Tailored anterior tension-free repair for the treatment of recurrent inguinal hernia previously repaired by anterior approach.

PURPOSE: The purpose of this study is to describe our policy in selecting different types of anaesthesia and anterior tension-free techniques for the repair of recurrent inguinal hernias previously treated by anterior approach and to evaluate early and late outcomes. METHODS: The medical records of 111 patients who underwent recurrent inguinal hernia repair by anterior approach in the period 2000-2013 were reviewed. Fifty patients (45 %) were over 70 years old and 63 (56.7 %) had one or more co-morbidities. Hernias with large defects were the most frequently observed (59.5 %), and no-mesh techniques were the most frequent failed repair (75.7 %). Different anterior tension-free techniques and types of anaesthesia were used, depending on hernia and patient characteristics. Seventy-three patients (65.8 %) were operated on an outpatient basis. RESULTS: Mean follow-up period was 89 months (range 10-183). No perioperative deaths, medical events, or visceral injuries were recorded. Early postoperative complications occurred in 11 patients: 4 haematomas (3.6 %), 5 seromas (4.5 %), 1 superficial wound infection (0.9 %) and 1 ischemic orchitis (0.9 %). Late complications consisted in 3 cases of chronic moderate pain (3.2 %) and 2 re-recurrences (2.1 %). CONCLUSIONS: Recurrent inguinal hernia previously treated by open anterior technique can be repaired using the same approach, often on an outpatient basis, with a low rate of recurrence and postoperative complications. To be safe and effective, the repair should be performed by appropriately trained surgeons, well versed in the use of different types of anaesthesia and surgical techniques depending on patient and hernia characteristics.

Unexpected post-operative diagnosis of primary rectal melanoma. A case report.

AIM: Anorectal melanoma (ARM) is a very uncommon and highly lethal malignancy. Due to its rarity and non-specific symptoms, preoperative diagnosis may be often erroneous and subsequent treatment inappropriate. We report a case of primary rectal melanoma and discuss the current diagnostic and therapeutic challenges. CASE REPORT: An 87-year-old man was admitted to our surgical unit with a history of progressive constipation, tenesmus, rectal bleeding and transanal mucous discharge. Preoperative investigations, including CT scan and colonoscopy with biopsy, were suggestive for locally advanced low rectal sarcoma and therefore the patient underwent abdominoperineal resection (APR). However, histopathological examination and immunohistochemistry resulted in a postoperative diagnosis of primary rectal melanoma. The patient died 6 months later due to local and systemic recurrence. CONCLUSION: ARM should always be considered when unusual anorectal lesions are discovered. Regardless of the pathological stage and the extent of surgery, prognosis of ARM remains poor. Thus, whenever feasible, wide local excision is now the preferred treatment, since it is associated with lower postoperative morbidity and better quality of life compared to APR. In our case, although the initial diagnosis was incorrect, APR was justified by the local invasiveness and large size of the tumor.

Acquired abdominal intercostal hernia: case report and systematic review of the literature.

PURPOSE: The protrusion of abdominal viscera through an intercostal space under an intact diaphragm is a very rare condition. The aim of this study is to elucidate the etiology, clinical features, and therapeutic options on what several authors call "abdominal intercostal hernia" (AIH). METHODS: A typical case of AIH of the 9th left intercostal space in a 48-year-old man is presented. A literature search was conducted on the Medline and Scopus databases. Only acquired AIHs (AAIHs) were considered, while lung, transdiaphragmatic, and congenital intercostal hernias were excluded. RESULTS: Eighteen studies met selection criteria and a total of 20 patients were useful for analysis. Etiology was related mainly to traumatism (65 %) or to previous surgery (20 %). The intercostal defects were mostly located under the 9th rib without significant differences as to side. The main symptom was chest swelling (85 %), often associated with discomfort or pain (76 %). Acute complications such as incarceration and strangulation occurred in three patients. CT was the most employed diagnostic tool (80 %). Early diagnosis was made in 25 % of cases. Seventeen patients underwent hernia repair with either open (73 %) or laparoscopic approach (28 %), and various techniques with and without prosthesis were described. Recurrence occurred in 28.6 % of patients, during a mean follow-up of 8.6 months. CONCLUSIONS: AAIH should be always suspected when chest swelling occurs after a minor or major trauma, and CT must be promptly performed to rule out diaphragmatic or abdominal viscera injury. This condition requires surgery to prevent serious complications, the first-choice technique should be mesh tension-free repair.

