[Identification of an objective reference parameter for the reconstruction of a large incisional hernia following physiological principles]. / Identificazione di un parametro obiettivo di riferimento per la ricostruzione secondo criteri fisiologici del grande laparocele.

Repairing a parietal defect of a large incisional hernia should not be limited to the closure of the breach by means of the modern biocompatible prosthetic sheets, but must also be able to restore a correct intra abdominal pressure, otherwise the derangement from the normal respiratory dynamics and the circulatory stasis in the abdominal veins and in those of the lower limbs remain unaltered. Over-correcting the parietal abdominal tension on the contrary can cause a dangerous compartmental syndrome. The attempts of an intraoperative measurement of the correct intra abdominal pressure restoration has been generally hampered from the condition of curarization of the patient during the operation. Using the automatic mechanical ventilator fixed at volume and not at pressure priority, as usual, can offer the possibility to calibrate, following objective parameters, the propriety of the surgical repair still during the final phases of the reparative operation. The simplicity and ingenuity of the here proposed method and the normal availability in every operative theatre of the necessary means for this measurements described, requires attention among the surgeons and a large diffusions of its simple use.

[Diagnostic, prognostic and therapeutic problems of cystic pneumatosis of the colon]. / Problemi diagnostici, prognostici e terapeutici della pneumatosi cistica del colon.

Two cases of cystic pneumatosis of the colon raised clinical problems that were mainly concerned with the diagnostic difficulties posed by this disease. These can only be solved by correct employment of radiology and endoscopy. Reference is made to the proper therapeutic approach, which must be moderate and conservative in all cases. An account is given of the pathogenesis of this form and support is expressed for the most commonly held theory, namely that mechanical factors are responsible for the penetration of air into the wall of the intestine.

[Y-shaped uretero-ureteral anastomosis. Notes on surgical anatomy in humans]. / Anastomosi uretero-ureterale ad Y. Note di anatomia chirurgica nell'uomo

Anatomosurgical investigation shows that Y-shaped ureteroureteral anastomoses can be performed even when the whole of the pelvic segment and part of the abdominal segment of the ureter have been lost. The very high level at which a crossover between the two ureters can be obtained is indicative of the area of application that this operation offers in the reconstruction of unilateral damage to the distal ureter.

[Endothoracic goiter with retro-tracheo-esophageal migration]. / Gozzo endotoracico a migrazione crociata retro-tracheo-esofagea

A case of endothoracic goitre with crossed, left-right, retrovascular, retro-tracheo-oesophageal migration is used as the basis for pathogenetic and diagnostic discussion and for stressing the surgical importance of correct topographic and migratory classification of each form.

[Arteriovenous fistulas]. / In tema di fistole artero venose.

Three cases of arteriovenous fistulae observed in recent years at the University of Rome's 3rd Surgical Clinic, and of different site, entity are aetiology, are presented. The recent international literature is reviewed and the more outstanding clinical and therapeutical features of this form are discussed.

[Criteria of surgical treatment in 148 cases of recto-sigmoid cancer]. / Criteri di terapia chirurgica su 148 casi di cancro del retto-sigma.

The clinical aspects of cancer of the rectum and sigmoid colon are discussed, and stress is laid on the importance of symptomatological, radiological and endoscopical examination, including biopsy. A description is given of the surgical criteria employed in 148 cases, with particular attention to the indications for anterior resection of the rectum and abdominoperineal amputation of the rectum according to Miles.

[Nutritional treatment in the therapeutic strategy in benign esophageal stenosis]. / Il trattamento nutrizionale nella strategia terapeutica delle stenosi esofagee benigne.

