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Background: The purpose of this study is to assess outcomes and 5-year survival after subtotal gastrectomy (SG) for early and advanced distal adenocarcinoma with D2 dissection performed by minimally invasive surgery (MIS)., Methods: From June 2000 to October 2009 a total of 70 patients with adenocarcinoma of the lower third of the stomach underwent SG with D2 nodal clearance by MIS. This series enrolled 37 patients with early gastric cancer (EGC) and 33 with advanced gastric cancer (AGC). SG was attempted by conventional laparoscopy (CL) in 52 cases and by robot-assisted (RA) technique in 18. Clinical and histopathologic results with 5-year survival were analyzed., Results: No intraoperative complication was registered. Conversion to laparotomy was required in five patients. Overall, the mean operating time for SG was 254 min (range = 145-460) and estimated mean blood loss was 146 ml (range = 45-250). Postoperative complications occurred in seven patients, including two duodenal leakages none of which required laparotomy. There were two postoperative deaths, one caused by hepatic failure and one by hemorrhagic stroke. Preoperative understaging occurred in ten cases (three were AGC). On average, 30 ± 8 lymph nodes were collected. The distance of proximal resection margin was 6.6 cm (range = 4-8.5 cm). Short-term results were equal with those of laparoscopic and RA gastrectomy. The mean hospital stay of all patients was 10 days (range = 7-24). The mean follow-up span was 53 months (range = 3-112). Relapse of disease occurred in 12 patients, 10 of whom died from the disease and their mean survival was 25 months (range = 12-38). The overall 3-year survival was 85% for CL gastrectomy and 78% for RA gastrectomy, but this difference was not significant with the log rank test (p > 0.05). The overall 5-year survival was 81% (97% for EGC and 67% for AGC)., Conclusion: D2 subtotal gastrectomy performed by MIS is reproducible and safe. The long-term outcomes and 5-year survival are acceptable. Extended lymphadenectomy was carried out for both EGC and AGC so as to ensure adequate nodal clearance and compensate preoperative underestimation.

Purpose: Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique that aims at reducing or abolishing skin incisions and potentially also postoperative pain. The purpose of this study was to analyse operative and long-term results of a series of hybrid transvaginal cholecystectomy., Materials and Methods: Between July 2007 and May 2009, transvaginal NOTES cholecystectomy for symptomatic cholelithiasis was performed by a hybrid technique in 18 women (mean age 54 years), including four women with a body mass index >30 kg/m(2). Dissection was conducted in the first four cases by a round-tip unipolar electrode (UE) introduced through the operative channel of the endoscope coming from the vagina and in the last 14 cases by a ultrasonic scalpel (US) introduced through a 5-mm abdominal port. The short-term outcomes and the long-term results of the two methods were compared., Results: The transvaginal approach entailed no intraoperative complication and no conversion. The overall mean duration of procedures was 75 min (range 40-190). In the first four cases (UE), the operating time was 148 min (range 140-190), whilst in the last 14 (US), it was considerably shorter, 53 min (range 40-60, p < 0.01). We experienced one biliary leak in the UE group, whilst morbidity with US was nil (p < 0.005). The biliary leak healed in 7 days with nasobiliary drainage. No other complications were encountered in either group. The mean follow-up was 12 months (range 1-22), and none of the patients has complained of dyspareunia or other colpotomy-related complications so far., Conclusions: Until specifically designed endoscopic tools are available for NOTES, the hybrid technique with US dissection conducted through a 5-mm port should be preferred in transvaginal cholecystectomy in order to shorten the duration of surgery and make this approach effective, safe and reproducible. After a mean follow-up of 1 year, none of our patients has complained of any problem related to transvaginal approach.

Background: The aim of this study was to assess feasibility and results of laparoscopic approach to repair incisional hernias of the abdominal borders, the weakest points of abdominal wall., Methods: Since 2002 through 2008 a total of 39 patients with fascial defects of the abdominal borders underwent laparoscopic repair. The defects were suprapubic (n=18), subxiphoidal (n=15), and lateral sided (n=6). The body mass index was >oe=30 Kg/m2 in 19 patients. The parietal defects was measured both externally and from within the peritoneal cavity and 56% of meshes were fixed only by tacks, especially in suprapubic site., Results: The mean operating time was 161.8+/-25 minutes. There was 1 intraoperative complication, an intestinal injury repaired laparoscopically. Conversion was needed in 1 patient for massive adhesions. Postoperative early surgical complications were 7 (1 seroma). Morbidity in obese and nonobese patients showed no statistically relevant difference (P>0.05). There was no postoperative death. Mean hospital stay was 5.1+/-3 days. The mean follow-up was 37 months and recurrence was observed in 3 cases., Conclusions: The onlay laparoscopic approach for repair of incisional hernias of the abdominal borders can warrant good results. Obesity is not a contraindication to laparoscopic repair. Anyway, further experiences are necessary to confirm these results.

