Enhancing visualization and guidance in general surgery: a comprehensive and narrative review of the current cutting-edge technologies and future perspectives.

BACKGROUND: In the last decade, there has been a great effort in developing new technologies to enhance surgical visualization and guidance. This comprehensive and narrative review aimed to provide a wide and extensive overview of the current state of the art on this topic and their near-future perspectives linked to the development of artificial intelligence (AI), by focusing on the most recent and relevant literature. METHODS: A comprehensive and narrative review of the literature was performed by searching specific terms on PubMed/MEDLINE, Scopus, and Embase databases, assessing the current state of the art on this topic. RESULTS: Fluorescence-guided surgery, contrast-enhanced ultrasound (CEUS), ultra-high frequency ultrasound (UHFUS), photoacoustic imaging (PAI), and augmented reality (AR) are boosting the field of image-guided techniques as the rapid development of AI in surgery is promising a more automated decision-making and surgical movements in the operating room. CONCLUSION: Fluorescence-guided surgery, CEUS, UHFUS, PAI, and AR are becoming crucial to give surgeons a new level of information during the intervention, with the right timing and sequence, and represent the future of surgery. As many more controlled studies are needed to validate the employment of these technologies, the next generation of surgeons must become more familiar with the basics of AI to better incorporate new tools into the daily surgical practice of the future.

Preventing iatrogenic ureteral injury in colorectal surgery: a comprehensive and systematic review of the last 2 decades of literature and future perspectives.

Iatrogenic ureteral injury (IUI) during colorectal surgery is a rare complication but related to a serious burden of morbidity. This comprehensive and systematic review aims to provide a critical overview of the most recent literature about IUI prevention techniques in colorectal surgery. We performed a comprehensive and systematic review of studies published from 2000 to 2022 and assessed the use of techniques for ureteral injury prevention and intraoperative localization. 26 publications were included, divided into stent-based (prophylactic/lighted ureteral stent and near-infrared fluorescent ureteral catheter [PUS/LUS/NIRFUC]) and fluorescent dye (FD) groups. Costs, the percentage and number of IUIs detected, reported limitations, complication rates and other outcome points were compared. The IUI incidence rate ranged from 0 to 1.9% (mean 0.5%) and 0 to 1.2% (mean 0.3%) in the PUS/LUS/NIRFUC and FD groups, respectively. The acute kidney injury (AKI) and urinary tact infection (UTI) incidence rate ranged from 0.4 to 32.6% and 0 to 17.3%, respectively, in the PUS/LUS/NIRFUC group and 0-15% and 0-6.3%, respectively, in the FD group. Many other complications were also compared and descriptively analyzed (length-of-stay, mortality, etc.). These techniques appear to be feasible and safe in select patients with a high risk of IUI, but the delineation of reliable guidelines for preventing IUI will require more randomized controlled trials.

Endoscopic failure for foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: an updated analysis in a European tertiary care hospital.

OBJECTIVE: Harmfulness of foreign body ingestion and food bolus impaction (FBIs) varies according to geographical area, population, habits, and diet. Therefore, studies may not draw generalizable conclusions. Furthermore, data regarding FBIs management in Europe are limited and outdated. This study aimed to analyze the endoscopic management and outcomes of FBIs in an Italian tertiary care hospital to identify risk factors for endoscopic failure. METHODS: We retrospectively reviewed patients who underwent upper gastrointestinal endoscopy for FBIs between 2007 and 2017. Baseline, clinical, FBIs, and endoscopic characteristics and outcomes were collected and reported using descriptive statistics and logistic regression analyses. RESULTS: Of the 381 endoscopies for FBIs, 288 (75.5%) were emergent endoscopy and 135 (35,4%) included underlying upper gastrointestinal conditions. The study population included 44 pediatric patients (11.5%), 54 prisoners (15.8%), and 283 adults (74.2%). The most common type and location of FBIs were food boluses (52.9%) and upper esophagus (36.5%), respectively. While eight patients (2.1%) developed major adverse events requiring hospital admission, the remainder (97.9%) were discharged after observation. No mortality occurred. Endoscopic success was achieved in 263 of 286 (91.9%) verified FBIs endoscopies. Endoscopic failure (8.04%) was associated with age, bone, disk battery, intentional ingestion, razor blade, prisoners, and stomach in the univariate analysis. Multivariate logistic regression revealed that intentional ingestion was associated with endoscopic failure (odds ratio: 7.31; 95% confidence interval = 2.06-25.99; P  = 0.002). CONCLUSION: Endoscopy for FBIs is safe and successful, with low hospital admission rate in children, prisoners, and adults. Intentional ingestion is a risk factor of endoscopic failure.