Oesophageal strictures prevent a normal alimentation, and in chronic and more prolonged cases are the cause of severe denutrition. Many organs then undergo changes reflected on ultrastructural morphology, that in most severe and lasting cases can demonstrate irreversible. The functional aspect of such changes correspond to a hindered performance of the damaged organs with possible sudden cardiovascular accidents, which are particularly meaningful in the surgical steps of reconstruction, that is heavy for the patient not only in the perioperative period but also during the recovery when higher are the caloric energetic requirements. For the positive outcome of the surgical therapy of these strictures it is therefore necessary to preventively restore an acceptable nutritional status of the patient by the use of one or more of the nowadays available techniques of artificial nutrition. A particular topic of the need of a efficacious nutritional treatment can be pointed in the cases of oesophageal caustic burns, where the caloric requirements is high since the beginning to meet the catabolic effects of the traumatic condition, while malnutrition represents one of the negative factors in prolonging connettival and fibroblastic proliferation, cause of most severe strictures and recurrences. After a general survey of the whole problem, the characteristics of the various artificial nutrition techniques are discussed, with the identification of an optimal scheme of global and nutritional treatment in oesophageal caustic burns.

[Reconstructive treatment with multiple tissue expanders after an extensive skin burn of the lower extremity]. / Trattamento ricostruttivo con espansori tissutali multipli dopo ustione cutanea estesa dell'arto inferiore.

The paper refers to an experience of skin reconstruction of a widely damaged lower limb as result of a hot water burn injury in a young girl. Evidence is given to adopted reconstruction times, and to the decision not to recur to flap transposition by skin innests, but to the tissue expansion technique, also to avoid new aesthetic damages. The peculiarity of the experience is in the employment of a multiple number of tissues expander, to meet characteristic problems of the limbs related to this reconstructive technique, particularly in presence of heavy burn scars. It is also widely illustrated the operatory phases and times which are necessary to obtain an optimal functional result, with very satisfying aesthetic final appearance.

[Optimal preparation of the colon for elective surgery. A personal proposal]. / La preparazione ottimale del colon all'intervento d'elezione. Una proposta personale.

Positive results of modern elective colon surgery are founded not only on a correct anatomo-surgical technique, but also on antibiotic prophylaxis and on the best possible "preparation" both mechanical and microbiological to surgery of colon. Also if in recent literature the opportunity of the last kind of preparation is controversial, here are considered principles and the various most modern related available methods. As regards the mechanical preparation, the most useful dietetic directives, a correct and safely employ of laxative, and also orthograde and retrograde use of physiologic and hyperosmotic solutions of bowel lavage are here considered. As regards the microbiological drainage of colon, criteria of choice between various available antibiotics and plans of their employ, mainly in a prophylactic use, are here recorded. At the end is offered the personal proposal of colon preparation, founded on a synthesis of preliminary mechanical endoscopic colon dressing with a preoperative microbiological drainage, following the most modern principles of antibiotic prophylaxis of colon surgery complications.

[Oncological bases and limits in the indications for total pancreatectomy in the treatment of pancreatic ductal cancer. Retrospective evaluation through a review of the literature]. / Motivazioni oncologiche e limiti delle indicazioni alla pancreasectomia totale nel trattamento del cancro duttale del pancreas. Valutazioni retrospettive su revisione dell letteratura.

Nowadays, pancreatic ductal cancer shows an increasing incidence, either absolute or relative, moreover in economically advanced countries: it needs a very early diagnosis and a surgical strategy both aimed to project a cure, also if at the price of a generally high operative mortality. The selection of the right operation must be deduced from a careful analysis of results of collective reviews of more numerically wide and pathologically definite cases. It is necessary above all to consider operative mortality, morbidity and late survival, both for conservative and resectional surgery (Whipple, TP), and confront it with the natural history of this cancer. The late survival is not yet satisfactory. Therefore revisiting and rationalizing the oncologic basis and the surgical issues of this deadly tumor, total pancreatectomy assumes an imposing meaning, provided the diagnosis is early, and the pre- and intra-operative staging is precise. In such a way it is possible to obtain a reasonable percentage of better immediate and late results.

[Direct exeresis of adenoma of the parathyroid glands]. / Exeresi mirata dell'adenoma delle paratiroidi.

