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Minimally invasive pancreaticoduodenectomy (PD) is attracting increased interest in the pancreatic surgical community with more and more teams reporting their experience worldwide. The pancreatic anastomosis (PA) is one of the key steps and challenging manoeuvre of this procedure. Since the introduction of the minimally invasive approach for PD, several PA types have been proposed, ranging from high to low complexity, but none of them have been proven unequivocally superior to the others. Therefore, definitive consensus has not been reached yet. In the present multimedia manuscript, we report the most commonly adopted minimally invasive PA and we propose a "complexity classification" to guide the choice accordingly to different characteristics of the pancreatic stump. We describe five possible different PA that might be tailored to each different case, depending mainly on texture of pancreatic stump (soft/hard, lean/fatty) and the size and visibility of main duct. This manuscript presents a step-by-step portfolio of the most commonly used mini-invasive PA. This technique requires experience in pancreatic surgery and advanced minimally invasive skills. Knowledge of and proficiency in different types of PA could help reducing the incidence of postoperative pancreatic fistula., (© 2022. Italian Society of Surgery (SIC).)

Objective: Deep infiltrating endometriosis(DIE) of the bowel may require segmental bowel resection. The subsequent reconstruction can be performed through an end-to-end(E-E) or a side-to-end (S-E)anastomosis, the latter being used in low resection due to the reduced risk of anastomotic leakage. This study aims at comparing those two anastomosis techniques in women submitted to bowel resection for DIE, in terms of post-operative morbidity and functional outcomes., Methods: This was a single-center retrospective study on women undergoing laparoscopic rectal resection for deep infiltrating endometriosis with subsequent E-E or S-E anastomosis performed according to the level of rectal resection. The two groups were compared for postoperative complication rates and functional outcomes by means of validated questionnaires., Results: The study population included 30 patients undergoing a S-E anastomosis (group A), and 49 cases undergoing an E-E anastomosis (group B). No differences were found between the two groups in terms of length of hospital stay, anastomotic leakages, protective ileostomies and short-term complications. At follow up no differences were found between the two groups in terms of bowel function and pain symptoms., Conclusions: A S-E anastomosis in case of low rectal resections for DIE presents similar complication rates and functional outcomes compared with an E-E anastomosis., Competing Interests: Declaration of Competing Interest all Authors declare that there is no conflict of interests regarding the publication of this article, (Copyright © 2022. Published by Elsevier Masson SAS.)

Background: The present case-series describes the first full-robotic colorectal resections performed with the new CMR Versius platform (Cambridge Medical Robotics Surgical, 1 Evolution Business Park, Cambridge, United Kingdom) by an experienced robotic surgeon., Methods: In a period between July 2020 and December 2020, patients aged 18 years or older, who were diagnosed with colorectal cancer and were fit for minimally invasive surgery, underwent robotic colorectal resection with CMR Versius robotic platform at "Casa di Cura Cobellis" in Vallo della Lucania,Salerno, Italy. Three right colectomies, 2 sigmoid colectomies and 1 anterior rectal resection were performed. All the procedures were planned as fully robotic. Surgical data were retrospectively reviewed from a prospectively collected database., Results: Four patients were male and 2 patients were female with a median (range) age of 66 (47-72) years. One covering ileostomy was created. Full robotic splenic flexure mobilization was performed. No additional laparoscopic gestures or procedures were performed in this series except for clipping and stapling which were performed by the assistant surgeon due to the absence of robotic dedicated instruments. Two ileocolic anastomoses, planned as robotic-sewn, were performed extracorporeally. One Clavien-Dindo II complication occurred due to a postoperative blood transfusion. Median total operative time was 160 (145-294) min for right colectomies, 246 (191-300) min for sigmoid colectomies and 250 min for the anterior rectal resection., Conclusions: The present series confirms the feasibility of full-robotic colorectal resections while highlighting the strengths and the limitations of the CMR Versius platform in colorectal surgery. New devices will need more clinical development to be comparable to the current standard., (© 2022. The Author(s).)

