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Introduction: Total mesorectal excision (TME) is the cornerstone of a correct surgical therapy for extraperitoneal rectal cancer. Aim of the study is to evaluate our 5 years experience confronting retrospectively laparoscopic (lap) TME in respect to its laparotomic (open) counterpart., Patients and Methods: 30 patients were treated laparoscopically for stage I-III extraperitoneal rectal cancer and retrospectively compared to a homogeneous group, stratified for sex, age, comorbidities and stage of disease., Results: 30 days mortality was zero for both groups, while morbidity was 20% for the lap group and 36.6% for the open group. Mean lymph nodes harvested was 24 ± 12 for the lap group, 26 ± 14 for the open group (p > 0.05). Five years overall and disease free survival was respectively 82.2% and 81.4% in the lap group, 79.9% and 79.6% in the open group, without statistical significance (p>0.05). Discussion. Minimally invasive TME resulted a safe, effective and oncologically adequate procedure when retrospectively compared to its laparotomic counterpart, with 5 years overall survival and disease free survival reaching no statistical significance compared to the open approach, but with all the advantages of the laparoscopy such as less pain and blood loss, faster recovery, less morbidity and better cosmetics., Conclusions: Our study has retrospectively demonstrated that laparoscopic TME is feasible and oncologically effective, even if it remains a complex minimally invasive procedure, requiring adequate skill. More prospective, randomized studies are necessary to define such a procedure as the new gold standard in treatment of stage I-III extraperitoneal rectal cancer.

Aim: Laparoscopic gastrectomy is becoming a minimally invasive procedure widely accepted by laparoscopic surgeons; yet, many doubts remain about its oncologic efficacy in treating malignant neoplasia. Aim of this study was to analyze our experience comparing completely laparoscopic total gastrectomy to its laparotomic counterpart, about safety, efficacy and five-year oncologic outcome., Methods: From January 2003 to October 2009, 25 patients with stage I-III/C gastric cancer (TNM Seventh Edition, 2010) were operated on and retrospectively compared to an homogeneous group of patients, stratified for age, stage of disease and comorbidities. Length of surgery, estimated blood loss, postoperative ileus, resumption of oral intake, morbidity, 30 days mortality, number of lymph nodes harvested, five years overall and disease free survival were analyzed, comparing the two groups., Results: There was no conversion. Thirty days mortality was zero for both groups, while morbidity was 16% in the lap group, 32% in the open group (P<0.05). Length of operation was 211±23 min for the lap group, and 185±19 min for the open group (P>0.05); the estimated blood loss was 250±150 mL for the lap group, 495±190 mL for the open group (P<0.05). Number of lymph nodes harvested was 35±18 for the lap group, 40±16 for the open group (P>0.05). No port site metastatic implantation occurred in any patient treated laparoscopically; five years overall and disease free survival were 55.7% and 54.2% for the lap group, 52.9% and 52.1% for the open group, respectively, with no statistical difference (P>0.05). Completely laparoscopic total gastrectomy represents a new challenge for the laparoscopic surgeon. In spite of clear advantage for patients, some debate remains about its oncologic efficacy in the middle and long period, even if many authors report comparable results to open total gastrectomy. In our experience, it is a safe and valid alternative to its open counterpart, with no statistically different number of lymph nodes harvested, five years overall and disease free survival in respect to the open gastrectomy. Yet, it remains a complex procedure requiring high laparoscopic skill., Conclusion: In our opinion, completely laparoscopic total gastrectomy is a safe and effective procedure, with long term oncologic results not statistically different from the open procedure; yet, it requires high laparoscopic experience, especially to carry out an extended lymphadenectomy and to fashion the anastomosis. More randomized prospective trials are needed to state this procedure as a new gold-standard in treating stage I-III/C non metastatic gastric cancer.

Aim: Laparoscopic Appendectomy (LA) is widely performed for the treatment of acute appendicitis. However the use of laparoscopic approach for complicated appendicitis is controversial, in particular because it has been reported an increased risk of postoperative IntraAbdominal Abscess (IAA). The aim of this study was to compare the outcomes of LA versus Open Appendectomy (OA) in the treatment of complicated appendicitis, especially with regard to the incidence of postoperative IAA., Patients and Methods: A retrospective study of all patients treated at our institution for complicated appendicitis, from May 2004 to June 2009, was performed. Data collection included demographic characteristics, postoperative complications, conversion rate, and length of hospital stay., Results: Thirty-eight patients with complicated appendicitis were analysed. Among these, 18 (47,3%) had LA and 20 (52,7%) had OA. There were no statistical differences in characteristics between the two groups. The incidence of postoperative IAA was higher (16,6%), although not statistically significant, in the LA compared with OA group (5%). On the other hand the rate of wound infection was lower (5%) in the LA versus OA (20%)., Conclusion: Our study indicated that LA should be utilised with caution in case of perforated appendicitis, because it is associated with an increased risk of postoperative IAA compared with OA.