The only therapy for primary hyperparathyroidism (PHPT) is total surgical removal of all parathyroid tissue responsible for hypersecretion. The biggest difficulty for such treatment is the preoperative differential diagnosis between simple parathyroid adenoma (incidence up to 85-90% of PHPT) and diffuse gland hyperplasia (incidence up to 50% of PHPT). Total removal of all parathyroid tissue is not only needless if the aetiology of the syndrome is a simple adenoma, but moreover it is responsible of a completely unnecessary and deeply disabling hypoparathyroidism. It is therefore of the utmost importance to make any preoperative effort for an accurate aetiological diagnosis, and to try the exact localization of the eventually responsible adenoma with all modern diagnostic tools. In spite of any preoperative effort very often the resolution of such problem must be relied to the surgical exploration of all sites of possible hyperplastic gland, with intraoperative hystological study of multiple biopsies. But only a relative help comes from peroperative biopsy, because it is not so easy to reach intraoperatively an hystological certainty in discriminating between hyperplastic and adenomatous tissue on fresh specimens. In the case report a single adenoma of the right lower parathyroid was localized preoperatively with combined researches, mainly with echography, and its surgical removal demonstrated curative at all. The massive lithiasis of left residual kidney was then successfully treated by shock waves. Echography can give therefore a relevant help in preoperative diagnostics of a parathyroid adenoma; is foreseeable its useful employment also intraoperatively, avoiding so an extensive bilateral dissection of all parathyroid sites, responsible of postoperative scarring that hinders any postoperative morphological control and makes dangerous any neck reintervention.

[Surgical choices and approaches in treating tumor metastases]. / Scelte e strategie chirurgiche nei confronti del problema delle metastasi tumorali.

In oncology metastatization modifies the prognosis and the quality of life of patients. Otherwise metastases are apt to make the surgeon to modify in many cases his operative decisions, and moreover means and times of the demolitive surgical procedures for curative purpose. Namely the presence of metastases at the diagnosis is not necessarily the cause of a refusal for potentially curative operations, both for sincrone or methacrone metastases, because there are still possible, also if less frequently, the hopes of success, especially if they are localized in particular target organs. Actual knowledge about pathogenesis of metastases during surgical procedures, induces us to adopt particular caution in demolitive operations, to avoid the risk that surgery facilitate their insurgence or dissemination. Finally the clinically primitive metastases pose diagnostic problems minimally different from what was the current strategy previously. The study consider these various facets of the problem, on the basis of personal experience and of literature data, and proposes operative protocols that are actually generally accepted.

A new surgical tool facilitating the low colo-rectal anastomosis. The original "grasping tie".

A new surgical tool is here proposed to be used together with a circular stapler to help performing a mechanical anastomosis of the low rectum after a sigma or rectum resection. Its name, grasping tie, indicates its main function to fix from outside the rectal stump to the axle of the stapler anvil by means of a nylon ribbon slipping knot before the connection of the two parts of the stapler. The small dimensions of the operative end of the tool make easy to operate in the narrow space of the deep pelvis.

[The "grasping tie". I. Introduction to and technical notes of an innovative mechanical tool aimed at formation of "purse string" in digestive surgery]. / "Grasping tie"--I. Presentazione e note tecniche di un innovativo strumento meccanico per la confezione della "borsa di tabacco" in chirurgia digestiva.

The grasping tie is an original and mechanical tool, conceived and planned to be used in digestive surgery, to temporary grasp and fasten at the axis of the head or the anvil of a circular stapler the tract of the gut chosen for anastomosis. Its use permit to fix the lower oesophageal stump in total gastrectomy, or that of the rectal stump in the lower rectal resection, respectively to the axis of the circular stapler component for the time necessary to perform the mechanical anastomosis. That is performed by the employment of a thin nylon ribbon, which will be progressively tightened as requested like a one way running knot about the tract of the gut and at the axis of the part of the stapler. The device will be repeatedly activated by an handle located at one of its ends, tightening progressively at the other end a thin nylon ribbon preventively put and laced around the chosen point of the digestive tract to grasp firmly and irreversibly the gut to the axis of the stapler, and then cut away by a trigger of the device in the same end of the handle. The nylon ring will be extracted together with the muscle-mucosal rings once completed the stapler suture, so that nothing of the ribbon remains in the patient. Its function is alternative to the classical tool used to prepare a purse-string suture on a segment of the digestive tract. Its advantages in front of that tool is the minimal space it requires for its use, therefore with operative advantages in fixing the head of the circular stapler in the oesophagus during the reconstructive steps after a total gastrectomy, and in fixing the lower rectum to the axis of anvil of a circular stapler preventively introduced in the anus and extruded. Moreover its employment is advantageous in closing from the outside the two ends of a tract of the gut where a tumour is located, so allowing a safe subsequent manipulation of the gut without oncologic prejudice.

