Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center.

BACKGROUND: Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC. METHODS: A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length. RESULTS: Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm). CONCLUSIONS: No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy.

Occult papillary thyroid microcarcinoma manifesting only as a symptomatic lateral cervical mass: report of a case.

We report a case of occult papillary thyroid carcinoma (PTC) manifesting as a solitary lateral cervical mass. Few such cases have been reported and, to our knowledge, this is the first report of cervical lymph node involvement from thyroid cancer being so massive that it is the cause of the local symptoms. The patient, a 64-year-old man, presented with vocal cord paralysis and voice alteration and was found to have a 4 cm lateral cervical mass infiltrating the ipsilateral internal jugular vein and recurrent laryngeal nerve. The diagnosis of PTC was made preoperatively following an open-biopsy of the lesion. The patient underwent total thyroidectomy with modified radical neck dissection, followed by radioactive iodine therapy. His postoperative course was uneventful and he remains well without any signs of recurrence 7 years after the operation.

Rives technique is the gold stardard for incisional hernioplasty. An institutional experience.

AIM: We report our clinical experience with incisional hernia surgery and we retrospectively analyze the outcomes obtained with the different techniques of repair used, confirming that Rives-Stoppa procedures actually represent the gold standard for incisional hernia. MATERIAL OF STUDY: 334 patients were observed for incisional hernioplasty at our Department of Surgery from 1996 to 2007. They were treated according to the following surgical procedures: 44 primary direct closures; 246 Rives-Stoppa procedures; 9 Chevrel procedures; 35 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications. RESULTS: In total, we had 13 cases of hernia recurrence (3.9%), 14 cases of infections (4.2%), 7 cases ofseroma/hematoma (2.9%) and one case of acute respiratory insufficiency. DISCUSSION: The choice of the surgical technique depends on several factors, such as the size of the hernia defect and the representation of the anatomical structures, essential for the reconstruction of the abdominal wall. We abandoned Chevrel technique due to high rate of recurrence and infective complications and reserved the intra-peritoneal repair only for cases where a fascial layer could not be reconstructed. Instead, the primary direct closure should be considered for high risk patients because of its low surgical impact, although it is characterized by higher incidence of recurrence. Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable results in terms of recurrence rate and morbidity. CONCLUSIONS: Rives-Stoppa procedures are the current standard of care for the surgical repair of incisional hernia and our treatment of choice.

Is minimally invasive surgery appropriate for small differentiated thyroid carcinomas?

PURPOSE: To retrospectively evaluate the surgical completeness of minimally invasive total thyroidectomy for small (<20 mm) differentiated thyroid carcinoma (DTC). METHODS: The subjects of this study were 30 patients who underwent minimally invasive total thyroidectomy as a single procedure. We registered the following postoperative measurements in the LT4 withdrawal period: serum thyroglobulin level, 6-h radioiodine uptake diagnostic test results, and neck ultrasound (US) findings. RESULTS: The mean serum thyroglobulin level was 4.99 +/- 4.67 ng/ml, the mean radioiodine uptake diagnostic test after 6 h was 3.11% +/- 2.90%, and US showed no thyroid remnant. CONCLUSIONS: The short-term outcome measures showed adequate resection of thyroid tissue, comparable with that reported after conventional surgery. Our findings suggest that small nodules with suspicious or malignant cytology are one of the best indications for minimally invasive surgery.

Outpatient repair for inguinal hernia in elderly patients: still a challenge?

BACKGROUND: Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. METHODS: Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. RESULTS: There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. CONCLUSIONS: Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment.

An unexpected case of giant hiatal hernia and review of literature. GHH: case report and literature review.

INTRODUCTION: The management of giant hiatal hernia remains one of the most complicated surgical challenge and several operative approaches have been proposed during the years. Currently, the most practiced is the laparoscopic approach, which adds functional outcomes overlapping those of the conventional open surgery to the own advantages of the technique. The main problem of this operation is the high rate of recurrence, occurring independently by the specific technique adopted. PRESENTATION OF CASE: An unexpected case of giant hiatal hernia, incidentally discovered in a patient candidate to cholecystectomy for gallstones, is presented. We describe the surgical procedure performed and our cornerstones for a correct and long-lasting hiatal hernia repair, comparing us with the current standards of care. DISCUSSION: Laparoscopy has facilitated the execution of some surgical steps, such as the hiatal visualization and the intra-thoracic esophagus mobilization, fundamental for the success of the operation. Inheriting the concept of tension free repair, the use of mesh reinforcing the hiatal defect is being encouraged, especially biologic meshes, although some authors warn their employment may introduce potential catastrophic complications for patient. CONCLUSION: Laparoscopy should be the approach of choice, whenever possible, to treat this condition, while the use of supportive prosthetic devices depends on the single patient's hernia characteristics and on the surgeon's personal experience and preferences. Anyways, many factors determine the final outcomes of the surgical intervention, some of which patient dependent, others operator-dependent but, independently from the approach adopted, this operation is often burdened by a high risk of recurrence.