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Laparoscopic deroofing of the solitary non parasitic cysts of the liver is a safe and effective procedure. This technique allows a wide access for surgical treatment of cysts localized in segments II, III, IVb, V, and VIII of the liver. On the contrary, the posterior segments, VI and VII, and the segment IVa, are difficult to approach laparoscopically. This report describes a laparoscopic technique used in treating 3 cases of symptomatic solitary cysts of the posterior segments of the liver. The patients were placed in the left lateral position. The fenestration treatment was easy and the mobilization of the right hepatic lobe was not required. At one year follow-up, neither postoperative complications nor recurring episodes were observed.

Background: This study aimed to compare the safety, efficacy and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with hematologic disorders., Experimental Design: prospective study;, Setting: II Department of Surgery, Santa Maria Nuova Hospital, Reggio Emilia and III Department of Surgery, Santo Spirito Hospital Pescara;, Patients: 48 consecutive adult patients underwent splenectomy; 30 patients under-went LS and 18 OS. Perioperative characteristics, outcomes, complications and costs were comparatively analyzed., Results: Mean age was 35.3 years in the LS group, and 40.8 in the OS group. Mean spleen size was 11.7 cm in the LS group and 15.2 cm in the OS group. Accessory spleens were found in 5 patients in the LS group and in 4 patients in the OS group; 4 conversions to laparotomy occurred in the LS group. A total of 4 complications occurred in 3 patients of the LS; 9 complications occurred in 5 patients of OS group. Mean surgical time was 141.5 minutes for LS and 89.7 minutes for OS (p<0.005). Mean postsurgical stay was 5.8 days in the LS group and 8.5 days in the OS group (p<0.005). Response rates were similar in both groups., Conclusions: LS is comparable to OS in terms of efficacy and safety and it is associated with a shorter hospital stay. LS should become the technique of choice for treatment of intractable benign hematologic disease.

The problems of the surgery of bulky laparoceles began to find concrete solutions with the introduction of materials of synthesis that can be used to reinforce or to substitute the abdominal wall. Despite that, the ideal prosthesis has still not been found, the Dacron (Mersilene), the Polypropylene (Marlex, Prolene) and PTFE (Goretex) are today considered the best materials for the alloplasty. The authors describe their experience in matter of bulky laparocels treated with the technique of Rives. 49 patients have been operated, using Dacron in 44 cases and Polypropylene in 5. They had no mortality and no relapse, while the most frequent complication was 6 seromas, all resolved with conservative therapy. In their series 3 infections of the subcuticular occurred more of which required the removal of the prosthesis.

Carcinoma of the gallbladder is the most frequent neoplasia of the biliary tract with an incidence of 2.5-4.4 cases for every 100,000 inhabitants; it more often affects females and elderly patients (60-70 years). It is an extremely malignant tumour with an often fatal prognosis owing to both its site and the generally late diagnosis; the majority of patients in fact undergo surgery at an advanced stage of the disease when surgery is only palliative. At the Surgical Division of S. Massimo Hospital in Penne (PE) a total of 897 operations on the gallbladder and biliary tract were performed between 1988 and 1994, revealing 21 cases of carcinoma of the cholecyst (2.3%). Sixteen patients were female (male-female ratio 1:3.2) with a mean age of 67.8 years (range 58-83 years). These patients were divided into 5 stages according to the UICC-1992 classification: 80.9% of cases were stage 3-4. Diagnosis was performed intraoperatively in 2 patients, whereas in 3 cases cancer had been diagnosed by the anatomo-pathologist. A total of 3 simple cholecystectomies were performed, 4 were associated with hepatic resection and lymphadenectomy of the hilus and hepatoduodenal ligament; surgery was enlarged in 2 cases due to the involvement of adjacent organs. After exploratory laparotomy, palliative surgery was performed in the remaining 12 patients in the form of biliary and derivation. Four system were implanted for intra-arterial chemotherapy. The most frequently found histological type was adenocarcinoma (76.2%). The mean survival rate of patients who died was 7.6 months. Six of the operated patients are still alive, of whom only one with a follow-up of 4 years. In conclusion, the authors agree with those who consider carcinoma of the gallbladder generally fatal in view of the rarity of early diagnosis and the difficulties of performing radical therapy.

Intraoperative cholangiography, a diagnostic method through images introduced in to clinical use in 1932, has recently become a different technical support from that attributed by traditional surgery and it has got a different diagnostic meaning with the introduction of video surgery. The authors used it in 54 of 194 patients submitted to a CVL, always making use of the trans-cystic access, with a percentage of success of 82.6%. It was not possible in 8 patients due to the complete section of the cystic duct during the work (3 cases) and the impossibility of introducing the catheter (5 cases). There is still no common agreement about the opportunity to use IC daily: the authors think selective use is better preceded by a careful clinical laboratory instrumental preoperative study to find patients with the common duct stone. Besides, they are of the opinion that a rigorous surgical technique is fundamental to reduce the lesions of the VBP that there are not in their experience.