De Garengeot hernia with acute appendicitis.

AIM: The presence of the appendix within a femoral hernia sac is a rare condition known as De Garengeot hernia. We report a case of De Garengeot hernia with concomitant appendicitis and a brief review of the literature on the pathogenesis, diagnosis and treatment of this uncommon condition. CASE REPORT: A 33 year-old woman was admitted to our Surgical Unit with acute-onset pain and swelling in the right groin region. Clinical signs and ultrasound imaging suggested the presence of a strangulated femoral hernia and the patient was operated on in emergency setting. An inflamed appendix was discovered within the hernia sac. Appendectomy via McBurney incision and prosthetic repair of the femoral ring were performed. The postoperative course was uneventful and at the 2 week and 1 year follow-up no signs of wound infection and no hernia recurrence were found. CONCLUSION: Since clinical signs are non-specific and radiological findings may often be misinterpreted, appendicitis within a femoral hernia sac is often an incidental finding during an emergency operation for strangulated femoral hernia. Appendectomy-associated hernia repair may be performed with or without prosthesis depending on the extent of surgical field contamination.

Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: a long-term follow-up study.

BACKGROUND: The aim of this retrospective study was to assess the incidence of trocar site hernias (TSH) following laparoscopic cholecystectomy (LC) through a long-term follow-up and to elucidate the significance of several technical and patient-related factors. METHODS: A total of 313 patients submitted to LC between 2000 and 2004 were included in our study. The pneumoperitoneum was always performed by means of Hasson's technique at the umbilical site and the operative trocars were positioned using either the American technique or the French technique. Closure of the fascial defect was performed only at the umbilical site. The effects of several variables, including age, gender, size of gallstones, co-existing umbilical hernia, complexity of operation, diabetes, obesity, malnutrition, smoking, and heavy manual work on the development of TSH were assessed by univariate and multivariate models. RESULTS: Thirteen cases of TSH (4.1 %) were detected over a mean follow-up period of 89.8 months (range: 60-128). Of these, 11 (84.6 %) developed at the umbilicus and 2 at the 10 mm subxiphoid site (15.4 %). At univariate and multivariate analysis, gallstones ≥ 2 cm (p = 0.030; OR = 9.95, p = 0.01) and obesity (p = 0.002; OR = 22.93, p < 0.01) were found to increase the likelihood of TSH development. CONCLUSIONS: After long-term follow-up, the incidence of TSH following LC was higher than expected. The insertion of large trocars at the umbilical site plays a key role in the development of TSH. Other conditions such as obesity and large gallstones can be additional risk factors since the umbilical defect must often be widened in these cases.

Chevrel technique for midline incisional hernia: still an effective procedure.

BACKGROUND: Prosthesis use in the treatment of incisional abdominal hernia is today an accepted concept worldwide. However, there is no agreement as to the most appropriate site of prosthesis insertion. The aim of this report was to analyse the operative steps of the premuscolo-aponeurotic repair and to present the results of our experience. METHODS: Between May 1996 and December 2006, 64 patients (52 women and 12 men, mean age 64 years) underwent a Chevrel repair for midline incisional hernia. They represented 52% of plasties performed for incisional hernia. Patients were subdivided according with Chevrel and Rath classification. Nineteen were operated on in emergency and 45 electively. Associated diseases, mainly cardiopathy, obesity, chronic pulmonary disease and diabetes, were recorded in 83% of the patients. Cholecystectomy and wide dermolipectomy were the more frequent procedures associated with plasty. Prosthetic material was polypropylene (53%), polyester (42%) and polypropylene + polyglactin 910 (5%). RESULTS: The mortality rate was 1.6%. Postoperative complications were exclusively parietal in 17 patients (26.5%), i.e. seroma, skin necrosis and superficial wound infection. No deep infection or intra-abdominal complications were observed. Mean postoperative hospital stay was 10 days, closely related to being elderly, associated operations and emergency admission. Two recurrences were registered, and chronic abdominal pain or late infections were not observed. CONCLUSIONS: Our experience shows that the Chevrel technique is a safe and effective procedure, easy to perform and reliable even in cases of septic risk.