Aims: Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival., Patients and Methods: Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up., Results: Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%., Conclusion: Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

Aims: Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported. This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined., Patients and Methods: The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC., Results: Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two postoperative deaths were registered. An average number 31.3+/-8.8 lymph nodes were collected. The mean hospital stay was 10 days (range 7-24). The mean follow up was 30 months (range 2-86) and the cumulative overall 5 year survival rate was 78%. Survival at 5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients)., Conclusions: Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study validated the effectiveness of minimally invasive technique in the management of gastric cancer.

Background: Despite good results in terms of safety and minimal recurrence ensured by laparoscopy in the management of incisional hernias, the use of minimally invasive techniques for large incisional wall defects is still controversial., Methods: Between 2002 and 2008 as many as 36 patients with abdominal wall defects > or = 15 cm were managed laparoscopically in our institution. The wall defects were > or = 20 cm in eight cases. The diameter of parietal defects was measured from within the peritoneal cavity. None had loss of domain. Body mass index (BMI) for 18 patients was > or = 30 kg/m(2)., Results: The mean duration of operations was 195 +/- 28 min (range 75-540). One patient needed conversion for ileal injury and massive adhesions. Post-operative complications occurred in nine patients; there were six surgical complications. Morbidity in obese and non-obese patients was not statistically different (p > 0.05). There was no postoperative death. Mean hospital stay was 4.97 +/- 3.4 days (range 2-18). Mean follow up was 28 months (range 2-68) and only one hernia recurrence was observed., Conclusions: Minimum-access procedures can provide good results in the repair of giant incisional hernia. Obesity is not a contraindication to laparoscopic repair. Further studies are expected to confirm our promising results.

Robot-assisted gastrectomy has been practised so far in very few centres in the world. The aims of this study were to assess the feasibility of robot-assisted gastrectomy for adenocarcinoma with D2 lymph nodal dissection and to analyze our preliminary results. Between January 2006 and August 2008, as many as 17 patients (11 females, 6 males) underwent laparoscopic robot-assisted surgery for non-metastatic adenocarcinoma of the stomach by a 3-armed da Vinci(®) Robotic Surgical System. The mean age of patients was 65.9 years. This series included eight patients with early gastric cancer (EGC) and nine with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for 16 distal cancers. Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy was performed for one AGC of the middle third of the stomach. No intraoperative complication was registered. Conversion to laparotomy was required in two patients with distal cancer. The mean operating time (excluding converted patients) was 352 min (348 for LSG). Morbidity consisted in one pancreatic leak that healed conservatively. One death occurred postoperatively for haemorragic stroke. On average, 25.5 ± 4 lymph nodes were collected (range 10-40). The resection margin was 6.4 ± 0.6 cm (range 4.2-8), and the margin was tumour free in all the specimens. The mean hospital stay of totally laparoscopic subtotal gastrectomy was 10 ± 1.2 days (range 8-13). The mean follow-up was 14 months (range 1-29) and three patients with AGC showed recurrence after LSG and died of disease. Robotics in gastrectomy for cancer is a feasible and safe procedure, yielding adequate D2 nodal clearance with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon's ability and precision in small surgical fields, i.e. during D2 dissection. This study demonstrated the feasibility of robot-assisted gastrectomy for cancer although further studies are required to validate our preliminary results, especially as far as patients' benefits are concerned.

The aim of this work was to describe the model and clinical results obtained by the Niguarda Trauma Team referral center for major trauma, in Milan. The Trauma Team is organized as a trauma service, where general surgeons, anesthesiologists, orthopedic surgeons and neurosurgeons work on a 24 hour rotation. When not in duty in the rotations, specialists work in their specific elective activities. The director of the Trauma Team has the responsibility for discussion and application of protocols, clinical assistance, quality assessment and training. The results of 1334 consecutive cases of major trauma during a 51 month period were reviewed using the trauma registry. 39% overtriage, which increased over the years, and 1.12% undertriage were recorded. Mortality of patients with injury severity scores > 15 was 21%, with a progressive decrease over the years. Blunt trauma accounted for 91.75% and were road-related in most cases. Skeletal injuries were the most frequent findings, but brain and thoraco-abdominal injuries were associated with a higher risk of death. 1476 surgical procedures (16.93% general surgery and 111 interventional angiographic studies) were performed. Quality assessment revealed a significant decrease in preventable deaths within the first 72 hours, after excluding patients admitted in extremis. The results presented in this study demonstrate the possibility of realising a model of organized trauma care in an emergency department in Italy, with patient outcomes comparable to those obtained in Trauma Center in other countries.

