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Highlights • Spigelian Hernia is a rare abdominal wall hernia. • Urgent presentation with small bowel obstruction is uncommon. • Laparoscopy could be an option in elective surgery but in emergent setting laparotomy is required. • Mesh repair is mandatory to avoid recurrence., Introduction Spigelian Hernia is an uncommon pathology of abdominal wall (0.12–2.4%), usually small sized and with vague symptoms. It rarely presents as Small Bowel Obstruction or reaches dimensions that becomes clinically remarkable. Presentation of case 84-year-old woman entered our Surgical Department for Small Bowel Obstruction due to a giant (8 × 7 cm) abdominal wall hernia, which was intraoperatively identified as Spigelian Hernia. We performed a minilaparotomy with reduction of viable small bowel and preperitoneal positioning of polypropilene mesh. Postoperative course was uneventfull. Discussion Due to its small dimensions and infrequence, the diagnosis could be challenging even if the patient undergoes a CT scan. The presentation with clear signs of small bowel obstruction associated with a large abdominal hernia is rare and suggests a urgent surgical approach with mesh repair to avoid recurrences. Conclusion Even if rarely symptomatic, the Spigelian Hernia is an entity to consider in the differential diagnosis of small bowel obstruction in a virgin abdomen. Preoperative diagnosis, when available, is mandatory to guide a correct surgical approach.

Enterocutaneous fistula is a rare but severe complication of prosthetic incisional hernia repair. Management requires re-exploration with intestinal repair/resection and mesh removal. Repair of the parietal defect in this contaminated field is challenging.A 58-years male patient presented to our department one year after synthetic mesh repair of large incisional hernia with mesh infection and enterocutaneous fistula. The diagnosis was confirmed by ultrasound guided drainage and CT scans with oral contrast. A multiple-step surgical approach has been adopted: first, the mesh was removed, intestinal resection performed and posterior fascial closure obtained by bilateral transversus abdominis release (TAR) and supra-fascial NPWT (negative pressure wound therapy) was positioned and maintained for one week; second, a definitive repair was obtained by a biological prothesis fixed to posterior fascia and covered by anterior fascia closure. Then, new NPWT was positioned and maintained for 6 days on the skin closure. At 18-months follow-up, the patient showed no clinical or radiological signs of recurrence or reinfection.Surgical strategies to face enterocutaneous fistula after prosthesis ventral hernia repair are not standardized. After bowel fistula treatment and mesh removal, the challenge of abdominal wall closure stay unsolved because of the high rate of complication and failure of a new prosthetic repair. A case-by-case management plan, often with the use of a multi-step strategy, may be an option.This is a single recovery multiple-step strategy combined approach using NPWT and biological prothesis to manage a case of mesh infection by an enterocutaneous fistula. This unique approach has revealed safe and effective for the treatment of parietal defect in infected field resulting from a mesh removing procedure.Biological prosthesis, Bowel mesh erosion, Enterocutaneous fistula, Negative Pressure Wound Therapy, Open incisional hernia repair.La fistola enterocutanea è una complicanza rara ma assai temuta legata all’utilizzo di reti per la plastica del laparocele. Non essendoci ancora una tecnica standardizzata, abbiamo descritto un caso clinico di rilevanza: maschio, 58 anni, a distanza di 1 anno dall’essere stato sottoposto a plastica per un voluminoso laparocele con utilizzo di rete sintetica, mostrava segni e sintomi clinici di infezione della protesi con presenza di una fistola enterocutanea. La diagnosi veniva confermata da ecografia, col drenaggio dell’ascesso e TC con mdc per os. Data la complessità del caso, abbiamo adottato una strategia multi-step: in primo luogo, rimozione della protesi, resezione intestinale e chiusura della fascia posteriore dei muscoli retti con associata TAR (transversus abdominis release) e posizionamento di dispositivo NPWT soprafasciale per 1 settimana; successivamente, chiusura definitiva con protesi biologica fissata tra la fascia posteriore ed anteriore dei muscoli retti, ancora con NPWT a protezione della cute per ulteriore 6 giorni. Il decorso postoperatorio è stato privo di eventi avversi e il paziente, ad un follow-up clinico-radiologico di 18 mesi, non presenta segni di recidiva o reinfezione. Questo approccio multi-step si è rivelato sicuro ed efficace nel nostro caso, e data la mancanza di standardizzazione per una patologia poco frequente, rappresenta una concreta possibilità terapeutica.