General Surgery Training and One Year of COVID-19. What Has Been the Impact on Residents' Operating Room Surgical Activity? A Report From an Italian Academic Hospital.

BACKGROUND: In the last year and a half, the COVID-19 pandemic has put great pressure on the healthcare systems of many countries, Italy included, leading to a reorganization of hospital activities and a dramatic reduction in surgical activity. Our study aimed to evaluate, from a quantitative and qualitative perspective, the impact of this reduction on the formation of surgery residents at the Academic Hospital of Udine. METHODS: We compared the resident's surgical activity during the pandemic year (March 2020-2021) with the one during the pre-pandemic year, declining the surgical procedures by timing, type, and complexity and categorizing the residents by postgraduate year (PGY) and surgical role. RESULTS: Our analysis highlighted how the main reductions occurred in the elective and medium complexity surgery due to the procrastination of benign pathologies such as hernias, cholelithiasis, and hemorrhoids, which also appeared to be the more frequent cases where the residents are first operators. On the other hand, the residents of the last PGY still maintained a good exposure to neoplasm and high complexity interventions, which are cardinal aspects in the last year of formation. CONCLUSIONS: These results mostly confirmed the critical points noted by the resident surgeons themselves, highlighting however the specific impact on different PGY and surgical activities, offering a starting point to better understand how to challenge the negative effect that the COVID-19 pandemic has had on the surgical resident formation.

Merkel Cell Carcinoma with Gastric Metastasis, a Rare Presentation: Case Report and Literature Review.

INTRODUCTION: Merkel cell carcinoma (MCC) is an infrequent, but highly aggressive neuroendocrine neoplasm of the skin with a propensity for recurrence and metastasis. We report a rare case of gastric metastatic localization of this cancer by focusing on the diagnostic, clinical, and surgical approach to the patient. CASE REPORT: Clinical presentation begins with a peripheral lymphadenopathy whose immunohistochemical characterization identifies the lymphatic dissemination of the disease. Gradually, the patient develops a severe anaemic state which requires several blood transfusions and surgical gastric resection to remove a large bleeding lesion of the antral region. The histopathological analysis of the specimen confirms the metastatic origin from MCC, but the primitive lesion remains unknown. DISCUSSION: Since this clinical situation is very rare, we conducted a review of the literature selecting the few cases reported, in order to evaluate the current knowledge on this topic. Metastatic involvement of the stomach from Merkel cell carcinoma is a rare presentation of this disease progression with a frequent delay in formulating the correct diagnosis and in further treatment which may be life-threatening for the patient. As regards the local treatment, there is no specific guideline, and the therapeutic indication should be tailored on the specific case.

Cholecystectomy in the elderly: clinical outcomes and risk factors.

AIM OF THE STUDY: Recent decades have seen a steady increase in the number of elderly patients undergoing cholecystectomy surgery. The objective of this study is to evaluate clinical outcomes in this cohort of patients and to identify any predictive factors correlative with adverse outcomes arising in the postoperative period. METHOD: A retrospective study was conducted regarding patients aged ≥65 years who underwent cholecystectomy surgery. The independent variables considered to be related to the patient were: age, gender, co-morbidities, and severity of cholelithiasis. The clinical variables were type of procedure, length of stay and hospitalization. The outcomes considered were mortality, re-intervention, transfer to intensive care and post-operative complications. RESULTS: 778 patients with an age between 65 and 74 and 508 patients with an age above 75 were reviewed. With the increase of age, patients who underwent cholecystectomy presented greater co-morbidity, more accesses in emergency, more cases of cholecystitis, which led to a higher number of interventions in open surgery. Considering postoperative outcomes: the need for intensive care, postoperative complications and mortality significantly increase in older patients. Negative predictive factors are the presence of co-morbidities, emergency access and cholecystectomy performed in open. CONCLUSIONS: Elderly patients undergoing cholecystectomy are an increased surgical risk group in particular because of the presence of co-morbidities and because of the frequent need to perform an emergency procedure often for complicated lithiasis pathology. This implies a special attention towards these patients, and towards those over 75 considering, when possible, alternative treatments such as percutaneous drainage. KEY WORDS: Cholecystectomy, Elderly, Outcomes, Risk factors.