[Elastofibroma dorsi: case report and review of the literature]. / L'elastofibroma dorsi: descrizione di un caso clinico e analisi della letteratura.

Elastofibroma dorsi (ED) is a rare, benign, often bilateral lesion of the thoracic wall, occurring most commonly in the infra-scapular region beneath the muscular tissue, generally found in elderly women. Whether ED should be considered as a true neoplasm or merely as a reaction of connective tissue to repetitive minor trauma is still debated. ED has characteristic features but a low incidence and is therefore not always easily distinguished from other benign and malignant soft-tissue tumors. Inappropriate treatment may thus be administrated in the absence of a definitive diagnosis. We report a case of a 51-year-old woman who presented with a right infra-scapular swelling associated with pain and a clicking sensation during selective arm movements. Upon clinical and ultrasound examination, the lesion had the appearance of a deep dorsal lipoma, but intraoperative findings were suggestive of a sarcoma originating from the periosteum of ribs. Nonetheless, marginal surgical excision was performed and the tumor was histologically diagnosed as ED. In conclusion, ED should be always considered in the differential diagnosis of tumors deeply located in the infra-scapular area, especially in elderly women. As it is a benign lesion, surgical treatment is recommended only in symptomatic cases or if a large swelling is present.

Operative cholangiography during laparoscopic cholecystectomy: considerations about routine or selective policy.

Operative cholangiography (OC) during laparoscopic cholecystectomy (LC) is still a matter of debate regarding its routine or selective use. The present report is based upon a series of 30 selective cholangiographies performed in 290 LC during the years 1999-2004. Indications to OC were decided according to clinical data, liver chemistries, ultrasonographic (US) and intraoperative findings. In cases of unequivocal common bile duct (CBD) stones, a preoperative ERCP was performed and OC was not applied to confirm clearing of the biliary tract. OC was successful in 26 cases (86.6%): in 18 cases a normal cholangiogram was obtained and in 3 cases stones were detected into CBD. These patients underwent a postoperative successful ERCP at a variable interval of time. In 4 cases cholangiograms showed a delayed transit and in a single case a lack of contrast into the duodenum. Such occurrence was due to morphine derivatives employed during anesthesia. The Authors evaluate advantages and drawbacks of routine and selective OC according to personal and other Authors experience. Decision on selective or routine policy should be taken according to each surgeon experience and local facilities. Each laparoscopic surgeon must be able to perform and interpret an OC, specially if he has in mind to develop competence in laparoscopic CBD exploration.

Endometriosis of the round ligament: description of a clinical case and review of the literature.

We report a case of endometriosis of the round ligament in a 29-year-old woman, who complained of a lump with a diameter of about 2.5 cm in the right inguinal region, which increased in bulk and was accompanied by intense pain during the menstrual period. The clinical suspicion of inguinal endometriosis, supported by ultrasonography and Magnetic Resonance (MR), was confirmed by histological examination of the surgical specimen, which included the mass and the extraperitoneal segment of the round ligament. The authors conclude that the appearance of a lump in the inguinal region associated with subjective and objective changes of the lesion in relation to the menstrual cycle must raise the suspicion of endometriosis among the possible diagnoses.

