Neuromuscular and cardiac adverse events associated with immune checkpoint inhibitors: pooled analysis of individual cases from multiple institutions and literature.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the management of multiple tumors, due to improved efficacy, quality of life, and safety. While most immune-related adverse events (irAEs) are mild and easily managed, in rare cases such events may be life-threatening, especially those affecting the neuromuscular and cardiac system. The management of neuromuscular/cardiac irAEs is not clear due to the lack of consistent data. Therefore, we carried out a pooled analysis of collected cases from selected Italian centers and individual data from published case reports and case series, in order to improve our understanding of these irAEs. PATIENTS AND METHODS: We collected retrospective data from patients treated in six Italian centers with ICIs (programmed cell death protein 1 or programmed death-ligand 1 and/or cytotoxic T-lymphocyte antigen 4 inhibitor) for any solid tumor who experienced neuromuscular and/or cardiovascular toxicity. Then, we carried out a search of case reports and series of neuromuscular/cardiac irAEs from ICIs with any solid tumor. RESULTS: This analysis includes cases from Italian institutions (n = 18) and the case reports identified in our systematic literature search (n = 120), for a total of 138 patients. Among these patients, 50 (36.2%) had complete resolution of their neuromuscular/cardiac irAEs, in 21 (15.2%) cases there was a clinical improvement with mild sequelae, and 53 (38.4%) patients died as a result of the irAEs. Factors significantly associated with worse outcomes were early irAE onset, within the first two cycles of ICI (Fisher P < 0.0001), clinical manifestation of both myositis and myocarditis when compared with patients who developed only myositis or myocarditis (chi-square P = 0.0045), and the development of arrhythmia (Fisher P = 0.0070). CONCLUSIONS: To the best of our knowledge, this is the largest collection of individual cases of immune-related myocarditis/myositis. Early irAE onset, concurrent development of myositis and myocarditis, as well as occurrence of arrhythmias are associated with worse outcomes and should encourage an aggressive immunomodulatory treatment.

The predictive and prognostic role of single nucleotide gene variants of PD-1 and PD-L1 in patients with advanced melanoma treated with PD-1 inhibitors.

Background: Despite having revolutionized the treatment paradigm for advanced melanoma, not all patients benefit from immune checkpoint inhibitor therapy. To date, there are no predictive biomarkers for response or the occurrence of immune-related adverse events (irAEs) to programmed cell death protein 1 (PD-1) inhibitors. Our aim was to investigate the predictive and prognostic role of single nucleotide variants (SNVs) of genes involved in the PD-1 axis. Methods: We analysed, in metastatic melanoma patients treated with nivolumab or pembrolizumab, five PD-1 SNVs, namely PD1.3 G>A (rs11568821), PD1.5 C>T (rs2227981), PD1.6 G>A (rs10204525), PD1.7 T>C(rs7421861), PD1.10 C>G (rs5582977) and three programmed death-ligand 1 (PD-L1) SNVs: +8293 C>A (rs2890658), PD-L1 C>T (rs2297136) and PD-L1 G>C (rs4143815). Association of SNV genotypic frequencies with best overall response to PD-1 inhibitors and development of irAEs were estimated through a modified Poisson regression. A Cox regression modelling approach was applied to evaluate the SNV association with OS. Results: A total of 125 patients with advanced melanoma were included in the analysis. A reduction in irAEs risk was observed in patients carrying the PD-L1 +8293 C/A genotype compared with those carrying the C/C genotype (risk ratio = 0.45; 95% CL 0.22-0.93; P = 0.031). A trend for a reduction in irAEs was also observed with the PD1.5 T allele (risk ratio = 0.70, 95% confidence limits 0.48-1.01 versus C allele). None of the SNVs was associated with response to therapy. Finally, a survival benefit was observed in patients harbouring the PD1.7 C/C genotype (hazard ratio = 0.37; 95% confidence limits 0.14-0.96; P = 0.028) in the homozygous model. Conclusions: Our study showed that PD-1.5 and PD-L1 +8293 SNVs may play a role as a predictive biomarker of development of irAEs to PD-1 inhibitors. PD1.7 SNV may also be associated with a reduction of the risk of death, although further translational research is needed to confirm these results.

Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review.

