ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group.

BACKGROUND: Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date. METHODS: This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire. RESULTS: Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. CONCLUSION: The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery.

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Critical view of safety during laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder hilar dissection since the introduction of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is therefore ideal for a safe dissection, even in less experienced hands. MATERIALS AND METHODS: We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times were examined with univariate analysis (Student t test). RESULTS: No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases. CONCLUSION: We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.

Rare cause of biliary obstruction by ascariasis associated with choledocholithiasis.

Ascariasis, the most common parasitic infestation of the gastrointestinal tract, is typical of tropical and subtropical countries. Migration of the worm to the bile ducts is rare and has been exceptionally observed in developed countries. This study reports a case of biliary ascariasis associated with gallbladder and common bile duct lithiasis observed in Italy in a 60-year-old woman originating from Senegal. The patient was treated with endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy, and antihelminthic therapy. In particular, ERCP allowed the diagnosis and the extraction of the parasite from the papilla of Vater. After a 6-month follow-up, the patient is in good condition, without signs of cholestasis in laboratory values and no dilatation of the biliary tree at abdominal ultrasound. Although biliary ascariasis is rare in Western countries, the increase in population migration makes it necessary for clinicians world-wide to consider this difficult diagnosis and to determine how to treat it in the most conservative way.

[Multilevel atherosclerotic lesions of the lower limbs. Simultaneous surgical and endovascular approach. A case report]. / Lesioni aterosclerotiche "multi-level" dell'arto inferiore. Approccio terapeutico simultaneo, chirurgico ed endovascolare. Caso clinico.

Surgical treatment of femoro-popliteal atherosclerotic occlusion usually consists in a femoro-distal bypass. However, the associated presence of proximal lesions that reduce prosthesis inflow, or of distal lesions that increase resistances may be decisive factors in determining the outcome of the revascularisation. Frequently, an iliac or common femoral artery stenosis can be treated with an endovascular technique prior to surgery, thus increasing the bypass inflow that is going to be created. On the contrary, in the case described here, the stenosis was distal to the femoropopliteal bypass and was treated with PTA + stenting, thus increasing the run-off and the theoretical long-term patency. Therapeutic indications and technical options are discussed in the light of the recent international literature and the new achievements in terms of endovascular technique.

Granular cell tumor of the male breast.

A 54-year-old male presented with a painless, hard, irregular lump in his right breast, with fixation to the pectoralis muscle. Mammography and ultrasound showed a 2.5-cm mass suspicious of malignancy. The patient underwent a wide local excision. A 2.5-cm hard, stellate lump was found and sent to the pathologist, which revealed this to be a benign granular cell tumor. Granular cell tumor of the breast is a rare neoplasm, of unknown etiology, which is benign in 98% of cases, but mimics breast cancer, causing challenging diagnostic and therapeutic dilemmas. Traditional imaging techniques do not recognize any feature specific for this tumor. Only excisional biopsy allows the detection of the distinct histological and immunohistochemical profile of the lesion (granular cytoplasm and staining for the S-100 protein). Only local surgical excision is indicated. General and senologist surgeons must be aware of this entity to avoid unnecessary mastectomy or lymphadenectomy.

Transvaginal evisceration after laparoscopic adrenalectomy in neurofibromatosis.

Transvaginal evisceration is a rare complication of hysterectomy. We describe this event following adrenalectomy for pheochromocytoma in a patient affected by neurofibromatosis. This is the first case reported in the literature following laparoscopic surgery. Prompt emergency intestinal reduction and vaginal cuff repair is required to prevent ischemia of the eviscerated bowel. Pneumoperitoneum, passage of stools, or an unknown connective tissue dysplasia due to genetic abnormalities might have contributed to this unpredictable event. The general surgeon must be aware of this rare but challenging gynecological complication.