Highlights • Retroperitoneal schwannomas are usually asymptomatic, rare neoplasms. • Diagnosis can only be achieved with surgical removal of mass. • Laparoscopy is the most useful therapeutic approach., Introduction Single pelvic schwannomas are rare tumor arising from the retrorectal, lateral or obturatory space. Laparoscopic approach to schwannoma located in lateral pelvic space has been previously described only in one case report. We present a case of a successful laparoscopic resection of pelvic schwannoma emphasizing the advantages of such a minimal invasive approach. Presentation of case A 54-years-old, obese, male patient was admitted to our hospital referring dysuria and strangury. Abdominal CT scan showed a lateral pelvic well-circumscribed mass with smooth regular margins. A CT-guided fine needle biopsy resulted non-diagnostic. An elective laparoscopic resection was performed. The patient had a short, uneventful post-operative course. Pathological examination revealed a benign schwannoma. Discussion Using PubMed database, we reviewed the English language international literature using the MeSH terms “laparoscopic,” “minimally invasive” and “schwannoma”. We identified quite 20 previous cases of pelvic schwannomas removed by laparoscopy or robotic surgery. We found out that a preoperative diagnosis of these rare neoplasms is difficult to be obtained; in most cases, laparoscopic approach was successfully performed. Conclusion Despite it could not be proven yet, due to the rarity of this tumor, we agree with literature that laparoscopic removal of pelvic benign tumor may offer several advantages. The direct high-definition vision deeply into this narrow anatomical space, especially in obese patients, provides a detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor. Furthermore, the pneumoperitoneum may create the right plane of dissection, minimizing the risk of tumor rupture and bleeding.

Background Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner. Methods This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm. Results On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%. Conclusions The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach. 43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube. In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated “satisfactory” along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin. From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.

Introduction Gastric Carcinoid Tumors (GCT) are very rare in general population, but some studies evidenced a higher incidence among bariatric surgery patients. Laparoscopic Sleeve Gastrectomy (LSG) is a widely accepted procedure for the surgical treatment of morbid obesity. LSG acts both in reducing food intake and interfering with hormonal balance in the gut-brain axis. In these patients, incidental GCT diagnosis can occur both during pre-bariatric surgery investigation and during post-operative follow-up. Methods We retrospectively analyzed the database of obesity patients submitted to LSG in two different centers to find out incidence of GCT in patients treated by surgery from May 2013 to March 2018. Results From the 560 obese consecutive patients underwent LSG, we recorded two cases of patients with GCT (0.36%): the case 1 was a patient who had a pre-operative diagnosis of GTC receiving a curative LSG which totally included the carcinoid in the resected portion; the case 2 was a patient that received a curative endoscopic resection 42 months after LSG. Discussion the predisposing factors that can correlate GCT with obesity and LSG and in particular the hormonal changes have been discussed. We illustrated our experience about the management of these tumors in obese patients. Conclusion there are neither certain data which evidence a correlation between obesity and GCT, nor data to support the hypothesis of a higher incidence of GCT after bariatric surgery. Based on our experience in obese patients the finding of GCT in the pre-operatory phase is not an absolute contraindication for bariatric surgery., Highlights • Recent observations showed a high incidence of Gastric Carcinoid Tumor (GCT) in candidate patients for bariatric surgery. • From a multicenter experience with Laparoscopic Sleeve Gastrectomy. • We retrospectively recorded two GCT cases in obese patients (the first found out during pre-operative investigations and the second one detected 52 months after surgery). • The possible correlations between obesity, LSG and GTC have been discussed.

Highlights • Methastases to thyroid gland are a rare condition. • RCC (renal cell carcinoma) is the most common primitive tumour which leads to thyroid methastases. • Preopeative diagnosis is hard to be established with routinary techniques. • Surgical approach (total thyroidectomy) is useful to obtain long survival rate., Introduction We report the case of an incidental solitary renal cancer cell (RCC) thyroid metastatic nodule treated by thyroidectomy. Presentation of case A 53 year male presented with a solitary, asymptomatic thyroid nodule. He was treated with left nephrectomy 1 year before for a RCC. Radiological standard follow-up was negative for secondary lesions but ultrasound (US) 12 months after surgery revealed a 1.5 cm solid nodule in the right lobe of the gland. Fine needle aspiration biopsy (FNAB) was inadequate and the patient was submitted to total thyroidectomy. Histology showed the presence of solitary metastasis from RCC. At 2 years follow-up, no evidence of recurrence has been found. Discussion Solitary RCC metastasis to the thyroid usually occurs late from nephrectomy and have no specific US pattern. When FNAB provides an uncertain cytological results, the patient received thyroidectomy for primary thyroid tumors and diagnosis of metastases from RCC was incidentally made. Conclusion Thyroid nodules in a patient with history of malignancy can pose a diagnostic challenge. The presence of a solitary thyroid nodule in a patient with history of RCC should be carefully suspected for metastasis. We suggest to extend at neck the thorax and abdomen CT scan routinely recommended during the follow-up in high-risk cases. Thyroidectomy may result in prolonged survival in selected cases of isolated thyroid metastasis from RCC.