Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results.

PURPOSE: Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature. METHODS: In March 2016, three consecutive male patients (mean age 46.6 years-mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded. RESULTS: All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6 min, ranging between 155 and 55 min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24 h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up. CONCLUSIONS: DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients' outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

Preoperative changes of forced vital capacity due to body position do not correlate with postoperative respiratory function in obese subjects.

BACKGROUND: Obese patients are at risk of developing postoperative pulmonary complications. We hypothesized that preoperative changes in dynamic spirometry due to body posture would correlate with the drop of forced vital capacity (FVC) measured early after surgery. METHODS: Thirty consecutive morbidly obese patients undergoing gastric banding were investigated. All subjects were studied the day before surgery (T0) and on postoperative day one (T1). Forced Vital Capacity (FVC) was measured, together with heart rate, mean arterial pressure and respiratory rate. At T0 measurements were taken in a random fashion with subjects in upright and in supine position. Subjects were then investigated after surgery in the supine position (T1). Postoperative pain was assessed at T1 using visual analogue scale. Intraoperative variables were also collected. RESULTS: Body Mass Index (BMI) of the investigated subjects was 43.9 ± 5.7 Kg/m2 (range 33.8-60); their age was 40 ± 8 years. All dynamic spirometric data decreased significantly from upright to supine position (P<0.05) and after surgery from 3.07 L (2.77-3.71) to 1.50 (1.15-2.12) (FVC T0 supine vs. T1, P<0.05). Changes of FVC due to body position did not correlate with changes of FVC occurring after surgery (R2=0.105, P=0.081). When subjects were stratified by the median postoperative drop of FVC (45.74%), preoperative (anthropometric and spirometric data), intraoperative (ventilatory settings and hemodynamics) and postoperative (FVC and pain) parameters were similar between groups. The duration of pneumoperitoneum was correlated with the drop of FVC (R2=0.551, P<0.05). CONCLUSION: The derangement of FVC that occurs in obese subjects after gastric banding is not predictable before surgery from anthropometric or spirometric data. The duration of pneumoperitoneum significantly contributes to postoperative impairment of respiratory function.

Increased insulin receptor substrate 2 expression is associated with steatohepatitis and altered lipid metabolism in obese subjects.

OBJECTIVE: The aim of this study was to evaluate whether dysregulation of molecules involved in FOXO1-dependent insulin signaling in the liver is associated with de novo lipogenesis (DNL) and altered lipid metabolism in severely obese subjects. DESIGN: Observational retrospective study. SUBJECTS: We considered 71 obese subjects (age 20-68 years; body mass index (BMI)>40 kg m(-2) or BMI>35 kg m(-2) in the presence of metabolic complications) classified into three groups according to liver histology: normal liver (n=12), simple steatosis (n=27) and nonalcoholic steatohepatitis (NASH; n=32). Key nodes in insulin signaling and gene expression of molecules implicated in insulin-dependent glucoregulatory pathway and DNL were evaluated by quantitative real-time PCR and western blotting. RESULTS: Patients with steatosis had decreased phosphorylation of the insulin kinase AKT1, mediating insulin receptor signaling, and the transcription factor FOXO1, which was therefore more active mediating insulin resistance at transcriptional level. Despite no changes in insulin receptor substrate (IRS)1 mRNA levels, the mRNA and protein levels of the FOXO1 target IRS2 increased progressively with the severity of steatosis from normal liver to NASH. IRS2 expression was correlated with the severity of steatosis, dyslipidemia and liver damage. In patients with NASH, upregulation of IRS2 was associated with preserved activation of AKT2, mediating the stimulating effect of insulin on DNL, and overexpression of its target sterol regulatory element-binding protein 1c (SREBP1c), inducing DNL at transcriptional level. Both FOXO1 and SREBP1c overexpression converged on upregulation of glucokinase, providing substrates for DNL, in NASH patients. CONCLUSION: Differential regulation of IRS1 and IRS2 and of their downstream effectors AKT1 and AKT2 is consistent with upregulation of FOXO1 and may justify the paradoxical state of insulin resistance relative to the glucoregulatory pathway and augmented insulin sensitivity of the liporegulatory pathway typical of steatosis and the metabolic syndrome in obese patients.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique.

AIM: With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed. METHOD: Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure. RESULTS: There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies. CONCLUSION: The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

Genetic variants regulating insulin receptor signalling are associated with the severity of liver damage in patients with non-alcoholic fatty liver disease.