Objective: To assess the feasibility and clinical utility of coronary artery stent (CAS) in securing pancreatico-jejunal anastomosis (PJ) and avoid stent displacement after pancreatoduodenectomy (PD)., Summary of Background Data: Externalized trans-anastomotic stent (ETS) is a standard mitigation strategy for postoperative pancreatic fistula (POPF) in high-risk patients. However, major morbidity remains extremely elevated, especially in case of ETS malfunction due to displacement., Methods: A pilot series of 72 patients underwent PD and PJ with CAS positioning between January 2016 and December 2019. All patients were at high-risk for POPF (soft pancreatic texture; main pancreatic duct diameter ≤ 3 mm) and underwent a CT-scan at postoperative day 5 and 10 to assess the correct CAS positioning. Postoperative outcomes were analyzed, and displacement rates were compared with a cohort of 141 patients with the same high-risk characteristics, undergoing PD with PJ and externalized trans-anastomotic stent (ETS)., Results: No CAS-related complications were registered in the study group. In particular, no CAS displacement was registered, compared to a 28% ETS malfunction (either displacement or occlusion). The POPF rate, major morbidity, and mortality were 11%, 6%, and 0% respectively., Conclusions: The CAS positioning appears to be a feasible and safe mitigation strategy to secure PJ anastomosis after PD with high POPF risk avoiding stent displacement. Further validation and comparison with current standard of care is required in a prospective controlled setting., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks., Competing Interests: None

Introduction: Recently, laparoscopic lavage emerged as an effective alternative for patients with perforated diverticulitis with purulent peritonitis., Case Report: A 96-year-old woman, diagnosed with Hinchey 3 diverticulitis after a computed tomography scan, was operated on with a single-access "lavage" to reduce surgical trauma and to avoid stoma., Methods: The procedure was performed under general anesthesia. Tracheal intubation, nasogastric tube, and urethral catheterization were mandatory. The patient was in a modified Lloyd-Davis position, with the table tilted in Trendelenburg position, left side up. Surgeons were on the right side., Instrumentation: The procedure was performed using a surgical technique similar to standard laparoscopy with traditional laparoscopic instruments. SURGICAL STEPS: The surgical procedure involved single-incision laparoscopic surgery (Covidien, Mansfield, MA) insertion, small bowel dissection, abscess opening, and peritoneal washing., Results: The procedure was completed in 75 minutes with an estimated blood loss of 120 mL. The patient was kept in the intensive care unit for 1 day. She was on postoperative analgesia for 2 days and was discharged from the hospital on postoperative day 5. The patient was able to drink on day 1 and eat on day 3 after flatus.

Background: Surgical treatment of advanced hypopharyngeal tumors is still a surgical challenge. We report a case of a hypopharyngeal tumor treated with a pharyngolaryngo-esophagectomy (PLE) and laparoscopic gastric tubulization and interposition., Methods: A 56-year-old man presented with a relapsing hypopharynx carcinoma, after primary chemoradiation therapy. Preoperative workup showed a stage IV cancer with esophageal invasion and multiple cervical lymph node metastases. Surgical treatment consisted of a cervical phase, with larynx, pharynx, and esophagus dissection, radical lymph node dissection, homolateral hemithyroidectomy and definitive tracheostomy, and an abdominal phase with a 4-trocar laparoscopy. The gastrocolic ligament was opened, and short gastric and left gastric vessels were divided preserving an accessory left hepatic artery. Gastric tailoring was carried out with 45-mm linear staplers. The hiatus was opened and the esophagus dissected free with Ultracision (Ethicon Endo-Surgery, Cincinnati, OH) to the tracheal bifurcation. The upper esophagus was bluntly mobilized by finger and sponge stick dissection. The gastric tube was pulled up, and the anastomosis between the stomach and the tongue base was performed with a 2-layer interrupted hand-sewn technique., Results: Total operative time was 390 min (abdominal time 180 min). Estimated blood loss was 400 cc. The number of dissected cervical lymph nodes was 32. Oral feeding was started after 10 days, and the patient was discharged after 14 days. Stage of disease was pT4N1M0 G3 R0., Conclusions: Laparoscopic surgery allows a minimally invasive gastric tailoring and tubulization and transhiatal esophageal dissection and represents a valuable alternative for intestinal reconstruction after PLE. CT scan showing a large hypopharynx carcinoma involving cervical lymph nodes and cervical esophagus.