How to resume safe access to a medical simulation center at the time of COVID-19 pandemic: The proposal of a protocol from a university institution in North-Eastern Italy.

INTRODUCTION: The Covid-19 global pandemic has suspended thousands of clinical education programs around the world. Also in Italy, as in the rest of the world, frontal teaching activities and internships in the medical field have been suspended. At the university hospital of Udine (North-Eastern Italy) it was decided to strengthen the use of simulation in all training stages to get over the block of training activities. METHODS: A protocol has been drawn up with the aim of providing training in safety for every student of the degree courses in medicine and health area and for doctors in residency training. In this way it was possible to carry out training sessions with a maximum of 6 students engaged in the simulation activities offered by the Center (3D) virtual cadaver, laparoscopic pelvic trainer stations, ultrasound laboratory, microsurgery, etc.). The key points of the protocol were represented by i) internet booking of the training activity; ii) respect of safety measures (hand hygiene, safe distance, restricted total number of presences, constant use of the surgical mask) and iii) reorganization of the material and cleaning of the rooms. RESULTS: Our educational strategy allowed to resume training activity maintaining adequate levels of safety for students and teachers. Applying our protocol, it was possible to guarantee safe access to our Medical Simulation Center (MSC) to a total of about 1400 students from different course of study during the period between June 2020 and February 2021. CONCLUSIONS: Our protocol could represent a practical tool in the management of resuming the activity at a MSC.

The rare Ogilvie's Syndrome in pregnancy. How to manage? A case report and literature review.

Acute colonic pseudo-obstruction, or Ogilvie's syndrome (OS), is a complication in gynaecology and obstetrics. Its occurrence during pregnancy is rare, redefining the therapeutic decision-making and treatment options. In this review we describe the case of a 37-year-old pregnant patient who developed OS at the 30th week of gestation. A laparotomy with colonic decompression was performed. Foetal condition, regularly monitored throughout the hospital stay, remained normal. The patient experienced an uncomplicated, natural delivery at 40 weeks. A comprehensive literature search, describing the occurrence of OS during pregnancy, was conducted. We identified six cases of OS arising during pregnancy. Demographic, clinical, diagnostic and therapeutic features were analysed. Non-surgical management is generally the first-line option, with intravenous drug administration, rectal and nasogastric tube positioning and colonoscopic decompression the treatments of choice. Surgical decompression in usually performed in cases of failure of the first-line treatments. Including our own experience, in all cases, neither maternal nor foetal mortality was reported. A conservative approach is mandatory as first-line treatment, but when prompt resolution is not achieved, a multidisciplinary team, involving the gynaecologist/obstetrician, the surgeon, the radiologist and the intensivist is mandatory to avoid diagnostic delays, thereby reducing morbidity and mortality rates.

Predictive Factors for Drain Placement After Laparoscopic Cholecystectomy.

PURPOSE: Currently, surgical drainage during a laparoscopic cholecystectomy (LC) is still placed in selected patients. Evidence of the non-beneficial effect of the surgical drain comes from studies with a heterogeneous population. This preliminary study aims to identify any clinical, demographic, or intraoperative predictive factors for a surgical drain placement during LC as the first step to identify population for a prospective randomized study. METHOD: The study was conducted in a single referral center and academic hospital between 2014 and 2018. Patients who underwent unconverted LC were divided into two groups: Group A (drain) and Group B (no drain). We explored baseline, preoperative, intraoperative characteristics, and postoperative outcomes. RESULTS: Between 409 patients who underwent LC: 90 (22%) patients were in Group A (drain). Age >64 years, male sex, cholecystitis, Charlson comorbidity index (CCI) ≥ 1, experienced surgeon, intraoperative technical difficulties, need for an additional trocar, operative time >60 min, and estimated blood loss >10 ml were predictive factors at univariate analysis. While at multivariate analysis, cholecystitis (odds ratio [OR]: 2.8, 95% CI:1.5-5.1; p < 0.001), CCI ≥ 1 (OR:1.9, 95% CI:1.0-3.5; p = 0.05), intraoperative technical difficulties (OR: 3.6, 95% CI:1.8-6.2; p < 0.001), need of an additional trocar (OR: 2.5, 95% CI: 1.4-4.4; p < 0.005), and estimated blood loss >10 ml (OR: 3.0, 95% CI:1.7-5.3; p < 0.0001) were predictive factors for a surgical drain placement during LC. CONCLUSIONS: This study identified predictive factors that currently drive the surgeons to a surgical drain placement after LC. Randomized prospective studies are needed to define the use of drain placement in these selected patients.