BACKGROUND/AIMS: The aim of this study was to assess the effect of functional ENPP1(ectoenzyme nucleotide pyrophosphate phosphodiesterase 1)/PC-1 (plasma cell antigen-1) and IRS-1 (insulin receptor substrate-1) polymorphisms influencing insulin receptor activity on liver damage in non-alcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, whose progression is associated with the severity of insulin resistance. PATIENTS AND METHODS: 702 patients with biopsy-proven NAFLD from Italy and the UK, and 310 healthy controls. The Lys121Gln ENPP1/PC-1 and the Gly972Arg IRS-1 polymorphisms were evaluated by restriction analysis. Fibrosis was evaluated according to Kleiner. Insulin signalling activity was evaluated by measuring phosphoAKT levels by western blotting in a subset of obese non-diabetic patients. RESULTS: The ENPP1 121Gln and IRS-1 972Arg polymorphisms were detected in 28.7% and 18.1% of patients and associated with increased body weight/dyslipidaemia and diabetes risk, respectively. The ENPP1 121Gln allele was significantly associated with increased prevalence of fibrosis stage >1 and >2, which was higher in subjects also positive for the 972Arg IRS-1 polymorphism. At multivariate analysis, the presence of the ENPP1 121Gln and IRS-1 972Arg polymorphisms was independently associated with fibrosis >1 (OR 1.55, 95% CI 1.24 to 1.97; and OR 1.57, 95% CI 1.12 to 2.23, respectively). Both polymorphisms were associated with a marked reduction of approximately 70% of AKT activation status, reflecting insulin resistance and disease severity, in obese patients with NAFLD. CONCLUSIONS: The ENPP1 121Gln and IRS-1 972Arg polymorphisms affecting insulin receptor activity predispose to liver damage and decrease hepatic insulin signalling in patients with NAFLD. Defective insulin signalling may play a causal role in the progression of liver damage in NAFLD.

Gene expression analysis of early and advanced gastric cancers.

Gastric carcinoma is one of the major causes of cancer mortality worldwide. Early detection results in excellent prognosis for patients with early cancer (EGC), whereas the prognosis of advanced cancer (AGC) patients remains poor. It is not clear whether EGC and AGC are molecularly distinct, and whether they represent progressive stages of the same tumor or different entities ab initio. Gene expression profiles of EGC and AGC were determined by Affymetrix technology and quantitative polymerase chain reaction. Representative regulated genes were further analysed by in situ hybridization (ISH) on tissue microarrays. Expression analysis allowed the identification of a signature that differentiates AGC from EGC. In addition, comparison with normal gastric mucosa indicated that the majority of alterations associated with EGC are retained in AGC, and that further expression changes mark the transition from EGC to AGC. Finally, ISH analysis showed that representative genes, differentially expressed in the invasive areas of EGC and AGC, are not differentially expressed in the non-invasive areas of the same tumors. Our data are more directly compatible with a progression model of gastric carcinogenesis, whereby EGC and AGC may represent different molecular stages of the same tumor. Finally, the identification of an AGC-specific signature might help devising novel therapeutic strategies for advanced gastric cancer.

Videolaparoscopic appendectomy: the current outlook.

BACKGROUND: Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies. METHODS: Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach. RESULTS: For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h. CONCLUSIONS: Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube.

Laparoscopic adjustable gastric banding (LAGB) is a widely performed surgical procedure for morbid obesity. The application of this mini-invasive approach has given the benefits of shorter hospital stay, less postoperative pain and quicker functional recovery. LAGB complications are related either to the access-port, such as port-site infection or tubing disconnection, or to the band, such as band slippage, pouch dilatation, or intragastric migration. We report a case of recurrent small bowel obstruction caused by the connecting tube around a jejunal loop, in a woman who had under-gone LAGB 3 years before. The diagnosis was difficult to establish because the clinical history and examination were non-specific. A 3-dimensional CT scan was needed to explain the cause of the recurrent abdominal pain, and the small bowel loop was freed from the connecting tube at laparoscopy.

Multimedia article. Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature, part 2.

BACKGROUND: Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed. METHODS: From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection. RESULTS: Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%). CONCLUSIONS: Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature.

BACKGROUND: Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed. METHODS: From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection. RESULTS: Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%). CONCLUSIONS: Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature.

BACKGROUND: Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable. METHODS: Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures. RESULTS: A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications. CONCLUSIONS: Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Major vascular injuries in laparoscopic surgery.

