Characteristics and outcomes of laparoscopic surgery in patients with large hiatal hernia. A single center study.

INTRODUCTION: Giant hiatal hernia is characterized by the presence of more than 1/3 of the stomach in the chest, through the diaphragmatic hiatus, with or without other intra-abdominal organs. It is a rare pathology, representing the 5-10% of all hiatal hernias. The advent of laparoscopic surgery led to new surgical techniques, which include the simple reduction with the excision of the hernial sac and the execution of a posterior hiatoplasty, with or without mesh, and the execution of a Collis-Nissen gatroplasty in case of short esophagus. PRESENTATION OF CASES: We followed 24 cases of giant hiatal hernia with more than 1/3 stomach located in the chest, analyzing the results reached by the miniinvasive procedure, and the long-term pathophysiologic results of the disease. DISCUSSION: Laparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally-invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced. CONCLUSION: Results from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach.

Uniportal bilateral video-assisted sequential thoracoscopic extended thymectomy.

Standard video-assisted thoracoscopic surgery has been reported as a minimally invasive approach alternative to sternotomy for management of myasthenia gravis (MG) associated with thymoma or thymic hyperplasia. Uniportal video-thoracoscopy is an evolution of standard multi-portal video-thoracoscopy for management of several thoracic diseases but its role for resecting mediastinal tumor remains under-evaluated. Herein, we describe our experience with bilateral uniportal thoracoscopic sequential extended thymectomy with case and video illustrations.

Interlobar fixation using TachoSil(®): a novel technique.

BACKGROUND: We evaluated the use of TachoSil(®) for anchoring middle lobe to lower lobe after upper right lobectomy. METHODS: The fixation of middle lobe to lower lobe was required in 39/213 consecutive upper lobectomies. In 19/39 (49%) cases, it was performed with suturing and/or stapler (standard group) and in 20 cases (TachoSil group) with Tachosil(®) alone. RESULTS: The operative time, complications, length of chest drain and hospital stay were similar between two groups. However, standard compared to TachoSil(®) group presented a higher incidence of atelectasis (5% vs. 0%, P=0.4) and air leaks (5% vs. 0%, P=0.4) but it did not reach significant difference. Our technique was safe, easy, and quick. CONCLUSIONS: Upon contact with pleura, the clotting factors of TachoSil(®) dissolved and formed a fibrin network which glued the collagen sponge to the pleura surface. It allowed to fix the middle lobe to lower lobe without restricting lung re-expansion and/or injuring the parenchyma.

Gallstone ileus without bilioenteric fistula years after bypass surgery for Crohn's disease. Case report and clues to etiology of a neglected cause of obstruction.

INTRODUCTION: Gallstone ileus is a very rare cause of bowel obstruction. Patients suffering from Crohn's disease are at increased risk of developing gallstone disease, especially when terminal ileum is involved. Gallstone ileus can occur, but etiology remains controversial. We report on a case of such a rare condition, illustrating etiology and treatments. PRESENTATION OF CASE: A patient with long-standing Crohn's disease, who had undergone ileotransverse bypass for ileocaecal involvement 40 years before, presented with cramp-like abdominal pain. Imaging was consistent with a gallstone ileus with no evidence of bilioenteric fistulae. DISCUSSION: At surgery, we found gallstones stuck at the site of ileotransverse anastomosis. No bilioenteric fistulae were found. Due to disease progression, many enteric fistulae were found, requiring a massive bowel resection. The diverted segment may have been responsible of gallstone formation, and etiology is discussed. Recovery after surgery was uneventful, but the patient required continued nutritional support. CONCLUSION: Physicians dealing with Crohn's disease patients with bypassed segments should keep in mind, the increased risk of gallstone formation, in order to not overlook gallstone ileus. Early suspect and diagnosis may allow for less aggressive approaches. A diverted segment should always be removed, and long-term follow-up encouraged.