Redesigning the Paradigms of Clinical Practice for Oral and Maxillofacial Surgery in the Era of Lockdown for COVID-19: From Tradition to Telesemeiology.

The rise of the COVID-19 pandemic has posed new challenges for health care institutions. Restrictions imposed by local governments worldwide have compromised the mobility of patients and decreased the number of physicians in hospitals. Additional requirements in terms of medical staff security further limited the physical contact of doctors with their patients, thereby questioning the traditional methods of clinical examination. Our institution has developed an organization model to translate the essential clinical services into virtual consultation rooms using a telemedicine interface which is commonly available to patients. We provide examples of clinical activity for a maxillofacial surgery department based on teleconsultation. Our experience is summarized and an organization model is drafted in which outpatient consultation offices are translated into virtual room environments. Clinical examples are provided, demonstrating how each subspecialty of oral and maxillofacial surgery can benefit from virtual examinations. The concept of "telesemeiology" is introduced and a checklist is presented to guide clinicians to perform teleconsultations. This paper is intended to provide an organization model based on telemedicine for maxillofacial surgeons and aims to represent an aid for colleagues who are facing the pandemic in areas where lockdown limits the possibility of a physical examination.

General surgery and COVID-19: review of practical recommendations in the first pandemic phase.

BACKGROUND: In March, 2020, the World Health Organization declared COVID-19 a pandemic. The absence of previous knowledge of COVID-19 has made decision-making difficult for all in health care, including surgical departments. We reviewed the management recommendations for surgical activity and changes to surgical practice, identifying concordances and discrepancies, based on the literature published in the early phase of the pandemic. METHOD: We searched the electronic datasets, PubMed Database, Google, and Google Scholar, using the keywords "SARS-CoV-2", "COVID-19", "surgery", "recommendations", "guideline", and "triage". The search was limited to the first 2 months after the pandemic began and was closed on May 6, 2020. RESULTS: Twenty papers were included in the analysis and their recommendations are divided into the following categories: 1. general aspects, such as maintaining the safety of health personnel and indications for surgery. 2. The preoperative phase, with recommendations about activating different care pathways for COVID-19 positive patients. 3. The operative phase, with recommendations about activating safety measures for aerosol-generating procedures. 4. The postoperative phase, with recommendations for managing operating theatres and patient transfers. CONCLUSION: The recommendations proposed in the revised documents are considered good practices aimed at keeping patients and healthcare professionals safe. However, these recommendations must be contextualized in each individual hospital.

The Impact of COVID-19 on Plastic Surgery Residency Training.

Nowadays didactic and surgical activities for residents in the surgery field are less and less due to an increasing burden of documentation and "non-educational work." Considering the current lockdown due to the COVID-19 pandemic, it has never been so important to find different ways to allow residents to improve their knowledge. We asked all plastic and esthetic surgery residents in our country to fill out a questionnaire to investigate changes in their didactical activity and analyze problems about their professional growth in the last few months. From the results of such questionnaires, we found that most of the residents feel the decrease in surgical activities during this time is a detrimental factor for their training and that even if all the schools have changed their didactical activities no school has introduced the use of virtual simulators to compensate for the decrease in surgical practice. Actually, the majority of residents use webinars to keep updated, stating that such technologies are useful but not sufficient to analyze plastic surgery topics in depth during COVID-19 lockdown. Virtual interactive tools are well known in different clinical and surgical specialties, and they are considered as a valid support, but it seems that in plastic surgery they are not so used. According to the most recent studies about residents' didactical program, we have investigated the potential of Anatomage Table in combination with Touch Surgery application as physical and mental aids to bypass the decreased number and kind of surgical interventions performed in this particular time. Anatomage is an academic user-friendly touch screen table; it is used by both medical students and residents to learn human anatomy and to master surgical anatomy. Touch Surgery is an application available on smartphones and tablets that gives the possibility to watch real and virtually designed surgical videos, accompanied by explanatory comments on the surgical phases; they are interactive and give the possibility to check what you have learned through tests administered after virtual classes. In our opinion, these tools represent reliable solutions to improve plastic residents' training, mostly during the COVID-19 pandemic. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Maxillofacial Surgery 5.0: a new paradigm in telemedicine for distance surgery, remote assistance, and webinars.