BACKGROUND: Major vascular injuries (MVI) still occur in laparoscopic surgery. METHODS: We report our institution's experience of two MVI (aortic lesions) in a series of 3545 laparoscopies (July 1991-December 2000). We compared this experience with other series reporting MVI from Medline, Embase, Current Contents, and Best Evidence. RESULTS: There were no deaths, but we had 23 postoperative and eight intraoperative bleedings, including two hepatic vessel lesions during dissection and six vascular lesions (four minor vessels and two aortic) related to trocar insertion. Prevention and treatment options are also discussed. CONCLUSIONS: The incidence of MVI reported in the literature is 0.05%, but the true incidence is difficult to estimate because results are not always comparable and there is a possibility of underreporting. The mortality rates (8-17%) are high. No technique or instrumentation is completely safe; therefore, a high level of alertness must be maintained at all times and precautions must be adopted to avoid major complications.

Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature.

OBJECTIVES: Tracheal sleeve pneumonectomy, although technically demanding, is considered the choice for tracheobronchial angle cancers. Complications in our 49 tracheal sleeve pneumonectomies are reviewed. Results, complications, and technical aspects are critically discussed. Although series in the literature differ in selection of patients and surgical techniques and extend over long periods, we attempt to compare our experience with results from the literature. METHODS: From 1983 to September 1999, 60 patients eligible for tracheal sleeve pneumonectomy after conventional staging underwent operation. A Sybilla Fome-Cuf ventilation tube (Bivona, Inc, Gary, Ind) was used starting in 1987 to facilitate anastomosis. Since 1993, all patients have undergone video-assisted thoracoscopy immediately before the operation. RESULTS: There were 11 (18.3%) exploratory thoracotomies, 48 right tracheal sleeve pneumonectomies, and 1 left tracheal sleeve pneumonectomy. Among the tracheal sleeve pneumonectomies, we recorded 4 (8.2%) perioperative deaths (myocardial infarction, n = 1; heart failure, n = 1; pulmonary edema, n = 1; gastric ulcer hemorrhage, n = 1; and anastomotic fistula in a patient who received high-dose radiation before the operation, n = 1). We observed 5 (10.2%) complications (lung edema, n = 1; transitory recurrent nerve palsy, n = 2; empyema without fistula cured conservatively, n = 1; and pneumonia, n = 1). Anastomotic stenosis did not occur. Twenty-six (53%) patients are alive 14 to 87 months postoperatively, 12 (24.5%) of these more than 5 years postoperatively. Five (10.2%) died of mediastinal recurrence at 6 and 54 months. Two others (4.1%) died in road accidents. CONCLUSIONS: Tracheal sleeve pneumonectomy is a demanding operation with a high risk of complications. Analysis of literature and personal experience shows that complications can be greatly reduced through accurate selection of patients, precise technique, and optimal postoperative care. Long-term survival equals that obtained after standard pneumonectomy.

Videothoracoscopic approach to primary mediastinal pathology.

STUDY OBJECTIVES: Personal results and validity of videothoracoscopic (VTS) approach to primary mediastinal diseases are analyzed. DESIGN: Retrospective review of personal experience. SETTING: Department of Surgery, San Giuseppe Hospital, University of Milano, Italy. PATIENTS: From September 1991 to January 1999, of a personal series of 1,653 VTS procedures, 118 regarded primary mediastinal diseases. In 47 cases, diagnostic videothoracoscopy was performed to obtain large biopsy specimens or to carry out accurate staging; in 71 cases, full resection was anticipated. INTERVENTIONS: The patient, intubated with a double-lumen Carlen's tube and in the lateral decubitus position, underwent videothoracoscopy. Two ports and a small anterior utility thoracotomy were completed. Thorough exploration of the mediastinum and, if possible, complete resection of the lesion were accomplished. MEASUREMENTS AND RESULTS: Videothoracoscopy yielded adequate diagnosis or staging in all patients operated on for diagnostic purposes. Of 71 patients operated on with resective intent, 66 had complete thoracoscopic resection (22 stage-I thymomas, 4 thymic cysts, 21 myasthenia gravis associated with thymic hyperplasia, 19 miscellaneous tumors). Conversion was required in five cases, mostly for invasion of mediastinal structures. Complications included the following: one patient developed intraoperative bleeding controlled endoscopically, two patients experienced postoperative bleeding requiring re-thoracoscopy, and one patient had postoperative pneumonia requiring assisted ventilation. One recurrence of malignant thymoma occurred 4 years postoperatively. CONCLUSIONS: Videothoracoscopy can attain a leading role in obtaining large samples in lymphatic mediastinal diseases. Dysembriomas, schwannomas, simple cysts, and similar lesions can benefit from VTS removal. Total thymectomy for myasthenia gravis associated with thymic hyperplasia can be performed thoracoscopically. Further data and more extensive experience are needed.

Can routine laparoscopy help to reduce the rate of explorative laparotomies for gastric cancer? Laparoscopy in gastric cancer.