BACKGROUND: Although depression and mood-related disorders are common in persons with cancer, these conditions remain frequently overlooked in clinical practice. Negative consequences of depressive disorder spectrum have been reported (e.g. suicidal ideation, increase physical complications and somatic symptoms, negative influence on prognosis), indicating the need for routine screening, assessment and management. METHODS: A search of the major databases (Medline, Embase, PsycLIT, PsycINFO, and the Cochrane Library) was conducted on the reviews and meta-analyses available in order to summarize relevant data concerning depressive disorders spectrum in terms of prevalence, risk factors, and screening and assessment among patients with cancer across the trajectory of the disease. RESULTS: The data show a prevalence of depression and depressive disorders between 5% and 60% according to the different diagnostic criteria, the tools used in the studies (e.g. semi-structured psychiatric interview and psychometric questionnaires), as well as the stage and type of cancer. Furthermore, despite the significant health care resources devoted to cancer care and the importance of addressing depressive symptoms, assessment and management of depressive spectrum disorders in cancer patients remains suboptimal. CONCLUSIONS: Routine screening and adequate assessment of depressive spectrum disorders is necessary in patients with cancer in order to effectively manage the multifaceted and complex consequences on cancer care.

MULTINDELS-BOV: Zebu traceback method based on DNA insertion-deletion polymorphisms.

Brazil is a major producer and exporter of beef, with a herd of approximately 210 million animals. For the meat industry, a reliable animal traceback from its origin to the consumer market is paramount. Of all available identification systems, DNA is the only one that survives the slaughterhouse and reaches the dish of the consumer. DNA polymorphisms are already used for cattle traceback, but primarily for the subspecies Bos taurus taurus. However, in Brazil, another subspecies, B. taurus indicus predominates. We describe here the development of a DNA traceback method designed primarily for B. taurus indicus (Zebu), without leaving B. taurus taurus aside. We used insertion/deletion (indel) polymorphisms, which have the advantage of being simple and easily automatable, since in most cases, the variable loci are biallelic. We studied 94 indels, with a difference of two or more base pairs, in DNA pools of 60 Zebu and 60 taurine animals. A set of 22 indels with heterozygosity greater than 0.3 were selected and used to construct two multiplex PCRs. On the basis of the allelic frequency of these indels, the probability of random match was calculated to be 1.12 x 10(-8) for B. taurus indicus and 1.60 x 10(-6) for B. taurus taurus. Moreover, we estimated that an analysis would cost less than US$15.00 per animal. Thus, this system (MULTINDELS-BOV) is perfectly suited for building large genetic databases and offering viable prospects of a national system for cattle traceback DNA in Brazil.

[Duplication of hospitalizations of nursing home residents from 2007 to 2009--a retrospective analysis]. / Verdoppelung der Hospitalisationen von Pflegeheimpatienten von 2007 bis 2009 - eine retrospektive Analyse.

AIM: To demonstrate why the number of hospitalizations of nursing home residents has doubled although several studies have established that hospitalizations do not diminish their mortality rate. METHODS: Retrospective analysis of medical databasis from 815 patients of the eight nursing homes of Zürich, thereof 180 were hospitalized in 2007, 234 in 2008 and 401 in 2009. The reasons for a hospitalization have been classified in nine categories. RESULTS: The category "fall with fractures" with a proportion of 29% contributes most to the augmentation of hospitalizations, followed by the categories "ambiguous condition" with 24% and "improving quality of life" with 17%. Hospitalizations for the sustained optimization of quality of life explain 62% of the increased hospitalization rate. CONCLUSION: Nursing home residents are not hospitalized to keep them longer alive, but to optimize their quality of life.

Emergency laparoscopic treatment of acute incarcerated incisional hernia.

BACKGROUND: The emergency treatment of incisional hernias can be accomplished by a laparoscopic approach in order to avoid the common complications following open techniques. METHODS: From January 2001 to September 2007, we performed 48 emergency laparoscopic treatments of incarcerated hernias. RESULTS: In our hospital, 320 patients with incisional hernia and 65 patients with primary abdominal wall hernia were treated laparoscopically. Forty-eight patients (30 females and 18 males) underwent emergency surgery. The mean operative time was 62 min (range 45­80 min). The average length of hospital stay was 4 days (range 3­6 days). We had eight post-surgical seromas, all of which were treated successfully by needle aspiration. We saw no mesh sepsis and no metabolic or surgical complications. We had no recurrence nor the need for a second operation. Mortality was nil. CONCLUSIONS: The results of this series prove the feasibility of emergency laparoscopic surgery in incarcerated incisional hernias using new-generation meshes.