BACKGROUND: Telemedicine can provide valuable strategies to deliver high-quality training to young doctors and students, as well as to discuss complex clinical cases and follow patients. However, in many cases, similar benefits are limited by the costs due to the expensive hardware resources and optimal infrastructure required. This study presents a novel protocol to improve the accessibility of telemedicine services into a modern hospital department. The protocol is referred to as "SEF" (Smart videosurgery, Easy teleteaching, Fast teleassistance) and was developed in an Oral and Maxillofacial Surgery department. The aims of this study were: 1) to provide a solution to the high initial costs of the configuration of a telemedicine network; 2) to support the simultaneous transmission of multiple video streams; 3) to adopt a modular architecture that amplifies the distance of transmission on the basis of the network infrastructure (department, academic hospital, city, region), thus permitting distance delivery of visual content without any quality loss. METHODS: A local Wi-Fi network was created to connect a wireless presentation device with smartphones, laptops, tablets, and a visualization platform represented by an interactive whiteboard (IWB), allowing to display multiple video streams at the same time. The SEF Project was applied during nine operations and a sample of 90 students (10 students for each procedure) was chosen to evaluate the impact of distance telementoring on their learning performance, in contrast with traditional surgical education. RESULTS: The interface was successfully tested in all surgeries without any quality loss for their whole duration. High resolution and fluidity were confirmed in the recorded clips as well. The impact of telementoring system was assessed by groups of 10 students for each procedure who were administered a questionnaire, and a total satisfaction index of 9/10 was achieved. CONCLUSIONS: SEF protocol appeared to be a stable and highly customizable interface, and has the potential to empower many centers with accessible telehealth systems.

Very Early Introduction of Everolimus in De Novo Liver Transplantation: Results of a Multicenter, Prospective, Randomized Trial.

Early everolimus (EVR) introduction and tacrolimus (TAC) minimization after liver transplantation may represent a novel immunosuppressant approach. This phase 2, multicenter, randomized, open-label trial evaluated the safety and efficacy of early EVR initiation. Patients treated with corticosteroids, TAC, and basiliximab were randomized (2:1) to receive EVR (1.5 mg twice daily) on day 8 and to gradually minimize or withdraw TAC when EVR was stable at >5 ng/mL or to continue TAC at 6-12 ng/mL. The primary endpoint was the proportion of treated biopsy-proven acute rejection (tBPAR)-free patients at 3 months after transplant. As secondary endpoints, composite tBPAR plus graft/patient loss rate, renal function, TAC discontinuation rate, and adverse events were assessed. A total of 93 patients were treated with EVR, and 47 were controls. After 3 months from transplantation, 87.1% of patients with EVR and 95.7% of controls were tBPAR-free (P = 0.09); composite endpoint-free patients with EVR were 85% (versus 94%; P = 0.15). Also at 3 months, 37.6% patients were in monotherapy with EVR, and the tBPAR rate was 11.4%. Estimated glomerular filtration rate was significantly higher with EVR, as early as 2 weeks after randomization. In the study group, higher rates of dyslipidemia (15% versus 6.4%), wound complication (18.32% versus 0%), and incisional hernia (25.8% versus 6.4%) were observed, whereas neurological disorders were more frequent in the control group (13.9% versus 31.9%; P < 0.05). In conclusion, an early EVR introduction and TAC minimization may represent a suitable approach when immediate preservation of renal function is crucial.

Does the status of surgical resident compared to that of consultant have an impact on patient's satisfaction over the informed consent process?

