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In 1991 Delaitre and Maignien described the first laparoscopic splenectomy, since when a rapid spread of this technique has been observed and the procedure has become the gold standard in the surgical management of benign and malignant haematological diseases. In the present study, the results of the first 30 laparoscopic splenectomies performed at the Division of General Surgery of the S. Eugenio Hospital of Rome are reported. The operations were performed in patients with benign (27 cases) and malignant (3 cases) haematological diseases, treated in the Regional Haematological Centre of the same hospital. The procedures were carried out according to criteria corresponding to those recently described in the guidelines of the European Association for Endoscopic Surgery. As regards the results, two procedures (6.7%) were converted to open surgery. One postoperative haemorrhage was observed, requiring a laparoscopic reoperation for haemostasis. No other major local or general complications were observed. Mortality was nil. The mean postoperative hospital stay was 4.2 days (range: 4-8 days). Medium-term surgical and haematological results were excellent. Laparoscopic splenectomy is the surgical gold standard, but should be performed in advanced centres in close cooperation with a haematology centre. The procedure is indicated in all patients who are candidates for splenectomy, with the sole exception of those affected by portal hypertension or with general contraindications to laparoscopy. In advanced centres, better early and late results can be achieved, in addition to the well-known benefits of the minimally invasive technique, particularly in aesthetic terms, which in younger patients affected by benign haematological pathologies are very important.

Adrenal myelolipoma is an uncommon tumour of the adrenal gland, usually unilateral, frequently associated with hypertension and obesity, with a benign biological behaviour and without hormonal activity, first described in 1905. The neoplasm consists of adipose tissue and myelopoietic cells of the bone marrow. These tumours have a very slow but continued growth and their volume and weight vary significantly from small lesions of a few grams to huge masses weighing up to several kilograms. If symptoms occur, surgery should be performed without delay, especially for large myelolipomas that are at high risk of spontaneous rupture with haemorrhage and life-threatening shock. In this report a case of a 43-year-old male with a 22 x 18 x 9 cm giant myelolipoma, weighing 3500 g and originating from the right adrenal gland is described. The large mass dislocating and compressing the inferior vena cava, was removed surgically. The early postoperative course and the late outcome were favourable without recurrence after 30 months. The different aetiological hypotheses of this rare neoplasm and its clinical features, diagnosis and treatment are discussed.

Zenker's diverticula commonly occur in the elderly, and quality of life is often impaired by typical symptoms such as dysphagia, regurgitation, halitosis, cough and aspiration pneumonia, malnutrition and weight loss. The "gold standard" treatment for pharyngo-oesophageal diverticula is the resection of the sac via left lateral cervicotomy and cricopharingeal myotomy. In the last decade, with the fast development of minimally invasive techniques, an endoscopic stapled approach has been proposed. This procedure rapidly encountered the favour of gastroenterologists because patients with Zenker's diverticulum often present serious co-morbidities and seem to benefit from the minimally invasive technique; but the crucial point in the treatment of Zenker's diverticula, in addition to the sac resection, is the myotomy of the cricopharyngeal muscle fibres and this could not be safely and completely achieved in endoscopic stapling owing to the risk of vascular lesions and incomplete sectioning of the sac. Moreover, many studies have reported similar results between open and endoscopic procedures in terms of postoperative morbidity and mortality, showing better functional outcomes in surgical patients even if elderly and presenting co-morbidities. In this report, the case of a 95 year-old patient, one of the oldest operated on for this disease and reported in the literature, is described. He was affected by a massive 8 cm Zenker's diverticulum and an oesophageal motility disorder (dyskinesia), with significant co-morbidity. Surgical diverticulectomy combined with cricopharyngeal myotomy was performed with excellent early and late results.