Background: This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy., Materials and Methods: This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin., Results: Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96)., Conclusions: Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.

Although the role of minimally invasive techniques in pancreatic surgery remains controversial, resection of the left pancreas for benign or endocrine lesions has been universally adopted as a routine technique over the last few years. This study was undertaken to assess feasibility and safety of minimal access resections of distal pancreas in benign, endocrine, and malignant diseases. Operative time, conversion rate, adequacy of dissection, respect for oncologic principles, morbidity rate, and short-term outcomes were analyzed. From the years 2002 to 2007, 14 patients affected by pancreatic neoplasm of body/tail region were approached by minimally invasive technique. Nine patients were affected by malignant neoplasms and distal splenopancreatectomy was successfully achieved by laparoscopy in 6. Five patients were affected by endocrine neoplasms; distal pancreatectomy with preservation of spleen and splenic vessels was achieved laparoscopically in 3, whereas 2 needed conversion to laparotomy. Four patients developed pancreatic leak after transection by linear cutting stapler plus oversewing, whereas no leak was observed within 30 days from surgery after transection by linear stapler with Seamguard reinforcement of the staple line (P<0.05 with Fisher exact test).

Introduction: The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies., Methods: A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag., Results: Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia., Conclusions: The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.

Background: Minimal access surgery for incisional hernia repair is still debated, especially for large and giant wall defects. This study was undertaken to analyze the results of the use of the laparoscopic technique in incisional hernias smaller and larger than 15 cm of diameter., Method: From 2002 to 2007 a total of 100 patients with incisional hernia were operated on by laparoscopy and were included in this study. As much as 38 patients were obese, with a body mass index (BMI) > 30 kg/m(2). The mean follow-up span was 24 months (range = 2-58). The fascial defect was recurrent in 19 patients, in 13 after previous repair with mesh and in 6 after repair without mesh. The wall defect was larger than 15 cm in 25 patients and in 6 of them it was 20 cm or larger as measured from within the peritoneal cavity., Results: The mean operating time was 152 +/- 25 min (range = 45-275), and for defects larger than 15 cm it was 205 +/- 101 min (range = 85-540). Two patients with massive adhesions needed conversion to open surgery, one after an intraoperative injury of an intestinal loop. Postoperative complications occurred in 23 patients; local complications were 10. Pulmonary embolism caused death in one obese patient. Morbidity and hospital stay were similar in obese and nonobese patients and the differences were not statistically relevant (p > 0.05). The outcomes in patients with wall defects larger than 15 cm showed no significant difference with outcomes of the remaining patients with smaller defects (p > 0.05). Recurrence occurred in three cases, and in one case local infection led to removal of the mesh., Conclusions: Minimal access procedures can provide good results in the repair of incisional hernia, even when the diameter is larger than 15 cm. Obesity is not a contraindication to laparoscopic repair. Further studies are expected to confirm these promising results.

Background: Laparoscopic excision of rectal tumors has gained favor in the last decade and several issues have reported encouraging results: still, the use of laparoscopy remains open to debate. The aim of the current study is to assess the reliability of laparoscopic anterior resection (LAR) for rectal cancer analyzing short-term outcomes and long-term survival., Methods: The charts of 157 patients were reviewed retrospectively after anterior resection for rectal adenocarcinoma performed by minimal access. Patients undergoing emergency surgery were excluded. LAR was excluded in presence of preoperative features at computed tomography (CT) scan suggesting bulky tumors unresectable by laparoscopy or in case of anesthesiologic contraindications. Conversion rate and functional and oncologic outcomes were analyzed. Data on long-term results and survival were evaluated., Results: LAR was performed in 157 patients, and conversion to laparotomy was required in 12 cases. Mean operation time for nonconverted patients was 229 minutes (overall 238 minutes). Total mesorectal excision (TME) was performed in tumors of the mid and low rectum and a temporary ileostomy was performed in 56 patients. The mean length of hospital stay (LOS) was 10.5 days. Morbidity of anterior resection included 17 anastomotic leaks after laparoscopic surgery (LS; 5 in the converted patients). Conversion increased significantly the risk of leak (P < .005). Two leaks caused death. The mean number of nodes collected was 12. The incidence of local relapse was 4%, and the rate of anastomotic recurrence was nil. Survival probability with LS was .73 at 5 years. Patients in stage III took advantage of adjuvant treatment and had a better survival than patients in stage II (P = not significant [NS])., Conclusions: The outcomes of this study suggest that LAR for rectal cancer is a reliable procedure. Oncologic requirements were respected; parameters such as length of specimen, distal margin, and number of nodes retrieved were quite acceptable. Incidences of local recurrence and long-term survival were comparable with those of other series.