[Intestinal obstruction due to perforated cecal volvulus. Case report]. / Occlusione intestinale da volvolo perforato del colon destro. Descrizione di caso clinico.

Cecal volvulus is an uncommon cause of large-bowel obstruction. Its developement is due to an abnormal mobility of the ileocecal loop because of lacking attachement of ascending colon. Clinical features are frequently aspecific and should be differentiated from sigmoid volvulus and neoplastic obstruction. Therapy depends on visceral circulatory conditions at the moment of diagnosis. Possible options include endoscopic decompression, cecopexy with or without cecostomy, right colectomy with immediate or delayed anastomosis. The present paper reports the case of cecal volvulus in a 44 year old woman, successfully treated with right colectomy and primary anastomosis.

Radical treatment of acute pilonidal abscess by marsupialization.

Simple drainage is the most common treatment of pilonidal abscess, but later definitive surgery is often necessary. However, radical treatment can also be performed in a single step by several procedures and even better results. The Authors describe the technique of marsupialization and analyse its long-term outcomes in a retrospective study. Between 1992 and 2001, 43 consecutive patients underwent drainage, curettage and marsupialization for acute pilonidal abscess. The procedure was carried out in outpatient setting (day surgery) after local or spinal anaesthesia. Management of the wound was left to the patient and was periodically checked at our out service. The average operating time was 20 minutes. Complete healing required 4-10 weeks in 95.3% of the patients; a persistent chronic fistula was observed in 4.7%. During the follow-up, 6 recurrences (14.6%) were observed in the healed patients. The treatment was then successful in 81.3% of the cases. Our experience shows that it is possible to carry out a radical management of pilonidal abscess in a single step with a high complete healing rate. Marsupialization proved to be a fast procedure and mainly feasible in the outpatient setting.

[Left pyo-pneumothorax: a rare complication of colon carcinoma]. / Pio-pneumotorace sinistro: rara complicanza di un carcinoma del colon.

A case of pio-pneumothorax complicating a splenic flexure colonic carcinoma is herein presented. The patient was a 58 years old male and was submitted 3 months earlier to a colo-colic bypass for a locally advanced tumor infiltrating stomach, spleen, tail of the pancreas and left emidiaphragm. Few days before the admittance in our ward, he experienced fever, anorexia, and severe dispnoea. Treatment was a water seal drainage of the chest evacuating nearly 8 Liters of purulent material where Escherichia coli was found. Death occurred 2 weeks after drainage. From the analysis of the literature thoracic empyema is an extremely rare complication of colonic carcinoma: 5 other cases have been reported so far. Pathogenesis in half of the cases was due to septicemia and in the others to infectious local spreading.

[Lymph node biopsy in the study of lymphomas: from the incisional biopsy to videolaparoscopic lymphadenectomy]. / La biopsia linfonodale nello studio dei linfomi: dalla biopsia incisionale alla linfoadenectomia videolaparoscopica.

The role of the surgeon in the treatment of lymphoproliferative diseases is mainly addressed to histological diagnosis and staging. The aim of this study was to analyze the results of lymph node biopsies in patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma NHL). Between January 1992 and March 2003, 37 patients (17 males and 20 females, mean age 57 years, range 17-90) were submitted to a node biopsy to determine type of lymphoma and clinical staging: there were 8 HD and 29 NHL. In a single case laparoscopy was adopted to remove abdominal nodes; the procedure was uneventful and the patients discharged in the third postoperative day. The Authors stress the importance of the minimally invasive approach in the management of lymphoproliferative diseases.

[Our experience in the diagnosis and treatment of diffuse peritonitis]. / La nostra esperienza nella diagnosi e nel trattamento delle peritoniti diffuse.

Acute diffuse peritonitis is still an unpredictable occurrence that hinders patient's survival and is a severe challenge for the surgeon regarding diagnosis and management. The Authors report their experience on 94 cases of acute diffuse peritonitis due to different causes observed during a period of 10 years. Surgical treatment was mainly based on severity of clinica data and general conditions of the patients. Overall mortality was 6.3%. Modern diagnostic techniques, proper usage of antibiotics and accurate timing of surgical procedure constitute the main factors for un update management of peritonitis.