Polymorphisms of steroid 5-alpha-reductase type I (SRD5A1) gene are associated to peripheral arterial disease.

Although animal studies support the hypothesis that androgenic biological actions may affect experimental atherosclerosis progression, evidence for a relationship between androgen effects and peripheral arterial disease (PAD), a common clinical form of atherosclerosis, is weak or contradictory. Testosterone, the main androgen hormone, is converted in a 5alpha-reduced form by enzymatic activities in the target cells and some specific actions are mediated by such metabolites. Steroid 5-alpha reductase isoenzymes (SRD5A1 and SRD5A2) catalyze the conversion to the bioactive potent androgen dihydrotestosterone and other reduced metabolites and represent relevant regulators of local hormonal actions. In the present study we tested for the association of selected single nucleotide polymorphisms (SNP) of SRD5A1 and SRD5A2 with symptomatic PAD patients. Two different SNP in the SRD5A1 were significantly associated which the PAD phenotype (p<0.03, odds ratio 1.73), while no association was found between PAD phenotypes and SRD5A2. Since the examined SRDA1 gene variant was previously associated with a low enzymatic activity, we suggest that a decreased local enzymatic conversion of testosterone may contribute to PAD genetic susceptibility.

Hepatic artery aneurysm rupture in a woman with primary antiphospholipid syndrome.

Primary antiphospholipid syndrome (APS) is associated with arterial and venous thrombosis. However, a small number of patients present with visceral aneurysms. Although such aneurysms are rare, their presence in patients who are usually treated with lifelong anticoagulation raises important therapeutic problems, in view of the risk of aneurysm rupture and acute abdominal hemorrhage. We report the case of a young woman with APS who presented with abdominal bleeding due to ruptured common hepatic artery aneurysm. She was successfully treated by proximal ligation. The features of such aneurysms are discussed.

Use of fibrin glue (Tissucol) as a hemostatic in laparoscopic conservative treatment of spleen trauma.

BACKGROUND: This study aimed to evaluate the effect of fibrin glue in laparoscopic spleen-preserving procedures for traumatic rupture. METHODS: From January 2002 to December 2005, six laparoscopic spleen-preserving procedures were performed for traumatic rupture using fibrin glue. Two of the cases had previous middle and lower abdominal surgery. Survey of the abdominal cavity was performed by inserting two 5- to 12-mm trocars, one 5-mm trocar, and a 30 degree scope. A complete survey of all the patients was performed. RESULTS: None of the patients required laparotomy, and no postoperative bleeding occurred. The fibrin sealant achieved immediate hemostasis, and all the patients recovered without further splenic bleeding. The mean postoperative stay was 4.3 days (range, 4-5 days). All the patients were followed up for 3 to 12 months. Postoperative immunoglobulin scanning, ultrasonography, and computed tomography (CT) results were normal. CONCLUSIONS: Laparoscopic management of spleen trauma can be used once a positive diagnosis has been made. It is useful for assessing the degree of splenic injury. A laparoscopic spleen-preserving procedure can be used safely for patients with stable vital data. It is an effective procedure for the evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial. The topical application of a fibrin sealant in splenic trauma achieves definitive hemostasis safely, rapidly, and reliably. It also is simple to use in either laparoscopic or open procedures.

Laparoscopic versus open incisional hernia repair: an open randomized controlled study.

BACKGROUND: Incisional hernia is a common complication of abdominal surgery, and it is often a source of morbidity and high costs for health care. This is a case-control study to compare laparoscopic versus anterior-open incisional hernia repair. METHODS: 170 patients with incisional hernia were enrolled in this study between September 2001 and December 2004. Of these, 85 underwent anterior-open repair (open group: OG), and 85 underwent laparoscopic repair (laparoscopic group: LG). The clinical outcome was determined by a median follow-up of 24.0 months for LG and OG. RESULTS: No difference was noticed between the two groups in age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and incisional hernia diameter. Mean operative time was 61.0 min for LG patients and 150.9 min for OG patients (p < .05). Mean hospitalization was 2.7 days for LG patients and 9.9 days for OG patients (p < .05). Mean return to work was 13 days (range, 6-15 days) in LG patients and 25 days (range, 16-30 days) in OG patients. Complications occurred in 16.4 % of LG patients and 29.4 % of OG patients, with a relapse rate of 2.3% in LG and 1.1% in OG patients. CONCLUSIONS: Short-term results indicate that laparoscopic incisional hernia repair is associated with a shorter operative time and hospitalization, a faster return to work, and a lower incidence of wound infections and major complications compared to the anterior-open procedure. Further studies and longer follow-up are required to confirm these findings.