Aim: Since 1990 when it was firstly performed, radical laparoscopic nephrectomy has gained wide popularity because of its less morbidity and adequate oncologic outcome. The aim of this study was to report our experience about oncologic 5-year outcome of laparoscopic radical nephrectomy., Methods: Fifteen patients were treated laparoscopically and retrospectively compared to a group of patients treated laparotomically, omogeneous for age, stage of disease and comorbidities., Results: There was no conversion in the laparoscopic group and duration of both procedure showed no statistical difference. Laparoscopic procedures showed less intraoperative blood loss, less postoperative ileus, shorter hospitalization and less morbidity, all with statistical significance. Overall 5 years survival showed no statistical significant difference in the two groups (88.9% laparoscopic group vs. 86.2% laparotomic group)., Conclusion: Laparoscopic radical nephrectomy has clear advantages compared to the traditional surgery, especially about less morbidity, less blood loss, shorter hospitalization, with an oncologic outcome absolutely comparable to the laparotomic procedure. Laparoscopic radical nephrectomy is a safe and oncologically adequate surgical procedure with clear advantages compared to the its open counterpart, so it must be considered as a valid alternative to laparotomic surgery in case of non metastatic T1-T2 kidney cancer.

Introduction: Laparoscopic gastrectomy represents an alternative procedure for treatment of gastric cancer. Yet, some debate remains about its efficacy, basically from an oncologic point of view. Aim of this study is to analyze our experience with totally laparoscopic total gastrectomy with termino-lateral esophago-jejunal anastomosis by Or-Vil device., Patients and Methods: From February 2007 to February 2008, 10 patients underwent the procedure with Or-Vil device for the esophago-jejunal termino-lateral anastomosis. ASA score, UICC-AJCC stage, number of lymph nodes harvested, mortality and morbidity were analyzed., Results: All procedures were concluded laparoscopically. No mortality was observed, morbidity was 20%. Median of lymph nodes harvested was 30+/-14. No port implantations were observed. Discussion. Laparoscopic gastrectomy, both partial and total, is a new challenge, with clear advantages for the patients, but it still must demonstrate its efficacy, especially from the oncologic point of view. In our experience, we can state that totally laparoscopic total gastrectomy is safe, effective and oncologically correct; yet, it is technically demanding and more studies are required to confirm its oncologic efficacy when compared with laparotomic gastrectomy., Conclusions: Totally laparoscopic total gastrectomy with esophago-jejunal termino-lateral anastomosis by Or-Vil device represents, in our experience, a valid alternative to open procedure; yet, more prospective randomized trials are needed to define this procedure as a new standard for gastric cancer treatment.

Total mesorectal excision (TME) is the cornerstone of surgical treatment for extraperitoneal rectal cancer. The aim of the present study was to analyse our five-year experience with laparoscopic TME, evaluating the overall five-year and disease-free survival rates. Twenty-five patients with low-middle rectal cancer were treated with laparoscopic TME. Patients with advanced rectal cancer were treated preoperatively with neoadjuvant radiochemotherapy. Five-year overall survival and disease-free survival were calculated according to the Kaplan-Meier method. Twenty-three ultralow anterior resections with Knight-Griffen anastomosis and 3 abdominoperineal resections were performed. At 30 days mortality was zero, while morbidity was 20% (all minor complications). The mean follow-up period was 30.5 months. Five-year overall survival was 80.2%, and five-year disease-free survival 80.9%. Our experience shows that laparoscopic TME is a safe and oncologically correct procedure. Oncologic outcomes were comparable to those reported in all major international experiences, and the results were very similar to those obtained with the laparotomic approach. However, it remains a complex technique, requiring an adequate learning curve. More prospective, randomised trials are needed in order to define laparoscopic TME as the new gold standard for the treatment of extraperitoneal rectal cancer.