Over the past few years, incidental thyroid microcarcinoma has become a frequent disease and its incidence in some reports is considerable. Discovering new cases depends on the extended indications for total thyroidectomy for benign disease, on progress in the field of diagnostic instruments (ultrasound, scintigram, fine needle biopsy for cytology, CT scan, MRI), and on the pathology examination of very thin slices of specimens. In spite of the high incidence reported in some autopsy series, suggesting that this tumour may have a good prognosis, some Authors report an overall incidence of up to 11% of local recurrence, metastasis or mortality. For all these reasons the surgical treatment of incidental thyroid microcarcinoma is still controversial. The aim of this study was to estimate the incidence and examine the clinical-pathological findings of incidental thyroid microcarcinoma in a series of 100 consecutive thyroidectomies and to evaluate whether complete removal of the gland should be adopted in all cases. In the present series the incidence of incidental thyroid microcarcinoma was 21.6% (19/88). Total thyroidectomy was considered the treatment of choice for diffuse benign disease and appeared to be necessary for both the diagnosis and treatment of incidental thyroid microcarcinoma.

More than 10 years after its appearance in clinical practice, laparoscopic cholecystectomy can now be considered the standard operation for gallstone disease. However, some aspects of this operation are still debated. The need to perform routine antibiotic prophylaxis in order to reduce the incidence of infectious complications is still a matter of controversy. International guidelines do not recommend its routine use. The evidence for this, however, is rather limited, because there are no randomized trials with a sufficient number of cases to avoid a type II error. The authors, on behalf of the Lap Group Roma, introduce the protocol of a multicenter prospective randomized controlled clinical trial designed to find a definitive answer to this problem.

Following the researches performed on lymphatic spread of gastric carcinoma, our study aimed to add useful informations to establish the extension of exeresis with radical intent on the basis of recent studies on sentinel node mapping. The study includes 120 consecutive cases of gastric cancer operated between 1996 and 2000. Sixty-nine (57.5%) males and 51 (42.5%) females, with age ranging between 29 and 84 years, were evaluated. Cancer location was in 17 patients upper third, in 35 middle third, in 59 distal third and in 9 cases gastric stump. Early cases (T1-2) were 65 and advanced cases (T3-4) were 55. Sixty-eight STG and 52 TG were performed with 21 D1, 73 D2 and 26 D3 lymphoadenectomy. Overall 3501 lymph-nodes were examined. Eighty-two cases (68%) showed lymph-nodal metastases, while 38 (32%) were negative. The lymphatic spread of gastric cancer resulted related to the depth of wall invasion (T): 25% of T1, 75% of T2, 85% of T3 and 95% of T4 were node positive (N+). The correlation between T and N+ was also significative concerning the diffusion to the first, second and third level stations, increasing with the depth of wall invasion. The possibility of extension to one single lymphnodal station was inversely related to the T. When the first level stations were negative the second and third were never positive. This study seems to confirm the complex but systematic and predictable lymphatic gastric flow. The skip metastases, rare but described in other retrospective studies, were never observed. Our study shows that sentinel node mapping could be reliable also for gastric cancer surgery, allowing tailored and less aggressive resections. Meanwhile, from this analysis it appears that nodal stations 7-8 should be included in the first level lymphoadenectomy, widening D1 exeresis considered until now sufficient in less advanced cases. In conclusion, studies of lymphatic spread and sentinel node mapping seems to require a different therapeutic approach to gastric cancer concerning D1 lymphoadenectomy, tailoring the exeresis on the basis of sentinel node mapping in negative T1-2 cases, but systematically widening the lymphoadenectomy from the perigastric only, to 7 and 8 stations.

Aim of the Study: The aim of the study was to define the efficacy of liver resection for metastases from operated breast cancer by means of analysis of the results of a single institution compared to the literature data., Materials and Methods: Over the period from 1990 to 1998, 15 patients with liver metastases from operated breast cancer were submitted to surgical resection. Thirteen patients were operated on for single metastases and two for multiple liver metastases. In the first group, a simple metastasectomy or wedge resection was sufficient, while in the second a bisegmentectomy and a right hepatectomy, respectively, were performed. Nine patients were subsequently submitted to adjuvant chemotherapy, two to chemo- and hormonotherapy, and two to hormonotherapy alone, while two other patients received no systemic treatment., Results: No major complications or postoperative mortality were observed. Median survival was 44 months. The actuarial 5-year survival rate was 38.3%. Eight patients are still alive, and 7 patients have died as a result of their liver and systemic metastases., Conclusions: Hepatic metastasis from breast cancer is a good indication for surgical resection. Resection is capable of providing curative treatment and better results in terms of quality of life and survival rates, as compared to chemotherapy and hormonotherapy, especially in patients operated on for primary tumours more than three years earlier.