apex suspension, anterior and posterior repair resulted in either complete resolution or improvement of hydronephrosis. Prepubic TICT did not interfere on mechanical obstruction and maintained postoperative continence in the event of occult Stress Urinary Incontinence (SUI).

Subcutaneous cervical emphysema and pneumomediastinum due to a diastatic rupture of the cecum.

Pneumomediastinum usually occurs after esophageal or chest trauma. Subcutaneous cervical emphysema as a presentation of non-traumatic colonic perforation following colorectal cancer or diverticulitis, is very rare. We report a case of a patient with rectal cancer who developed a diastatic cecum retroperitoneal perforation with a secondary pneumomediastinum and cervical emphysema. The patient was in treatment with a neoadjuvant chemo-radiotherapy for a low rectal cancer. Treatment consisted in an emergency right hemi-colectomy with ileostomy and performance of distal colonic fistula. The Authors discuss the occurrence of pneumomediastinum and cervical emphysema complicating rectal cancer, pointing out ethiopathogenesis, clinical presentation, diagnosis and treatment. The importance of performing a diverting colostomy when neoadjuvant chemotherapy is scheduled in patients with stenotic rectal cancer, although not clinically occluded.

Ovulation induction with clomiphene citrate and metformin in women with polycystic ovary syndrome.

AIM: Polycystic ovary syndrome (PCOS) is one of the most common causes of ovulatory infertility. It is an endocrine disorders characterized by a high level of male hormones (androgens) and frequent anovulatory cycles associated with multiple ovarian microcysts. The aim of this paper was to evaluate effects of a Clomiphene citrate alone versus a combined treatment (Metformin and Clomiphene citrate). METHODS: A total of 60 women with PCOS and infertility were evaluated. Inclusions criteria were: age 26-34 years, nulliparity, above 3 years of sterility, multiple ovarian microcysts, BMI>27.5, oligomenorrhea/amenorrhea, hyperandrogenism and normal male fertility. Four patients were excluded (renal damage 2, tubal occlusion 1 and Pelvic Inflammatory Disease 1). The remaining 56 were divided into 2 groups: group A were inducted with Clomiphene Citrate alone, while group B were inducted with Clomiphene citrate and Metformin. RESULTS: In group A we obtained ovulation in 20 women (71.4%), 8 pregnancies (28.5%) and one (3.5%) spontaneous abortion. In group B we obtained ovulation in 24 women (85.7%), 15 pregnancies (53.5%) and no spontaneous abortions. CONCLUSION: Combined treatment was found to be more effective (53.5) in improving pregnancy rate compared to monotherapy (28.5%).

Unexplained infertility and ovulatory induction with menopausal gonadotropins.

AIM: Unexplained infertility affects 30% of infertile couples. Management depends on duration of infertility and age of female partner. Ovulation induction, together with intrauterine insemination, is commonly offered to couples with infertility of unknown origin. Intrauterine insemination gained its popularity because it is simple, non-invasive and cost-effective technique. The association with pharmacological stimulation is suitable to induce follicular maturation. The most used drugs to induce ovulation are clomiphene citrate and menopausal or recombinant gonodotropins. The aim of this paper was to evaluate the success rate after homologous intrauterine insemination (IUI) combined with menopausal gonadotropins stimulation. METHODS: A total of 90 couples were evaluated. Twelve couples (13.3%) were excluded from the treatment (6 vaginal infections, 4 tubal occlusions and 2 male infertility). Informed consent was applied for every couple. The remaining 78 couples were divided in two groups: group A (39 couples) were inducted with menopausal gonadotropins, while group B (39 couples) underwent placebo (multivitamin). RESULTS: In group A (gonadotropins) 25 (64.1%) pregnancies and 2 (5.1%) abortion were registered, while in group B (placebo) there were 7 (17.9%). pregnancies and 1 (2.5%) abortion. CONCLUSION: Ovulation inductions with menopausal gonadotropins, together with intrauterine insemination, improves fecundity in patients with infertility of unknown origin without recur to more invasive techniques.

Ovulation induction with clomiphene citrate for infertile couple.