Meckel's diverticulum is a pathology not rarely found everyday clinical medicine especially when it present with one of its complications. The specific diagnosis is a bit difficult to put because of the low sensibility and specificity of symptoms of diagnostic and instrumental techniques used. The reported case shows a rare type of complication constituted by the phlogosis of Meckel's diverticulum, itself due to an extraneous thing ingested by the patient. The authors discuss the entity of the manifestations of this pathology and highlight every aspects.

The authors describe a case of giant vesical calculus in an 89 year old patient. The diagnosis, as in the other cases reported in the international literature, was made after a series of laboratory and instrumental exams, for groups reported by the patient in the lower abdomen. Operated for the removal of the vesical calculus, he was considered healed after a fortnight. The vesical calculus has a mixed composition and it weighs about 380 grams. The revision of the literature shows the various chemical composition of the vesical calculus that does not permit to identify a common aetiology. It is not possible to demonstrate if the formation of this kind of calculus is primary (in the urinary bladder) or if it is proper of the high urinary tract or mixed. The most recurrent causes being various and different confirm the mixed aetiopathologic theory. The diagnosis, often casual, is made thanks to the most common diagnostic exams; as it is difficult to make a complete cystoscopic control because the bladder is almost completely occupied by the lithiasic formation. The surgical therapy consists of a epicystotomy with a following removal of the calculus. In literature, moreover, cases treated with extra-body lithotripsy are not reported, on the contrary ot happens daily for the lithiasis of the high urinary tract.

The authors present the guidelines which have been followed to introduce into their own Surgical Division an alternative method to cholelithiasis treatment: laparovideocholecystectomy (l.v.c.). They point out how the directions for use of the new surgical method, in place of the traditional laparectomic technique, must be limited to non-complicated cholelithiasis cases, especially in the initial learning stages. That sets the global "morbility" of the above said l.v.c. beneath the cholecystectomy performed with traditional technique. In addition, they point out the sure economic advantages at social and contributions level arriving at the conclusion that l.v.c. is the best treatment for Gallstones.

The authors describe two cases of recent observed internal-hernia, regarding in the first case the right para-duodenal dimple, and in the second a mesenteric breach. They report the clinic presentation and the diagnostic and therapeutic approach compared with the data deriving from the international literature. A complete clinical classification of the internal-hernia is illustrated showing the different clinical signs. The respective symptomatology that in the initial phases of this pathology is not too evident, shows that the internal hernia should always be held in due consideration at the moment of diagnosis because the consequent mortality due to complications such as intestinal-gangrene is rather high.

The authors discuss their experience of six cases of cancer of the gastric stump observed by them in the period from 1988 to 1992 inclusive. All the patients were operated; five total gastrectomies and a gastric re-resection were effected. In association also the spleen was removed in four patients, in one of them a hepatic metastasectomy and a distal pancreasectomy were effected. In the discussion the problems concerning the diagnostic and therapeutic implications with some references to the more likely etiopathogenetic theories were dealt with.

The Chilaiditi syndrome or viscero hepato diaphragmatic interposition is a rare anomaly. The authors describe one case they observed. Even if it is often asymptomatic, it may manifest also by recurrent sub-occlusion or occlusion. Only a few patients need corrective surgical operation. The operation of choice is hepatic extra-peritonealization, which after replacement of the dislocated gastroenteric tract, brings the superior face of the liver again into direct contact with the related diaphragmatic dome.

The authors discuss a case of Grynfeltt's quadrilateral lumbar hernia in an 85-year-old patient. These rather rare hernias can be classified as Grynfeltt's hernias of the superior lumbar space, as Petit's inferior lumbar space and as diffused hernias concerning the whole hip. In our case this hernia was located in the superior lumbar space and it was delimited on the upper part by the 12th rib and by the serratus posterior-inferior muscle; in the lower part by the internal oblique muscle and by the lumbar quadratus muscle. Surgical treatment was effected by plastic surgery with synthetic material put in the extra-peritoneum space and fixed by serum-muscular stitches. Postoperative control effected after a month from the operation proves a good keeping of the plastic surgery reconstruction with total disappearance of the hernia.

Following a discussion of the various methods of colorectal anastomosis in cancer surgery, the Authors describe a technical variant using a mechanical stapler in a high rectal location. The rapidity of anastomosis as well as the decreased risk of dehiscence, fistula and stenosis are underlined.

Three cases of chronic gastrointestinal bleeding are described; the Authors emphasize the important role of mesenteric arteriography in establishing site and nature of bleeding. The review of international literature shows a success rate between 41 and 73% of cases studied with this method after negativity of other diagnostic procedures.