Laparoscopic left hemicolectomy is still uncommon in surgical practice, because of both an unjustified fear of oncological inadequacy and technical difficulties with a steep learning curve. The aim of the present study was to analyse our 5-year experience with laparoscopic left hemicolectomy and its short- and long-term results. Thirty patients with non-metastatic non-infiltrating left colon cancer were treated laparoscopically and retrospectively compared to a group treated laparotomically and well matched for age, comorbidity and stage of disease in respect to the laparoscopic group. The duration of the laparoscopic procedures was longer, but intraoperative blood loss, passage of flatus and hospital stay were significantly less. Morbidity was similar and there was no 30 days mortality in either group. Specimen length and number of harvested lymph nodes were similar and 5-year cumulative survival curves showed no significant statistical difference (73.1% laparoscopic vs 70.8% open). Today, laparoscopic colon procedures are rarely performed, due both to fear of oncological inadequacy and to technical difficulties, yet several recent trials have presented evidence of safety, and oncological results comparable to those of the open counterpart. Our 5-year experience confirms these studies: our short- and long-term results show no statistical differences between the laparoscopic and "open" procedure. Laparoscopic left hemicolectomy is a safe, effective and oncologically adequate surgical procedure for non-metastatic non-infiltrating left colon cancer and is therefore a valid option for the surgical treatment of these neoplasms.

Early gastric cancer is a gastric carcinoma confined to the mucosa or submucosa of the stomach, regardless of the presence of nodal involvement, which in any event is present only in about 20% of patients. This uncommon nodal involvement is a distinct clinical problem, because standard D2 lymphadenectomy constitutes overtreatment in more than 80% of patients. A review of the literature shows that the present surgical tendency for those patients who do not fulfill the Gotoda criteria (i.e. not amenable to an endoscopic mucosal or submucosal dissection) is to modulate the extent of the lymphadenectomy on the basis of the characteristics of the cancer: for mucosal early gastric cancers located in the upper third of the stomach, gastrectomy with D1 lymphadenectomy is sufficient; if located in the middle third the extent should be D1 +alpha (D1 + n. 7), while if located in the distal third, D1 +beta (D1 + n. 7,8a,9) is the best option. In all these cases, minimally invasive surgery can be a valid option, with results which are comparable to those of open surgery, but with all the advantages of the laparoscopic approach. For submucosal early gastric cancers, D1 +beta lymphadenectomy is indicated for neoplasia > 20 mm and of the protuberance type, while, for all other submucosal early gastric cancers (> 20 mm and of the depressed type, penetrating more than 500 micron into the submucosal layer, not differentiated, with lymphovascular invasion), standard D2 lymphadenectomy is the safest oncological procedure. In these cases, too, the laparoscopic approach can be a safe option, even if it requires greater laparoscopic skill.

Laparoscopic right hemicolectomy has developed less markedly than rectosigmoid resection, probably because of the more complicated regional anatomy and greater difficulty in performing an adequate regional lymphectomy. The aim of the present study was to analyse our 5-year experience with laparoscopic right hemicolectomy. Twenty patients were enrolled with non-metastatic, non-infiltrating right colonic cancer, treated laparoscopically and compared to a group well matched for age, sex, comorbidity and stage of disease, treated laparotomically. The duration of the laparoscopic procedures was slightly longer, but intraoperative blood loss, passage of flatus and hospital stay were reduced compared to the laparotomic procedure. Morbidity was similar and there was no 30-day mortality in either group. Specimen length and number of harvested lymph nodes were similar and the 5-year cumulative survival curves showed no statistically significant difference (72.5% versus 72.2%). Our experience shows that laparoscopic right hemicolectomy is a safe, effective and oncologically adequate procedure, comparable in all respects to open hemicolectomy, but with all the advantages of the minimally invasive technique. Yet, it remains a complex surgical procedure, requiring skill and a long learning curve. Further studies, possibly prospective and randomised, are necessary to define the exact role of this technique for the treatment of non-metastatic, non-infiltrating right colonic cancer.