1. Background We developed this surgical protocol about performing intraoperative laparoscopy for staging in every patient affected by stomach cancer. Sensitivity and specificity of intraoperative laparoscopy are compared with conventional preoperative staging techniques.2. Methods From January 1994 to June 1999, 83 patients affected by stomach cancer were accepted in our department: 12 patients (14.5%) were excluded from our study after the preoperative staging; in 71 patients (85.5%) an explorative laparoscopy as the first step of the operation was performed.3. Results Laparoscopy confirmed preoperative staging in 53 cases (74.6%), in 12 patients demonstrated an overstaging. Laparoscopy demonstrated in 6 patients unsuspected causes of unresectability.4. Conclusions When performed in patients affected by malignant neoplasm and declared resectable, intraoperative laparoscopy can demonstrate conditions not detectable by traditional preoperative investigations, consequently reducing to zero explorative laparotomies.

False radiographic appearance of a right bronchial stump following extended right pneumonectomy.

The authors describe three cases in which postoperative frontal chest radiographs following extended right pneumonectomy showed a right hilar lucency producing the false appearance of a residual main bronchus that is shown by additional studies to represent a dilated esophagus.

Techniques of pneumonectomy. Video-assisted thoracic surgery pneumonectomy.

Thoracoscopic major pulmonary resections such as lobectomies or pneumonectomies are the most difficult operations that can be attempted thoracoscopically, and still have limited routine application in thoracic surgical practice. The precise indications for thoracoscopic pneumonectomy are very rare and have not yet been defined precisely; we limited the procedure only to double tumors, small tumors infiltrating the fissure, and small tumors at the secondary carina not amenable to a bronchoplasty procedure. Although the technique still has very limited applications, the advantages include reduced surgical trauma and consequent minimal postoperative pain, a shortened hospital stay, and a rapid resumption of normal activities which ultimately reduces costs. Wider acceptance, larger series, and a more extensive follow-up will assess the role of thoracoscopic anatomical lung resection in modern thoracic surgical practice.

Video-assisted thoracoscopic surgery (VATS) major pulmonary resections: the Italian experience.

Videoendoscopic lobectomies or pneumonectomies are infrequently performed, mostly because of technical difficulties, concern for intraoperative accidents, and radicality in case of malignancy. The work diffusely describes technical details and a personal experience of videothoracoscopic major pulmonary resections (MPRs). All patients are first explored thoracoscopically. The procedure can then be completed thoracoscopically or converted. Videothoracoscopic exploration was performed in 211 candidates to MPR. Six patients' cases became nonresectable owing to pleural carcinomatosis or mediastinal infiltration, 171 patients completed a thoracoscopic MPR (165 lobectomies and 6 pneumonectomies), and 34 required conversion for technical (20) or oncological (10) reasons. Video MPRs were performed for benign disease (24), for lung metastases (5) and for preoperatively staged T1N0 or T2N0 primary lung cancer (142). No perioperative mortality was recorded. In 154 patients (90%), postoperative course was uneventful. One patient died after 33 days because of contralateral pneumonia; 15 elderly patients had prolonged air leaks. One patient developed partial dehiscence of the bronchial stump (healed conservatively) after a severe respiratory insufficiency on his third postoperative day had required mechanical ventilation. Even though video MPR can present remarkable difficulties, its undeniable advantages will benefit from further improvement of instrumentation. In case of tumors, larger series and longer follow-up will allow evaluation of long-term survival and local recurrence.

Videothoracoscopic treatment of oesophageal leiomyoma.

BACKGROUND: Oesophageal leiomyomas are usually so easily removed that thoracotomy seems out of proportion and thoracoscopic removal is therefore highly desirable. METHODS: Out of a total of 1003 thoracoscopic operations undertaken between July 1991 and December 1996, seven patients underwent thoracoscopic removal of oesophageal leiomyoma. All of them had been preoperatively studied by oesophagogastroscopy and computed tomographic scanning of the chest which had confirmed the presence of a lesion with benign features. The surgical technique required intubation with a double lumen tube. Operative access was gained through the right chest via three ports and a small utility thoracotomy in the inframammary sulcus. The mean operating time was 120 minutes. RESULTS: Conversion to open thoracotomy was necessary in one case with a very large horseshoe-shaped leiomyoma which was firmly adherent. The mean postoperative hospital stay was seven days. No intraoperative deaths or postoperative complications occurred. CONCLUSIONS: The simplicity and safety of the thoracoscopic approach, combined with reduced surgical trauma and postoperative pain and functional and cosmetic advantages, make this technique the approach of choice for the removal of oesophageal leiomyomas.