Cellular fibrous histiocytoma of the skin: evidence of a clonal process with different karyotype from dermatofibrosarcoma.

Recently, a distinct variant of cutaneous fibrous histiocytoma (FH) has been histologically characterized as a "cellular" subtype. This variant is often mistaken for sarcoma, including dermatofibrosarcoma protuberans. We report a case of cellular FH of the skin in which the cytogenetic analysis demonstrated a novel chromosome pattern, possibly allowing distinction from its histologic simulants.

[Neuroendocrine carcinoma of the skin]. / Il carcinoma neuroendocrino della cute.

Merkel cell carcinoma is an unusual neuroendocrine tumour that arises in the derm. The case reported seemed to deserve the author's attention because of the clinical features, pathological findings and natural history (local recurrence, regional lymph node metachronous metastases, distant metastases). The authors believe that a differential diagnosis between Merkel cell carcinoma and other tumours located in the subcutaneous tissue is mandatory, in order to perform specific immunohistochemical and ultrastructural study.

[Ambulatory surgery: current status and prospects]. / Chirurgia ambulatoriale: stato attuale e prospettive.

Ambulatory Surgery (AS) was born some 20 years ago in USA pushed by economic requirements and rapidly spread over the European countries as one of the main factors of progress in health care. The Authors, after evaluating the actual situation of AS in the international literature, report their personal experience from January 1991 to December 1994. The series includes 810 surgical operations performed as outpatients procedures with immediate discharge. The following types of anaesthesia were used: local infiltration (86.6%), monolateral ultraselective spinal (10%), blended or general (3.4%). Hernias of the abdominal wall, varicose veins and anorectal diseases were the more frequent pathologies operated on. Results of surgery are satisfactory supporting the advantage of AS such as the absence of complications due to anaesthesia and hospital stay, the better relationship between patient and surgeon, the short return to working activities. AS proves its value on the clinical and socio-economic grounds provided that a well organised program and careful selection of patients are adopted. No extemporary organisation are advisable.

[The choice of the intervention in the surgical treatment of nontoxic diffuse multinodular goiter]. / La scelta dell'intervento nel trattamento chirurgico del gozzo multinodulare diffuso non tossico.

The choice between sub-total (STT) and total (TT) thyroidectomy in surgical management of multinodular goitre should be based on the disease pathophysiology and the critical review of short and long-term results of these treatments. In order to make a comparative evaluation the authors carried out a retrospective analysis on a series of patients operated from 1970 to 1993 and on the results of a 16.3 years mean follow-up. Of 551 patients operated on the thyroid gland, 389 (70.6%) affected by multinodular goitre were considered. 340 were female and 49 male (39 years medium age). 341 (87.6%) underwent STT and 48 (12.4%) TT. Post-operative opotherapy was adjusted according to hormonal assays. Post-operative vocal cord motility and calcemia were assessed. A routine endocrinological follow-up protocol has been carried out on all patients since 1980. Transitory vocal cord palsy and hypocalcemia were significantly more frequent in TT, while permanent damage was not. Of 40 TT (complete 5 years mean follow-up, 97.5% of the patients reached euthyroidism with replacement therapy. Of 189 STT (complete 16.3 years mean follow-up), 61.4% of the patients received opotherapy. A recurrent goitre was ascertained in 39.1% of the total (73.3% in the patients not receiving opotherapy) and operated in 16.2% of the cases. According to the authors their results support the choice of TT as it matches the rationale of surgical treatment of multinodular non-toxic goitre based on the pathophysiology of the disease. Moreover it allows easy achievement of euthyroidism avoiding goitre relapse and subsequently re-operation, with an incidence of permanent recurrent nerve palsy and hypoparathyroidism not significantly different from that after STT.