Adenocarcinoma of the gastro-oesophageal junction is progressively rising in western countries and, because of its poor prognosis, presents a real clinical challenge for the oncological surgeon. We evaluate our initial experience with wholly laparoscopic trans-hiatal extended total gastrectomy with the Or-Vil device for treating Siewert type II and III tumours of the gastro-oesophageal junction. Ten patients were enrolled in the present study; ASA score, stage of disease, length of surgery, estimated blood loss, number of lymph nodes harvested, length of proximal margin clearance, morbidity and mortality were analysed. Mortality was nil and morbidity 20%; the average proximal clearance margin was 5.7 cm and all margins were tumour-free (RO). The number of lymph nodes harvested was 38 +/- 19. Neither anastomotic fistulas nor major dehiscence were observed. In our initial experience, wholly laparoscopic trans-hiatal extended total gastrectomy for treating Siewert type II and III tumours of the gastro-oesophageal junction is safe, effective and, according to our preliminary results, oncologically correct, but it remains a complex, advanced laparoscopic procedure, requiring major skills and adequate experience. Prospective, randomised trials--possibly multicentric--are required to establish its efficacy in terms of long-term oncological outcomes.

Numerous techniques exist for inguinal hernia treatment. Currently, open mesh tension-free repair is regarded as the repair method of choice. In particular Lichtenstein repair is the most common procedure performed, although several articles have reported long-lasting postoperative pain and a higher recurrence rate than originally reported. This study describes the P.A.D. (Protesi Autoregolantesi Dinamica) prosthesis implantation technique and reports postoperative complications and long-term results. From June 2002 to May 2005 a total of 214 patients underwent P.A.D. prosthesis inguinal repair. All patients were male, with a mean age of 51 years. All hernias were treated via an open inguinal approach using the original technique described by Valenti, with slight modifications. A total of 171'patients (80%) were available to follow-up 3 years after surgery. Early postoperative complications occurred in 14 patients (8.4%). Four patients (12.1%), who had undergone regional anaesthesia, developed urinary retention. Wound infection occurred in 3 patients (1.4%). There were two direct recurrences (0.93%) whereas chronic postoperative inguinal pain was reported in 4.2% of patients. Within the limitations of a short follow-up, our results show that the P.A.D. prosthesis procedure is a reliable technique with a low recurrence rate and low postoperative morbidity.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the GI tract, deriving from interstitial Cajal cell degeneration. Over 95% of GISTs express CD-117 and CD-34, thus differing from other mesenchymal-derived tumours. The aim of this study was to evaluate our experience with a multifocal GIST, treated by laparoscopic total gastrectomy, and review the literature. A 74-year-old man with a preoperative diagnosis of sub-cardial GIST, obtained by endoscopy, CT scan and endoscopic ultrasound, was submitted to laparoscopic total gastrectomy with an end-to-side oesophago-jejunal anastomosis, using the Or-Vil system. GISTs account for only 1% of all GI tumours, with a variable behaviour, from indolent forms to aggressive tumours with potential for hepatic and peritoneal metastasis. Surgery is the cornerstone of therapy, the aim being to obtain an R0 resection, so as to minimise the risk of recurrence. Laparoscopic total gastrectomy is an excellent solution for their treatment, with possible adjuvant therapy based on imatinib-mesylate, for high-risk GIST.

Conventional repair of incisional hernia is associated with significant complications and a high recurrence rate (30-50%). The laparoscopic approach offers an effective alternative and reduces the recurrences to less than 5%. The aim of this study was to review our experience with laparoscopic incisional hernia repair. Medical records of all patients who underwent laparoscopic incisional hernia repair from January 2002 to December 2006 were reviewed. Demographic and postoperative data were recorded. The study population consisted of 105 patients, 72 females (68.5%) and 33 males (31.5%); the mean age was 56 years (range: 17-83 years). The mean fascial defect size was 116.9 cm2 and the average mesh size used was 256 cm2. Operative time was 118 min and the average hospital stay was 5 days. An expanded polytetrafluoroethylene (ePTFE) prosthesis was used In all patients. Perioperative complications occurred in 33 patients (31.4%) including seroma, cellulitis at the trocar site and prolonged ileus. During the follow-up there were 3 hernia recurrences (2.8%). Our study shows that laparoscopic incisional hernia repair resulted in a moderate rate of perioperative complications, a short hospital stay and a low recurrence rate. Hence the laparoscopic technique should be considered an effective and safe alternative to conventional incisional hernia repair.

Laparoscopic treatment of simple hepatic cysts is reported. Recent indications to conservative surgical treatment for this benign disease are considered and different therapeutic options are analyzed. Surgical technique adopted in two cases observed is illustrated. In conclusion, the Authors consider laparoscopic treatment as an effective method for a mini-invasive surgical approach.