Unlabelled: Blunt abdominal trauma is the most common cause of pancreatic injury in children. Laparoscopic distal pancreatectomy in a child with complete duct disruption has not been reported in the literature in children, although it has been well described in adults., Methods: In this paper report a case of a 7-year-old male, with grade 4 pancreatic trauma, who was treated nonoperatively in the acute phase and subsequently by laparoscopic distal pancreatectomy 3 months after the trauma., Discussion: Although in adults the surgical management of grade 3-4 pancreatic traumatic injury is well described, including the laparoscopic approach, no report of laparoscopic distal pancreatectomy was found in the literature. We would like to emphasize the importance of using a conservative management in the acute phase of pancreatic injury, including grade 4 injuries. After this phase, the use of the high-definition computed tomography scan and endoscopic retrograde pancreatography were fundamental., Conclusion: Magnification of laparoscopic technique allowed us to identify the structures much better than open surgery.

The therapeutical choice in patients affected with esophagus disease depends on patients' conditions, as well as on the benign or malignant nature of the lesion. Actually, the surgical option is strongly conditioned by the state of health, particularly, the surgical therapy of resection, that is a mayor kind of surgery, has to value the heavy engagement to which the patient is submitted, meant as a clinical stress, caused by the clinical situation in which the patient can frequently feel: malnutrition, immunological and hematological conditions. It is in this field that the mininvasive surgery can be considered the most important surgical choice. The target of the treatment of the traditional and mininvasive surgery, to cure the intestinal transit, by means of other internal organs, is the same: that is curative or palliative. In this study we analyzed and compared 8 patients, from July 1999 to March 2003; all of them undergone a therapy of resection in order to cure esophageal lesions (we applicated the same technique of esophagectomy according to Orringer): 5 of them underwent a mininvasive surgery, while the other 3 patients underwent a traditional surgery. As a result we saw the same mortality in both groups, with a minor morbidity in the second one (mininvasive surgery); this fact is very important because we can suppose an increase in the number of patients threatened with a curative or a palliative surgery, thanks to a minor load of the mininvasive surgery compared to the same surgical operation performed with the traditional methodology.

Background: The aim of the present study was to evaluate retrospectively the experience of six surgical units currently performing laparoscopic colorectal surgery., Methods: From November 1991 to January 1994, 200 patients (103 male, 97 female; mean age 62.5 years) were candidates for, and received, laparoscopic colorectal resection for benign (54) or malignant (196) lesions. All the units excluded patients with locally advanced organ tumors and all cases with suspected perforation and ascites. One center submitted to laparoscopic resection only stage I and IV adenocarcinoma. All surgeons considered obesity a relative contraindication. The following data were analyzed: indications, conversion rate to open surgery, operative time, morbidity and mortality, resumption of gastrointestinal function, number of lymph nodes harvested, hospital stay., Results: Twenty-one out of 200 patients were converted to open surgery (10.5%); 37 patients had a complete laparoscopic procedure (17.1%); 137 had an assisted resection (68.5%); and the remaining 5 patients had a facilitated resection. The mean operative time was 208 min (90-480) for assisted resection and 275 min (54-550) for complete laparoscopic resection. The mortality rate was 1.7%; the overall morbidity was 19.6% (major complications 11.2%). All patients quickly became ambulatory and showed a prompt resumption of gastrointestinal functions, and less postoperative pain if compared with converted cases. The average number of lymph nodes was 12.1 (range 1-32). The mean hospital stay was 8.6 days (range 5-14.5). The mean follow-up was 16 months (range 6-24). The recurrence rate 11.7%., Conclusions: Laparoscopy seems to offer the possibility of minimally invasive treatment, but long-term follow-up is needed to evaluate the efficacy of laparoscopic surgery in the treatment of colorectal cancer.