AIM: Among couples unable to conceive without any identifiable cause, 30% are defined as having unexplained infertility. Management depends on duration of infertility and age of female partner. In order to increase pregnancy rate, couples with infertility of unknown origin can undergo ovulation induction and intrauterine insemination. These techniques are able to increase pregnancy rate in case of unexplained infertility. Clomiphene citrate and menopausal or recombinant gonodotropins are the most used drugs to induce ovulation. Aim of the present study was to evaluate the success rate after homologous intrauterine insemination (IUI) combined with clomiphene citrate (CC) stimulation. METHODS: A total of 77 couples were evaluated. Nine couples (11.6%) were excluded from the treatment (vaginal infections 4, tubal occlusions 3 and male sterility 2). Informed consent was applied for every couple. The remaining 68 couples were divided in two groups: group A (34 couples) were inducted with CC, while group B (34 couples) underwent placebo (multivitamin). RESULTS: In group A (CC) 15 (44.1%) pregnancies and 3 (8.8%) abortion were registered, while in group B (placebo) there were 4 (11.7%) pregnancies and 1 (2.9%) abortion. CONCLUSION: Ovulation inductions with CC, together with intrauterine insemination, improves fecundity in patients with infertility of unknown origin with no need to recur to more invasive techniques.

Comparison between three mini-sling surgical procedures and the traditional transobturator vaginal tape technique for female stress urinary incontinence.

OBJECTIVES: To compare mini-sling and traditional tension-free operations for female stress urinary incontinence. STUDY DESIGN: A systematic review of articles in the Literature published between 2002 and 2012, was conducted. A Pubmed search was performed. Primary outcomes were subjective and objective cure rates at 12 months comparing the three single-incision mini-slings techniques (TVT-Secur, MiniArc and Monarc systems) with the standard midurethral sling procedure TOT (Transobturator Vaginal Tape). Secondary outcomes included peri-operative (vaginal and/or bladder perforation, urine retention, urinary tract infection, bleeding, pain) and post-operative (mesh exposure, de novo urgency, and dyspareunia) complications. RESULTS: In term of objective cure rate at 12 month after surgery, it is evident that TOT at first, and MiniArc are the most effective procedures. The incidence of post-operative urgency and UTI was lower in TOT technique, while vaginal perforation was described in equal frequency both in TOT and in MiniArc procedures. The advantages of the three above described mini-invasive techniques seem to consist into lower cases of urinary retention, pain and bleeding. Furthermore, bladder perforation and bleeding are not described in the Literature for TVT-Secur and Monarc systems. CONCLUSIONS: Some single-incision slings look promising and as effective as conventional sub-urethral slings at short term evaluation. However, at this moment a clear statement in favor of the widespread use of single-incision slings cannot be made. More studies must define the efficacy of these techniques.

Mini-invasive tension-free surgery for female urinary incontinence.

The Authors describe the techniques they perform of prepubic, retropubic and transobturator mini-invasive anti-incontinence surgical procedures and point-out some technical details. The state of art and the results of these three main surgical procedure are compared and discussed. Data from the Literature have been reviewed in order to evaluate the efficacy of the techniques. A Medline search has been performed, and 65 relevant articles from 1996 to 2012 were selected. Literature showed similar cure rates among retropubic (71,4-91%), trans-oburator (77,3-95%) and prepubic (81-87,2%) anti-incontinence procedures. Cystoscopy was considered necessary in the retropubic, optional in transobturator and in the prepubic techniques. Intra-operative cough stress test was believed useful only in the retropubic and prepubic procedures. Obstruction symptoms prevailed in the retropubic, were rare in the transobturator and missing in the prepubic technique. Erosion rate was very low and similar for all the three techniques. Intra-operative vascular and perforating risks prevailed in the retropubic technique, due to the danger present in the retropubic space, whereas late infective complications overcame in the transobturator procedure. Severe complications in the prepubic procedure were not reported, but the procedure is performed only in few centers.

Breast cancer and sentinel lymph node micrometastases: indications for lymphadenectomy and literature review.

An increasingly early diagnosis for discovering breast cancer, an improvement of surgical procedures with refining techniques for research and study of sentinel node, currently allow a more conservative surgical approach. Association with suitable chemo-radiotherapy allows a good control of breast disease. Our study, although modest, was carried out on 63 patients suffering from breast cancer, who underwent surgical treatment with assessment of sentinel lymph node. Aim of study was to establish the most correct strategy in the presence of isolated tumor cells (ITC) and/or micro-metastases of sentinel lymph node. Many studies have been carried out to find which was the most appropriate treatment, nevertheless, in the absence of univocal guidelines, we prefer to proceed to axillary dissection, though the topic is very debated and controversial. Following this strategy we obtained quite satisfactory results.

Laparoscopic removal of a giant paratubal cyst complicated by hydronephrosis.

Paratubal cysts represent approximately 10% of all adnexal masses. In most cases they are very small, but very few cases are reported in the literature where they exceed 15 cm of diameter. Furthermore, giant paratubal cysts complicated by bilateral hydronephrosis are unique. The Authors describe a case of a huge paratubal cyst (30 cm in diameter), in a 14 year old obese girl, treated by complete laparoscopic enucleation.