Simulated use of the "grasping tie" as for colo-rectostomy after low rectal resection.

Simulated test of effectiveness of the original tool grasping tie, technically already illustrated in two previous papers listed in bibliography, for fixing a spongy rubber tube, simulating a rectal stump on the anvil's axle of a circular stapler, by tightening over it a nylon ribbon slip-knot (the tie). After connecting the anvil to the stapler head through an other spongy rubber tube simulating a colonic loop, and the firing of the stapler, it is demonstrated the correct circular anastomosis achievable.

[The scientific videotape with digital processing in surgery. The new opportunities offered surgery for videotape recording and postprocessing with the use of information and digital technologies]. / Il videotape scientifico ad elaborazione digitale in chirurgia. Le nuove opportunità offerte alla chirurgia dalle registrazioni in video-tape e dalla post-produzione con l'impiego delle tecnologie informatiche e digitali.

The facility of the tape recording of a surgical operation, by means of simple manageable apparatuses and at low costs, especially in comparison with the former cinematography, makes it possible for all surgeons to record their own operative activity. Therefore at present the demonstration in video of surgical interventions is very common, but very often the video-tapes show surgical events only in straight chronological succession, as for facts of chronicle news. The simplification of the otherwise sophisticated digital technology of informatics elaboration of images makes more convenient and advisable to assemble the more meaningful sequences for a final product of higher scientific value. The digital technology gives at the best its contribution during the phase of post-production of the video-tape, where the surgeon himself can assemble an end product of more value because aimed to a scientific and rational communication. Thanks to such an elaboration the video-tape can aim not simply to become a good documentary, but also to achieve an educational purpose or becomes a truly scientific film. The initial video will be recorded following a specific project, the script, foreseeing and programming what has to be demonstrated of the surgical operation, establishing therefore in advance the most important steps of the intervention. The sequences recorded will then be assembled not necessarily in a chronological succession but integrating the moving images with static pictures, as drawings, schemes, tables, aside the picture-in picture technique, and besides the vocal descriptive comment. The cinema language has accustomed us to a series of passages among the different sequences as fading, cross-over, "flash-back", aiming to stimulate the psychological associative powers and encourage those critical. The video-tape can be opportunely shortened, paying attention to show only the essential phases of the operation for demonstrate only the core of the problem and utilize at the best the physiological period of active attention of the observer. The informatic digital elaboration has become so easy that the surgeon himself can be able to elaborate personally on his personal computer, with professional and scientific attitude, the sequences of his surgical activity in a product of more general value. His personal engagement also in the phase of post-production gives him the possibility to demonstrate uprightly with images the complex surgical experience of science, skill and ability to communicate, perhaps better than he is able to do with words.

[Guideline concepts of the present-day surgery in breast cancer]. / Concetti informatori la moderna chirurgia del cancro mammario.

The more important trends of nowadays surgery for breast cancer are those of an advanced rationalization of combined strategies in a multidisciplinary view. Moreover it takes advantages from the availability of an extremely modern diagnostic instrumentation used in search of a truly early diagnosis, based on scheduled screening and surveillance criteria both for general population and particularly for that at risk. In this way it is easier and possible to adopt less radical and more conservative surgical techniques, whose effectiveness is well demonstrated in association with adjuvant treatment thanks to the convergence of multiple competences. The better results of the last years are certainly related to the collaboration of surgeons with oncologists, thanks to the ever more effectiveness of adjuvant chemo- and radiotherapy, that make more acceptable the attitude for the reconstructive and the conservative surgery whenever possible. This interpretation of the actual positive results of breast cancer surgery point the way to follow, and are the basis for hoping further improvement in the treatment of this disease, ever more efficacious whilst that diagnosis precocious be more and more.