Use of fibrin glue (Tissucol) in laparoscopic repair of abdominal wall defects: preliminary experience.

INTRODUCTION: The aim of this study was to establish the efficacy and tolerability of human fibrin glue (Tissucol) for the nontraumatic fixation of a composite prosthesis (Parietex) in the laparoscopic repair of small to medium-sized incisional hernias and primary defects of the abdominal wall. MATERIALS AND METHODS: From October 2003 to October 2005, 40 patients underwent laparoscopic repair at the hands of one surgeon with expertise in laparoscopic surgery; all meshes were implanted in an intraperitoneal position. Follow-up visits were scheduled for 7 days and 1, 6, and 12 months. These included assessments for pain and postoperative complications. RESULTS: Forty patients (24 females, 16 males) with a mean age of 50 years (range, 26-65 years) and a mean Body Mass Index (BMI) of 27 (range 25 to 30) were included in the study. Sixteen patients had incisional hernias, and 24 had primary defects. The size of the defects varied from 2 to 7 cm. Adhesiolysis was necessary in 92.5% of cases (25/40). There were no intraoperative complications or conversions. After a mean follow-up of 16 months (range, 3-24 months), no postoperative complications were observed. The mean surgical intervention time was 36 min (range, 12-40 min), with an average hospitalization time of 1 day. CONCLUSIONS: The use of fibrin glue in the present study provided stable and uniform fixation of the prosthesis and minimized intraoperative and postoperative complications. Consequently, laparoscopic treatment of small to medium-sized abdominal defects using this approach is our therapeutic option of choice.

Fibrin glue for mesh fixation in laparoscopic transabdominal preperitoneal (TAPP) hernia repair: indications, technique, and outcomes.

BACKGROUND: The efficacy and safety of prosthesis fixation were studied by means of fibrin glue (Tissucol, Baxter Healthcare) during laparoscopic transabdominal preperitoneal (TAPP) treatment of inguinal and femoral hernias. METHODS: Between September 2001 and December 2004, fibrin glue was used for mesh fixation during TAPP. RESULTS: In this study, 320 hernias were treated for 230 patients (225 men and 5 women) with an average age of 45 years (range, 20-75 years). No perioperative complications were observed. After an average follow-up period of 26 months (range, 1-40 months), the only postoperative complications observed were six seromas (1.8%) and one trocar-site hematoma (0.3%). The mean operating time was 30 min for unilateral hernias and 50 min for bilateral hernias, whether primary or recurrent. Patients usually were discharged the day after surgery and returned to work after 5 days. CONCLUSIONS: The authors' experience demonstrates that fibrin glue (Tissucol) is an effective method for mesh fixation during TAPP.

Prospective clinical study of laparoscopic treatment of incisional and ventral hernia using a composite mesh: indications, complications and results.

