Diagnosis of incidental gallbladder cancer after laparoscopic cholecystectomy: our experience.

BACKGROUND: Gallbladder carcinoma is a rare high malignancy neoplasm. The incidence of intra or post-operative incidental gallbladder carcinoma diagnosis is estimated between 0,2 and 2,8%. Primary aim of our study is to evaluate incidental gallbladder carcinoma's incidence in our experience. METHODS: We retrospectively reviewed our Surgery Division's experience about the totality of laparoscopic cholecystectomies with post-operative histological evidence of incidental gallbladder cancer. We evaluated patients' characteristics, surgical related variables, histological response, surgivcal radicalization characteristics and surgical outcome. RESULTS: In the considered sample we observed 7 accidental gallbladder adenocarcinomas in post-operative histological examination. Pathological results were:1 pT1b N0 (G1), 2 pT2 N0 (G2), 2 pT2 N1 (G3b), 2 pT3 N1 (G3b) (Table 1). In 5 cases we performed neoplasm radicalization surgery with standard procedure revision. Two patients died before radicalization. Median global survival was 34 months. CONCLUSION: With the increase of laparoscopic cholecystectomies both elective and urgent performed in our centre we observed also an increase of incidentally diagnosed gallbladder neoplasms. Early diagnosis, meticulous peri-operative study and accurate surgical strategy are essential factors to obtain good results in incidental gallbladder cancer.

Elective and emergency laparoscopic cholecystectomy in the elderly: our experience.

BACKGROUND: We aimed to analyze outcomes of early and delayed laparoscopic cholecystectomy in the elderly in our General Surgery Division. METHODS: We analyzed 114 LC performed from the 1st of January 2008 to the 31st of December 2012 in our General Surgery division: 67 LC were performed for gallbladder stones and 47 for acute cholecystitis. RESULTS AND DISCUSSION: Comparison between Ordinary and Emergency groups showed that drain placement and post-operative hospital stay were significatively different. There were no significative differences between Early Laparoscopic Emergency Cholecystectomy (E-ELC) and Delayed Laparoscopic Emergency Cholecystectomy (D-ELC). There weren't any differences about Team's evaluation. CONCLUSION: We consider LC a safe and effective treatment for cholelitiasis and acute cholecystitis in Ordinary and Emergency setting, also in the elderly. We also demonstrate that, in our experience, LC for AC is feasible as well.

Laparoscopic appendectomy in the elderly: our experience.

BACKGROUND: Laparoscopic appendectomy for acute appendicitis is one of the most common surgical procedures performed in the world. We aimed to compare laparoscopic and open appendectomy in the elderly in our experience. METHODS: We performed a retrospective review of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2006 to the 31st of July 2012. We analyzed 39 appendectomies in elderly patients: 20 procedures were performed using open technique (Group O) and 19 using laparoscopic technique (Group L). RESULTS: In the analysis of intraoperative variables there was no statistically significant difference. In this study there was no statistically significant difference also in peri-operative variables. CONCLUSION: Laparoscopic appendectomy is a safe and feasible technique in acute appendicitis also in the elderly.

Laparoscopic repair of wound defects in the elderly: our experience of 5 years.

BACKGROUND: Laparoscopic approach for wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments. METHODS: We report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II) from June 2007 to September 2012. RESULTS AND DISCUSSION: In our experience there was no significant difference in laparoscopic procedure between normalweight and overweight patients. CONCLUSIONS: Laparoscopic repair for primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches.

Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience.

BACKGROUND: Aim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables. METHODS: We described our standardized TAPP technique according with Stuttgart technique 1, and we evalutated our team's experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs). RESULTS: We retrospectively reviewed our Surgery Division's experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients. CONCLUSIONS: According with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.

Transcystic videolaparoscopy for choledocholithiasis with holmium: YAG laser lithotripsy. A case report.

Randomised prospective studies have shown that single-stage management of cholecysto-choledocholithiasis yields results equal or superior to sequential treatment, with a lower incidence of complications primarily associated with choledochotomy. We report the first case of transcystic Holmium:YAG laser lithotripsy using a flexible ureteroscope. The method was found to be a valuable aid in reducing the percentage of choledochotomies when calculi are too large to be retrieved from the common bile duct with normal graspers.

Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients.

Laparoscopic transabdominal preperitoneal inguinal hernia repair is a safe and effective technique. In this study we tested the hypothesis that self-gripping mesh used with the laparoscopic approach is comparable to polypropylene mesh in terms of perioperative complications, against a lower overall cost of the procedure. We carried out a prospective randomized trial comparing a group of 30 patients who underwent laparoscopic inguinal hernia repair with self-gripping mesh versus a group of 30 patients who received polypropylene mesh with fibrin glue fixation. There were no statistically significant differences between the two groups with regard to intraoperative variables, early or late intraoperative complications, chronic pain or recurrence. Self-gripping mesh in transabdominal hernia repair was found to be a valid alternative to polypropylene mesh in terms of complications, recurrence and postoperative pain. The cost analysis and comparability of outcomes support the preferential use of self-gripping mesh.

Management of venous ulcers: State of the art.

Venous ulceration is a complex and serious problem that affects 1-2% of the global elderly population (>65 years), and its incidence is constantly increasing. The population group with higher risk of development of venous ulceration is the elderly. These lesions have a significant negative impact on patients' quality of life. Our aim was to analyze the state of the art, starting with the medical literature review. The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared with persons who are not managed by such a team.

Learning curve for endorectal ultrasound in young and elderly: lights and shades.

Aim of the study is to highlight difficulties faced by an inexperienced surgeon in approaching endorectal-ultrasound, trying to define when learning curve can be considered complete. A prospective analysis was conducted on endorectal-ultrasound performed for subperitoneal rectal adenocarcinoma staging in the period from January 2008 to July 2013, reported by a single surgeon of Department of Oncology, Section of General Surgery, "San Luigi Gonzaga" Teaching Hospital, Orbassano (Turin, Italy); the surgeon had no previous experience in endorectal-ultrasound. Fourty-six endorectal-ultrasounds were divided into two groups: early group (composed by 23 endorectal-ultrasounds, made from January 2008 to May 2009) and late group (composed by 23 endorectal-ultrasound, carried out from June 2009 to July 2013). In our experience, the importance of a learning curve is evident for T staging, but no statystical significance is reached for results deal with N stage. We can conclude that ultrasound evaluation of anorectal and perirectal tissues is technically challenging and requires a long learning curve. Our learning curve can not be closed down, at least for N parameter.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient. Electronic databases were interrogated to better define the terms "surgeon", "specialized surgeon", and "specialist surgeon"; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy. Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee's progress. CONCLUSIONS: The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor's ability, the trainee's own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

Informed consent in robotic surgery: quality of information and patient perception.

INTRODUCTION: Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature. In robotic surgery we believe in the necessity to follow three arrangements to make the informed consent more complete. MATERIAL AND METHODS: This study presents correlations and descriptions based on forensic medicine concepts research, literature review, and the proposal of an integration in the classic concept of informed consent. CONCLUSION: In robotic surgery we believe in the necessity to follow three arrangements to make the IC more complete. Integrate the information already present in the informed consent with data on the surgeon's experience in RS, the number of procedures of the department and the regional map of expertises by procedure.

Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view.

Robotic surgery (RS) technology has undergone rapid growth in the surgical field since its approval. In clinical practice, failure of robotic procedures mainly results from a surgeon's inability or to a device malfunction. We reviewed the literature to estimate the impact of this second circumstance in RS and its consequent legal implications. According to data from the literature, device malfunction is rare. We believe it is necessary to complement surgical training with a technical understanding of RS devices.

Excellence and safety in surgery require excellent and safe tutoring.

The surgical education in Italy has always been a very important issue. The aim of this article is to bring together the feedback of the definitions of the various components of the learning scheme and to evaluate the importance of the legal point. In March 2016 we performed a literature review. We have also examinated the internet pages of the Italian Department of Education, Health and Medical Order. In Italy the tutor had an unclear role from a legal point of view. He is the person who must be able to perform a specific procedure with expert technical and who must know how to stop the student if this is about to perform a dangerous maneuver. In Italy the ability to work for the trainee is limited in all reality, it depends on several factors including the increase of numbers of medical-legal disputes, the timing, the commitment it requires mentoring and a lack of mentors. CONCLUSION: In surgery, the problem is greater because of the increasingly of medico-legal implications that we are after surgical procedure. It would be necessary to define a role of the tutor in a regular protocol and a proper assessment of his performance.