The role of laparoscopic techniques in pancreatic surgery is still controversial especially regarding to exocrine malignancies. Operative time, conversion rate, adequacy of dissection, and morbidity do represent factors of major concern. Whereas laparoscopic resection of left sided pancreatic lesions requires no anastomosis and therefore has gained worldwide acceptance over the last years, excision of cephalic lesions by mimimal access has little place in surgeons' practice because of its technical complexity and duration of surgery. This study was designed to assess the feasibility and results of laparoscopic pancreaticoduodenectomy for neoplasms of the pancreatic head, analyzing steps of learning curve, conversion rate, and short-term outcomes. From August 2002 to December 2006, 19 patients affected by pancreatic neoplasm of the head were approached by minimally invasive technique. A video-assisted procedure with pancreaticoduodenal resection and anastomoses fashioned through a midline minilaparotomy of 7 cm was achieved in 7 patients. Conversion to laparotomy was required in 6 patients, in 3 for bleeding and in 3 for difficulties in dissection. Cephalic pancreatoduodenectomy was achieved by thorough intracorporeal technique in 6 patients. Mortality was nil. Oncologic principles with adequate lymphadenectomy and resection margins were respected and short-term outcomes and mean survival were quite acceptable and equal to those of conventional surgery.

Laparoscopic treatment of lesions of the distal pancreas has gained favour worldwide in the last decade. The objective of this study was to analyze 3 cases of insulinoma successfully treated with the laparoscopic approach. From 2000 to 2007 in our institution 3 patients with insulinoma of the left pancreas were treated with a laparoscopic approach. The insulinoma was diagnosed by helical CT scan, Two cases were treated by left pancreatectomy and one by enucleation. The resections were achieved by laparoscopy with no conversion to laparotomy. There were no intraoperative complications. Average blood loss was 180 mi (range: 150-350). Mean operative time was 232 minutes (range: 225-240). Morbidity consisted in one mild pancreatic fistula after left pancreatectomy that was healed by conservative treatment after 24 days. The mean hospital stay was 13 days (range: 10-20). During the follow-up insulinoma symptoms have disappeared in all patients. This study confirms the feasibility of laparoscopic resection for insulinoma. Operative times were quite acceptable and the conversion rate was nil. Times to oral intake and walking were shorter than after open surgery, as was the mean postoperative hospital stay.

Aims: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers., Methods: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival., Results: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50., Conclusions: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Background: Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma., Methods: From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed., Results: In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study., Conclusions: Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.

The Authors present a case of thoracoabdominal trauma from a road accident in a young woman who received care initially in a level II hospital. She was then transferred to a level I Trauma Centre with the onset of haemorrhagic shock due to haemopericardium and haemoperitoneum from liver injuries. A chest CT scan led to the suspicion of aortic dissection, hence a cardiopulmonary bypass (CPB) for life support was instituted just before laparotomy through the femoral vessels. Exploration of the peritoneal cavity was performed as a first step because haemoperitoneum was deemed to be the main cause of shock. One litre of blood was aspirated and hepatosplenic tears were sutured to obtain haemostasis. Subsequently, aortic dissection was ruled out by median sternotomy, while a right atrial disruption was identified and repaired by stitches and a pericardial homologous patch. Nevertheless, the ascending aorta was explored by transverse arteriotomy. The postoperative course was uneventful and the woman has never presented cardiac or abdominal symptoms as a result of trauma or surgery.

