[Incisional hernia repair in the region of Brescia and in Lombardy: results of a survey and discussion]. / Il trattamento del laparocele in provincia di Brescia e in Lombardia. Risultati di un'inchiesta e loro discussione.

This paper reports the results of a survey on the surgical therapy of incisional ventral hernia in the county of Brescia (19 surgical wards) compared with the results in Lombardy. Using epidemiological data on open and laparoscopic surgery we investigated the recent trends in this kind of surgery, addressing aspects that are not yet supported by evidence-based data in the literature. Laparoscopic repair is performed in about half of the surgical wards, and in the majority (85%) of Lombardy hospitals that replied to the questionnaire. It is also performed in a small number of primitive ventral hernias. The creation of a pneumoperitoneum is accomplished both by the Verress and the Hasson techniques, without significant differences. Composite meshes have proved most interesting, and fixation by titanium spiral tacks is most commonly used. We found rapid discharge and low morbidity rates, similar to the published data. The preferred open technique is still the Rives-Stoppa submuscular mesh repair. It is generally agreed that there will presumably be a major diffusion of laparoscopic repair, in spite of the fact that it is nowadays performed only by surgeons familiar with advanced laparoscopic techniques and is still more expensive than open repair, which, however, is offset by the distinct benefit afforded by the patient.

Hemoperitoneum after percutaneous liver biopsy. Video-laparoscopic management.

BACKGROUND: Percutaneous liver biopsy is a safe procedure, with a low rate of major complications. Among these massive hemoperitoneum is the most life threatening, and its management sometimes leads to an emergency invasive surgical approach. CASE REPORT AND RESULTS: The following case highlights the possible role of laparoscopy in diagnosis and treatment of this condition. In this patient a significant intraperitoneal bleeding developed from a liver lesion 48 hours after needle-biopsy. Video-laparoscopic exploration evidenced a grade III laceration of the right lobe, successfully managed with coagulation and apposition of an absorbable haemostatic gauze. Peritoneal toilette and multiple drains completed the procedure. No surgical complications developed and the patient was discharged on 5th post-operative day. DISCUSSION: Minimally invasive surgery has been, in this case, an adequate alternative for the treatment of this bleeding complication of liver biopsy, offering advantages in terms of low morbidity, quick recovery and satisfying cosmetic results. CONCLUSIONS: Laparoscopy is gaining a prominent role in penetrating liver trauma, whenever conservative or angiographic management fails, and should be considered as the first surgical attempt especially in patients with stable hemodynamics despite active intraperitoneal bleeding.

Laparoscopy in afferent loop obstruction presenting as acute pancreatitis.

BACKGROUND: We describe an afferent loop obstruction caused by an adhesion band in a case of distal gastrectomy with Roux-en-Y end-to-side jejunal anastomosis for cancer. METHODS: An initial clinical presentation of acute pancreatitis was ruled out by a computed tomography scan, which revealed intestinal obstruction; it was then confirmed on laparoscopy. Definitive treatment was laparoscopic adhesiolysis. A complete review of the literature concerning afferent loop obstructions is presented. RESULTS: The treatment was successful, with minimal postoperative pain, and the 5-day hospital stay was uncomplicated. The patient remains asymptomatic at 1-year follow-up. CONCLUSIONS: The authors advocate minimally invasive surgery as a complete diagnostic and therapeutic alternative to emergency laparotomy in cases where afferent loop syndrome is suspected, and acknowledge that prompt surgery has a higher rate of success and reduces operative morbidity and mortality.

Introduction of laparoscopic appendectomy: a retrospective comparison with the open technique.

Laparoscopic appendectomy (LA) is gaining favour as an alternative to the traditional laparotomic technique (OA) despite the persistence of controversy regarding indications, morbidity, hospital stay, costs and surgical time. We present a retrospective analysis of our first three years of experience with the procedure. During this period we performed 235 appendectomies (102 laparoscopic and 133 laparotomic). The conversion rate was 9.7%, due to severe peritonitis, high-grade inflammation and an unfavorable position of the appendix; we found a significantly higher percentage of difficulty due to these factors in the laparotomic procedures. Operating time was similar in the two groups. The rate of associated pathology was higher (22.5% vs 6%) after laparoscopy, but conversion to laparotomy was never necessary for treatment. Early morbidity was limited to 2 patients who underwent laparoscopic appendectomy (1 re-operation for a micro-abscess and 1 conservatively treated haemorrhage), while wound infections (13.5% vs 1.9%) and incisional hernias (0% vs 2.3%) were more frequent in the open procedures. Hospital stay was slightly less in the laparoscopic group (4.0 vs 4.7 days). In our initial experience, laparoscopic appendectomy has shown significant advantages in terms of intraoperative diagnosis of associated diseases and diminished morbidity. We advocate a laparoscopic approach to appendicular disease, reserving conversion to laparotomy for selected cases after exploration.