The aim of this study is to establish the indications, safety, efficacy, feasibility and reproducibility of the laparoscopic technique in treating defects in the abdominal wall, including those of large dimensions, to standardise the surgical technique and to confirm the performance of the composite prosthesis used (Parietex, Sofradim). The study encompassed the period from January 2001 to December 2004 and included 178 nonselected patients (108 women and 70 men), with an average age of 56 years (range: 26-77 years) and an average body mass index (BMI) of 30 (range: 26-40). These patients were treated for either abdominal hernia (156 patients; 89.7%) or a primary defect (22 patients; 10.3%). The dimensions of the abdominal hernias treated varied from 4 to 26 cm (average: 12.1 cm). All patients were treated using the laparoscopic technique, and all meshes were placed in the intraperitoneal position. Eleven (7%) postoperative complications arose after an average follow-up period of 29 months (range: 1-48 months): seven seromas (4.4%) lasting for 4 weeks, with one becoming infected after being punctured repeatedly; we removed the infected prosthesis by laparoscopy; three (1.9%) patients with persistent neuralgia, which were resolved after 2 months with a prescription for FANS; one patient with a haematoma at the trocar site. There were also four recurrences (2.5%), all of which occurred between 1 and 3 months postsurgery: one in the 'small' group of abdominal hernias (less than 9 cm) and three in the 'large' group of abdominal hernias. With the exclusion of any primary defects, an adhesiolysis was carried out in 99.3% of the patients. In seven cases (4.4%) we carried out a raphe for speritonealisations of loops in the small intestine; in four patients (2.5%), following tenacious adhesion (one patient) and loops fixed to the previous scar by stitches (three patients), we carried out an intestinal perforation (ileus) which was sutured by laparoscopy. The average operating time was 65.6 min (range: 28-130 min), with an average postoperative period in the hospital of 2.1 days (range: 1-5 days). No conversion was observed, and mortality was zero. The results obtained during the clinical trial demonstrate the safety and efficacy of the laparoscopic technique and of the mesh used as well as the reproducibility of the technique in the intraperitoneal treatment of congenital and postincision defects in the abdominal wall, including those of large dimensions.

Laparoscopic versus open appendectomy in acute appendicitis: a randomized prospective study.

BACKGROUND: Laparoscopic appendectomy is a safe and effective procedure, as both a diagnostic and therapeutic tool. It seems to be more effective than the corresponding open procedure. Aim of this study is to evaluate a group of patients randomly allocated either to laparoscopic appendectomy (LA) or to open appendectomy (OA). METHODS: From January 1998 to December 2002, 252 consecutive and nonselected patients, 155 women and 97 men, were randomized either to LA or OA. Recorded data were operative time, postoperative length, of stay and complications. RESULTS: Mean operative time was 45 min (range 30-120) for OA and 36 min (25-60) for LA, mean postoperative stay was 5.5 days (4-12) for OA and 3.4 days (2-8) for LA. Complication occurred in 20 patients (14.5%) for OA and in four patients (2.6%) for LA. CONCLUSION: We believe that LA is effective in any kind of clinical situation, with low traumatic impact and best comfort for the patient.

[Laparoscopic transabdominal preperitoneal repair of inguinal hernia: indications, technique, complications and results in 10 years experience]. / Ernioplastica inguinale transaddominale preperitoneale laparoscopica. Indicazioni, tecnica, complicanze dopo 10 anni di esperienza.

AIM: Inguinal hernia play a major role in a general surgical division. In the last 10 years laparoscopy has gained a key role even in the treatment of this disease. This study aims to review a single institution's experience with laparoscopic transabdominal preperitoneal repair of inguinal hernia (TAPP). METHODS: A retrospective study of 715 operations in 500 patients from 1992 to September 2002. Two hundred and eight six (56.6%) of these were monolateral hernias and 214 (43.4%) were bilateral while 215 (30%) were recurrent. RESULTS: Of 214 operations recurrence rate was 0.43 with a mean operating time of 30 min (range 25-50) for monolateral hernias and of 70 min (range 45-120) for bilateral hernias. Mean length of stay was 2 days (range 1-10). Return to work occurred in 6 days while sports were resumed after 10 days. Complications occurred in 40 (8.6%) patients with only 2 (0.4%) major complications. Mean follow up time was 58.3 months. CONCLUSION: According to personal experience, and in agreement with international literature, laparoscopy showed to be effective mostly in treating bilateral and recurrent hernias, particularly for faster recovery and less postoperative pain compared to traditional techniques.

Laparoscopic liver resection with radiofrequency.

BACKGROUND/AIMS: In this report, the feasibility, efficacy and safety of laparoscopic liver resection with radiofrequency has been evaluated in a small series of patients. METHODOLOGY: From January 1993 to May 2002 we carried out 7 laparoscopic liver resections (3 men and 4 women), five of which were for benign pathology and two for metastases from colorectal cancer. In four of the above resections we used an argon coagulator; the last three were accomplished by means of a radiofrequency instrument. RESULTS: We had no perioperative or postoperative complications in this small series of patients. There were no deaths. Perioperative blood loss was of 120 mL (range 80-200) and the procedure took about 90 minutes (range 80-110). Hospitalization was of 4 days and pain was adequately controlled by 2 mL of Toradol twice a day. CONCLUSIONS: We think that the advantages of laparoscopic techniques together with the efficacy of the radiofrequency instrument in hepatic surgery will allow the diffusion of this method and its extension to safe execution of major resections.