Anal sphincter dysfunction in multiple sclerosis: an observation manometric study.

Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient. RESULTS: Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively). CONCLUSIONS: The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy.

BACKGROUND: Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion. METHODS: This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed. RESULTS: Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension. CONCLUSIONS: Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.

Surgeon's clinical valuation and accuracy of ultrasound in the diagnosis of acute appendicitis: A comparison with intraoperative evaluation. Five years experience.

INTRODUCTION: Acute appendicitis is the most common cause of acute abdomen in adolescents, with an overall incidence of 7%. Two such tools are used to diagnose acute appendicitis: ultrasound and Computer Tomography imaging. End point of this study was to verify the accuracy of ultrasound imaging in the diagnosis of acute appendicitis with respect to intraoperative observations and the respective clinical and laboratory findings in young and in the elderly. METHODS: We considered all the appendectomies for acute appendicitis performed between 1 January 2010 and 1 January 2015. We evaluated clinical symptoms, laboratory findings, ultrasound findings, intraoperative signs, and anatomical and pathological findings. In the study we compared the ultrasound and intraoperative findings and then compared these with the respective clinical and laboratory data. RESULTS: In a comparison of diagnostic accuracy, the difference between clinical and ultrasound examinations was not significant. The differences between the diagnostic accuracy of clinical and laboratory findings and between ultrasound and laboratory investigations were statistically significant. CONCLUSION: We defined white blood cells and C protein levels as non-diagnostic of the type of acute inflammation but rather as indicators of the severity of the inflammatory process. We also agree with the authors who proposed the incorporation of ultrasonography into routine practice in the diagnosis of acute appendicitis, but only and exclusively to support other diagnostic procedures and preferably within emergency departments. A thorough clinical examination of patients with suspected acute appendicitis is still the best diagnostic procedure available to us.

Surgical treatment of recidivist lymphedema.

Lymphedema is a chronic disease with a progressively ingravescent evolvement and an appearance of recurrent complications of acute lymphangitic type; in nature it is mostly erysipeloid and responsible for a further rapid increase in the volume and consistency of edema. The purpose of this work is to present our experience in the minimally invasive treatment for recurrence of lymphedema; adapting techniques performed in the past which included large fasciotomy with devastating results cosmetically; but these techniques have been proposed again by the use of endoscopic equipment borrowed from the advanced laparoscopy surgery, which allows a monoskin access of about one cm.

Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man.

Celiac Axis Compression Syndrome by the Median Arcuate Ligament is a very rare condition characterized by chronic postprandial abdominal pain (angina abdominis), nausea, vomiting, which occurs mostly in young patients. The main treatment is a surgical procedure that consists of the division of the arcuate ligament combined with the section of the close diaphragmatic crus and the excision of the celiac plexus. Actually laparoscopic management is feasible and safe.

Laparoscopic management of non-midline incisional hernia: A multicentric study.

BACKGROUND: The laparoscopic repair of non-midline ventral hernia (LNM) has been debated. The aim of this study is to analyze our experience performing the laparoscopic approach to non-midline ventral hernias (NMVHs) in Northwest Italy for 6 years. METHODS: A total of 78 patients who underwent LNM between March 2008 and March 2014 in the selected institutions were analyzed. We retrospectively analyzed the peri- and postoperative data and the recurrence rate of four subgroups of NMVHs: subcostal, suprapubic, lumbar, and epigastric. We also conducted a literature review. RESULTS: No difference was found between the four subgroups in terms of demographic data, defect characteristics, admission data, and complications. Subcostal defects required a shorter operating time. Obesity was found to be a risk factor for recurrence. CONCLUSIONS: In our experience, subcostal defects were easier to perform, with a lower recurrence rate, lesser chronic pain, and faster surgical performance. A more specific prospective randomized trial with a larger sample is awaited. Based on our experience, however, the laparoscopic approach is a safe treatment for NMVHs in specialized centers.

Laparoscopic perspectives for distal biliary obstruction.

BACKGROUND: In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. METHODS: We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. RESULTS: In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. CONCLUSIONS: Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.