OBJECTIVE: The informed consent process is a fundamental element of best practice in the surgical patient's care. The aim of the present study is to investigate the value of informed consent from the patient's perspective in a Teaching Hospital. In particular, the role of the Residents within this process is analyzed to compare their performance with that of Consultants. DESIGN: This is a prospective observational study based on a consecutive cohort of patients who were offered an elective surgical procedure during the period April 2015 - September 2015. SETTING: The study was conducted in the Surgical and Transplantation Unit of the University Hospital of Udine, Italy, accredited by the Joint Commission International. PARTICIPANTS: The study population consisted of 236 patients. The participants were asked on a voluntary basis to fill in a self-evaluating questionnaire after being requested to complete a written informed consent before the operation. RESULTS: In the present study we didn't register any significant difference of patient's satisfaction over informed consent when we evaluated the performance of Residents in comparison to Consultants. CONCLUSIONS: We believe that our positive results may be related to our educational training approach. However, adequate education of Residents about seeking informed consent is not sufficient to guarantee an effective informed consent process if it is not supported as a counterpart by the promotion of correct and positive patient knowledge and perception of the Residents' skills, clinical role and responsibilities. KEY WORDS: Educational program, Informed consent, Informed consent process, Patient's satisfaction, Resident.

Ileocecal Fistula Caused by Multiple Foreign Magnetic Bodies Ingestion.

The incidence of accidental foreign body (FBs) ingestion is 100,000 cases/year in the US, with over than 80% of cases occurring in children below 5 years of age. Although a single FB may pass spontaneously and uneventfully through the digestive tract, the ingestion of multiple magnetics can cause serious morbidity due to proximate attraction through the intestinal wall. Morbidity and mortality depend on a prompt and correct diagnosis which is often difficult and delayed due to the patient's age and because the accidental ingestion may go unnoticed. We report our experience in the treatment of an 11-year-old child who presented to the emergency department with increasing abdominal pain, vomiting, diarrhea, and fever. Surgery evidenced an ileocecal fistula secondary to multiple magnetic FB ingestion with attraction by both sides of the intestinal wall. A 5-centimeter ileal resection was performed, and the cecal fistula was closed with a longitudinal manual suture. The child was discharged at postoperative day 8. After one year, the patient's clinical condition was good.

Clinical strategies to aim an adequate safety profile for patients and effective training for surgical residents: The laparoscopic cholecystectomy model.

BACKGROUND: Training programs for resident surgeons represent a challenge for the mentoring activity. The aim of the present study is to investigate the impact of our training program for laparoscopic cholecystectomy on patient's safety and on the modulation of the residents' exposure to clinical scenario with different grades of complexity. MATERIAL AND METHODS: This is a retrospective study based on a clinical series of laparoscopic cholecystectomy performed in a teaching hospital. Study population was grouped according to the expertise of the attending primary operator among resident surgeons. Four groups were identified: consultant (C), senior resident (SR); intermediate level resident (IR); junior resident (JR). The intraoperative and postoperative outcomes were confronted to evaluate the patient's safety profile. RESULTS: 447 patients were submitted to LC: 96 cases were operated by a C, 200 by SR, 112 by IR and 39 by JR. The mean operative time was the longest for the JR group. A statistically higher rate of conversion to open approach was registered in C and IR groups in comparison to JR and SR groups. However, in C and IR groups, patients had worse ASA score, higher BMI and more frequent past history of previous abdominal surgery, cholecystitis or pancreatitis. Overall, it was not registered any statistically significant difference among the groups in terms of length of hospital stay and prevalence of major postoperative complications. CONCLUSION: Applying an educational model based on both graduated levels of responsibility and modulated grade of clinical complexity can guarantee an high safety profile.

Fatal hemoperitoneum due to bleeding from gallbladder varices in an end-stage cirrhotic patient A case report and review of the literature.

UNLABELLED: Gallbladder perforation with hemorrhage may be the source of massive hemoperitoneum under rare and extreme circumstances. In cirrhotic patients the bleeding may be associated with the tearing of gallbladder varices and represents a fatal complication, as reported in all the cases available in literature. The incidence of gallbladder varices in the setting of portal hypertension ranges 12-30%, although literature data are limited. We describe the case of an end-stage cirrhotic patient without portal thrombosis awaiting for orthotopic liver transplantation, who developed a fatal hemoperitoneum caused by massive bleeding from ruptured varices of both gallbladder wall and cholecystic fossa. The review of the literature was also performed. KEY WORDS: Cirrhosis, Gallbladder, Hemoperitoneum, Perforation, Portal hypertension, Varices.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients.

BACKGROUND: Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy. THE AIMS OF OUR STUDY WERE: (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy. METHODS: This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed. RESULTS: The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94). CONCLUSIONS: Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.