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Peritonitis complicating diverticular disease may be treated by sigmoid resection (with or without primary anastomosis) or by a conservative surgical approach, either laparoscopically or by open surgery. The choice depends on the severity of the peritonitis (Hinchey), the patient's conditions (ASA) and the surgeon's experience. Sigmoid resection with primary anastomosis has a lower morbidity and mortality vs Hartmann's procedure. After the introduction of laparoscopy in colorectal surgery, exploratory laparoscopy combined with drainage has been proposed to treat acute episodes, followed by laparoscopic resection. Since 1982, over 1000 patients have been operated on for colorectal disease: 119 for complicated diverticulitis, 55 of which complicated by peritonitis. In the latter, we performed conservative surgery (25 patients) and resection (30 patients) laparoscopically or by open surgery. Our results show a higher morbidity and mortality for the Hartmann procedure vs sigmoid resection with primary anastomosis and a lower specific morbidity in patients undergoing laparoscopic exploration and drainage. Moreover, there was a low percentage (52%) of re-canalisations with the Hartmann procedure, with a morbidity of 32% associated with this procedure. In conclusion, we believe that a conservative laparoscopic surgical approach may be advocated in selected cases (Hinchey II and III without clear perforation), followed by laparoscopic sigmoidectomy, resection with primary anastomosis in Hinchey I or in cases of evident perforation with purulent or faecal peritonitis (possibly combined with a stoma), reserving the Hartmann procedure for compromised patients.

The authors present their initial experience with minimally invasive surgery of the oesophagus. Two emblematic cases of benign and malignant oesophageal pathology, treated by laparoscopic transhiatal oesophagectomy, are reported. The surgical procedure is described in detail and compared with other techniques reported in the literature. Its advantages in terms of postoperative pain and morbidity are stressed. The role of the procedure in neoplastic diseases of the oesophagus is still debated, above all with regard to the accuracy of the mediastinal node dissection.

The authors present two cases of inflammatory abdominal aortic aneurysms complicated by an aorto-caval fistula in one case and by an aorto-duodenal fistula in the other. The aetiology of such aneurysms is still debatable, the histological features are typical, and the preoperative clinical and instrumental findings do not always allow them to be differentiated from atherosclerotic ones. The complications may be rapidly fatal or asymptomatic, as in the case of occult aorto-caval fistulas. The surgical approach is technically more difficult because of inflammation and adhesions between the aneurysmal sac and contiguous structures which make dissection and aorto-iliac clamping more demanding. In the case of aorto-caval fistulas, clamping of the vein should be avoided and manual compression preferred to assure haemostasis; with aorto-enteric fistulas, it is necessary to reduce the contamination of the operative field. Ureterolysis is not always necessary in patients with hydronephrosis. Endovascular devices may be an alternative also for a number of complications.

The authors present two cases of toxic megacolon. A proctocolectomy with ileostomy was performed in both cases. One of the two cases was detected late; the patient underwent surgery in desperate conditions and died on postoperative day one. The authors regard a prompt diagnosis as fundamental for the correct timing of the surgical approach in patients with toxic megacolon and severe acute colitis. Clinical and laboratory findings and, above all, plain films of the abdomen should be evaluated very carefully. The authors suggest total proctocolectomy with section-suture of the rectal stump at levator level and ileostomy, which makes it possible to avoid postoperative rectal haemorrhages and recurrences.