Perspectives of scientific publications of surgery in Italy. Perspectives on the article of M. Rubino and Al. "Types of surgical articles. Comparative analysis of three Italian and three foreign journals".

The globalization of the information and the wide use of the English language in the scientific world impose a not avoidable comparison to the scientific Italian journals, but with value indicators that if accepted without criticism could humble the undeniable internal values. In fact such comparison is based certainly on the quality of the contents, but it has already as background parameter the language of publication if the aim is that of an adequate diffusion. The questions that rise from the analysis of the problem are essentially two: if there is still room nowadays for surgical scientific publications in Italian language and if it is correct to accept in a closed box the indicator of international comparison conditioned by the English language, with the consequence that the definite value judgement is entrusted to external opinions. Certainly the Italian journals of surgery must aim both to quality and to their diffusion for reaffirm and validate their cultural rights. The quality depends on the authors and on the surgical environment in which they operate, beyond the engagement of the scientific direction of the journal; the diffusion on the correct employment of the English language, at last of the abstracts, and on the general editorial strategy pointing to encourage and promote the widest coverage of critique. It remains but to bravely loose the knot represented from the proposal of a uncritical acceptance of the indicator of the IMPACT FACTOR with the consequent absolute judge of quality, that fatally depends from an egemonic Anglo-Saxon filter, not exempt from an unavoidable lobbystic imprint.

Modern surgical technique for thyroidectomy.

Extracapsular lobectomy or total thyroidectomy are the surgical techniques normally used to deal with either benign or malignant thyroid diseases needing surgery. Both the well-known pathogenesis of benign surgical pathology and the positive role of post-operative radiometabolic treatment for differentiated carcinomas justify this surgical approach. Of course a complete understanding of anatomic structures and skilled operative techniques are necessary. The thyroid's parenchyma preventive extracapsular devascularization allows a strictly bloodless operative field, which makes it easier to preserve both the superior and inferior laryngeal nerves and the parathyroid glands of both sides. Therefore this procedure can be primarily considered a "vascular" technique. Our surgical technique is thoroughly described here, stressing anatomical landmarks and surgical steps, and maintaining awareness of pathophysiological implications and related operative choices.

[Clinical research on the possibility that renal cysts may be responsible for the appearance of hematuria]. / Ricerca clinica sulla possibilità che le cisti renali siano responsabili della comparsa di ematuria.

New techniques of study, namely echography, urography, TC, give evidence of a great number of asymptomatic renal cysts in the everyday experience. Then also if haematuria was classically considered one of the symptoms of renal cysts, there are now many reasons to consider such evidence very infrequent, and downright there are some valid doubts that renal cysts may cause haematuria at all. So the authors have analysed 113 patients, most of them coming from Institute of Radiology of Chieti University Faculty of Medicine; all of them had renal cysts diagnosed by echographs and/or urography but only a minority were just from the beginning studied for haematuria, whereas the majority for many different symptoms. Total cases was then divided into two groups: one of 102 patients, all without haematuria; 78 of them had been studied only with echography, whereas other 24 patients had been examined both with echography and urography. The second group, of 11 cases, included all the patients who had both renal cysts and haematuria. Only in two cases of this second group was lacking evidence of any associated pathology which must be responsible for haematuria, whereas in all the other 9 cases a different aetiology of the haematuria was demonstrated, for simultaneous presence of various pathologies (cystopyelitis with associated prostatis, haemorrhagic cystitis, bladder diverticula and renal papillomas and upper urinary ways tumours), all much easier responsible by themselves of haematuria, also if with different features from case to case.(ABSTRACT TRUNCATED AT 250 WORDS)