Swenson's procedure, first described in 1948 for Hirschsprung's disease, consists in resection of aganglionic intestine and distal colo-anal anastomosis provided a precise dissection of extra peritoneal rectum. Potential jeopardy of pelvic vessels and nerves stimulated alternative surgical techniques to prevent complications on bladder and genital function. We performed in laparoscopy Swenson's procedure after Toupet, taking advantage from closer view and magnification of this technique, in a 15 months girl. Laparoscopy simplified and made safer pelvic dissection and resulted in a better postoperative period and cosmetic outcome.

Transplenic decompression of esophageal varices by distal splenorenal shunt according to Warren (DSRS) aims to a selective detention of the esophago-gastric varices, also assuring an adequate portal perfusion and hypertensive state of the porto-mesenteric district. The DSRS though, should and must not be performed in emergency as a high mortality rate is registered in all cases of emergency porto-systemic derivations. A mortality risk is reported even during endoscopic sclerosis if performed in emergency compared to the elective procedure. The scope of our study was to test the validity of a new approach of the hemorrhagic cirrhotic patient: the end point was to stop the bleeding with Glypressin and deferred sclerotherapy, associating a selective shunt at 40-60 days. Out of 32 patients with esophago-gastric variceal bleeding, 8 were selected also for derivative surgery. Results show Glypressin as the first and best therapeutic approach. The drug in many cases stops bleeding or at least reduces the blood loss allowing an easier endoscopic sclerosis. Further sclerosis and/or surgical therapy may assure variceal eradication.

A multi-center study was carried out to compare the healing rates of ranitidine 300 mg nocte and 150 mg b.i.d. in the short-term treatment of gastric ulcers and to assess the side-effect liability of ranitidine 300 mg given in a single daily dose. Forty-five outpatients suffering from endoscopically and bioptically proven uncomplicated benign gastric ulcer were selected for the study. The patients were treated, for 4 weeks, on the basis of a double-blind randomized design. An endoscopic examination was repeated within 4 days after the end of the treatments. The patients who did not demonstrate complete healing were treated for an additional 4-week period. Clinical controls were performed to evaluate symptoms, antacid consumption, compliance with trial tablet consumption; hematological and biochemical tests were also carried out at the end of the 4 and 8-week periods. No differences were observed between the healing rate induced by 300 mg nocte and 150 mg b.i.d., after 4 weeks of treatment (76% and 79% respectively) and after 8 weeks (100% in both groups). Similar results were obtained as far as symptoms, antacid consumption and compliance are concerned. Neither treatment regimen induced appreciable side-effects.

Those surgeons who have had experience of Sofield's treatment in case of osteogenesis inperfecta would be unanimous in agreeing that this method offers great advantages to these unfortunate children. Although the technic is exact and the results often cancelled out by the growth so that the re-operation is indicated, nevertheless the long fracture-free period gained and the control of deformity confer very worth-while benefits. A case of O.I. is reported; the subject presented fracture sequaele in the lower limbs and bone alterations of extreme seriousness. Sofield's treatment was not possible in the rodding time; the Authors describe a modified treatment which has proved useful in practice. Notes on the specific features, course and treatment are presented; a particular attention is paid to its genetic and etiopathogenetic aspects.

The authors describe a transendoscopic wire snare excision of three jejunal polyps in a patient with Peutz-Jeghers syndrome. Two years previously the patient had undergone surgical jejunal segmental resection for invagination caused by several polyps, one of which revealed carcinoma in situ. The procedure was well tolerated, and the subsequent course was uneventful. Endoscopic follow-up of the proximal jejunal polyps in this syndrome is stressed.

The peritonitis from the rupture of the amebic liver's abscess is a not rare complication of the hepatic amebiasis in the children, with a poor prognosis. The usual treatment is loaded with a high morbility and mortality. The AA show a therapeutic screen based on saucerization with debridment and on the installation of a disposal of peritoneal washing. The above mentioned treatment is looking at the recovery of the organ and consequently at the direct removal of the "primum movens" of the septic shock and generalized peritonitis.