The role of diagnostic tests in therapeutic choices for gastroesophageal reflux disease.

Gastroesophageal reflux disease has different clinical presentations that require different diagnostic and therapeutic approaches. This paper describes the appropriate use of diagnostic tests before and after treatment. Each diagnostic tool is examined from a practical point of view to determine the information it can provide and its possible pitfalls, and to comment on how it can influence therapeutic choices. Performing a preoperative diagnostic evaluation is especially stressed, so as not to select the wrong patient or the wrong procedure. Finally, failures of surgery are examined to understand their causes and to prevent them. The value of the most relevant examinations for diagnosing the causes of failures and choosing the appropriate solution are discussed.

Laparoscopic colectomy: indications, standardized technique and results after 6 years experience.

BACKGROUND/AIMS: The aim of the present study was to perform a retrospective study of our experience in performing laparoscopic colon surgery after 6 years experience. METHODOLOGY: From April 1992 to April 1998, 215 patients underwent colon laparoscopic surgery. There were 121 females and 94 males, whose average age was 66.7 (range: 31-92). RESULTS: 170 laparoscopic procedures were completed out of 215 (79%): 151 resections (22 for a benign lesion and 129 for a malignant one), 4 reversal of Hartmann's procedures, 6 rectopexy, 3 ileotransverstomies and 6 suture of traumatic colon perforation. There were 3 mortalities out of 215 (1.9%). The conversions were 45 out of 215 (20.9%); 22 (10.2%) cases were, however, converted to a laparoscopic facilitated procedure. The most common causes for conversion were the presence of bulky tumors and/or tumors that contaminated the adjacent structures (16/215), adhesions due to previous operations (9/215) and the patient's obesity (8/215). There were 39 complications (18.1%), 10 (4.6%) out of which required reoperation (2 anastomotic fistula, 2 anastomotic leak, 2 anastomotic stenosis, 2 hemorrhage, 1 colic iatrogenic perforation and 1 occlusion to rotation of anastomosis). There were only 2 recurrences (1.3%), 15 months (C2) and 8 months (B2) after the operation for intraoperative technical error. The average number of lymph nodes harvested in resected specimens was 12.8 (range: 1-41), whereas the mean distance of the tumor from the proximal margin of resection was 11.5 cm (range: 5-35), and from the distal margin 7.5 cm (range: 1-25). The average operative time was 165 min (range: 40-360), and the mean hospital stay was 9.2 days (range: 6-40). CONCLUSIONS: A colon resection for a malignant lesion, if performed with the highest respect for the oncologic principles, proves that it is impossible to develop a wall and intraluminal recurrence, which, in our opinion, may be caused by an improper surgical technique. Therefore, neoplastic colon laparoscopic surgery must be the perogative of a few selected and specialized centers.

Mini-invasive surgery may be advised in oncology.

In the last decade mini-invasive surgery has consistently developed with good results, but also with some unjustified clinical applications. This review is aimed at defining evidence based indications and procedures ('clinical practice') and those still worthy of controlled studies in oncologic centers with expertise in mininvasive surgery ('clinical research'). At present, diagnostic and staging laparoscopy and thoracoscopy represent the 'standard' for different tumors. Conversely, therapeutic indications according to evidence based medicine criteria are still limited. Tumors treatment by mini-invasive surgery requires 'expertise' on the part of the surgical team; this can be achieved by extensive training of a correct use of instruments and methods following the general surgical principles of traditional 'open surgery'.

Intracorporeal knot-tying and suturing techniques in laparoscopic surgery: technical details.

BACKGROUND: Intracorporeal suturing and knot-tying in laparoscopic surgery require great manual dexterity; these techniques must absolutely be mastered by every surgeon who is interested in pursuing the minimally invasive approach. METHOD: The initial and final knot of a laparoscopic continuous suture can be accomplished in several ways and with easy technical solutions that are fully illustrated in the present study. CONCLUSION: We think it is better to perform a continuous suture than an interrupted one. It is advisable, moreover, to use traditional suture materials (not specially created for laparoscopy) that cost less than the more sophisticated ones.