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

The treatment of liver traumas has evolved considerably over recent decades with the possibility of non-operative management and arteriographic embolisation for selected patients in haemodynamically stable conditions. The aim of the study was to compare two periods with different approaches to the management of blunt or penetrating liver injuries. From January 1989 to October 2004, 252 patients were admitted to the emergency surgery department of Niguarda Hospital in Milan for liver traumas. Hepatic lesions accounted for 66% of abdominal lesions due to trauma and were classified according to the Organ Injury Scaling system. Abdominal ultrasound and CT scans were used to investigate the injuries. The study consisted of two periods: during the first period (1989-1993) surgery was the only treatment for trauma-induced hepatic lesions of any grade. Damage control surgery was employed for unstable patients undergoing laparotomy. From 1994 on, grade 1-2 injuries in patients with haemodynamically stable conditions were treated by non-operative management and grade 3 injuries by embolisation. In this second period only unstable patients with active bleeding or haemoperitoneum >500 ml with grade 3-5 injuries underwent laparotomy. The overall mortality for liver traumas was 27% (68/252) and was intraoperative in 97% of cases (66/68). Deaths were due to liver haemorrhage in 30 cases and to bleeding from extrahepatic or extra-abdominal injuries in the other 38 cases. Liver trauma was therefore directly responsible for mortality in as many as 12% of cases (30/252). The present study analysed two periods characterised by different approaches to the management of liver trauma. In the first period, laparotomy was the only choice, whereas subsequently non-operative management came to play an important role in haemodynamically stable patients and proved to be a safe method in selected cases. Major liver resections are seldom indicated in liver injuries. Damage control surgery has been practised since the first period and, before any surgical manoeuvres are performed, still represents a valuable tool to guarantee haemodynamic stability, which is the crucial factor for the outcome of liver resections for trauma.

After the introduction of corticosteroids fifty years ago the indications for splenectomy in benign haematological diseases became more controversial, also due to the morbidity and mortality associated at that time with open splenectomy. The advent of minimally invasive techniques has provided safe procedures for removal of the spleen in cases of benign as well as malignant haematological disease. Laparoscopic splenectomy has been performed for spleens of normal size or larger size or weight. In this study the indications in haematological diseases and the results after splenectomy are analysed. From June 1998 to December 2004 107 patients with benign or malignant haematological disease were referred to our unit for splenectomy. Splenomegaly was defined as a spleen diameter > 15 cm and weight > 400 g and was present in 53% of cases in this series. Open splenectomy was carried out in 30 cases and laparoscopic splenectomy in 77. Operating time, blood loss, conversion rate, need for transfusion, complications, length of hospital stay and operative morbidity were analysed for both open and laparoscopic procedures. In the laparoscopic splenectomy group the outcomes after removal of spleens < 15 cm and > 15 cm were compared. Clinical results after splenectomy in haemolytic anaemia and idiopathic thrombocytopenic purpura are reported. In the open splenectomy group the spleens were larger and heavier, hence the operating time was greater than in the laparoscopic splenectomy group. The mean age of patients in the open group was 65 years as against 43 years in the laparoscopic group. Morbidity was 23% in the open group and 10% in the laparoscopic group. Mortality was nil in both groups. The overall conversion rate in the laparoscopic group was 2.6% owing to extensive adhesions and bleeding in 2 large spleens measuring > 27 cm and weighing > 2 kg (conversion rate for larger spleens: 6.2%). Spleens > 15 cm were associated with greater blood loss (p < 0.01), longer operating times and a longer hospital stay. No cases of overwhelming post-splenectomy infection were registered in either group. The healing rate for idiopathic thrombocytopenic purpura after splenectomy was 87%, while for haemolytic anaemia it was 100%. In this study splenomegaly was associated with malignant haematological disease occurring in patients aged 65 on average in whom an open splenectomy was generally carried out. Benign diseases occurred in patients aged 43 on average in whom laparoscopic splenectomy was the preferred procedure. Conversion rate, morbidity and length of hospital stay were comparable with those of other series. Laparoscopic splenectomy can be considered the gold standard procedure for benign disease in young patients and also as a safe procedure in selected cases of malignant haematological disease.

Background: Nonoperative management (TNO) of traumatic liver injury is the choice in hemodinamically stable patients without other abdominal injuries requiring celiotomy, apart from liver injury grading and amount of free peritoneal blood. CT-scan and angiographic embolization availability increase TNO feasibility., Aims: To investigate feasibility of TNO in 16-months period consecutive liver injuries., Materials and Methods: All data of severe trauma patients admitted to our facility during the study period were recorded. Clinical decision scheme of our facility indicates TNO in hemodynamically stable patients with liver injury and no need for celiotomy. CT-scan is performed and injury grading evaluated. Angiographic embolization is done if contrast medium extravasation is present at CT-scan. Laparoscopy is suggested if ongoing bleeding with negative CT-scan for blushing., Results: Liver injury was detected in 34 of 452 severe trauma patients. Fifty percents of patients underwent TNO. In this group, bleeding control was achieved by angiographic embolization in 8 cases and by laparoscopy in 1. None of these patients needed celiotomy. None of TNO patients died., Conclusions: In a trauma referral center TNO of liver injury is possible in about 50%. TNO in severe trauma is improved if a correct CT-scan evaluation at the admission is performed and angiography correctly applied. Laparoscopy is an useful adjunctive tool in control of bleeding.

Aim: Although many studies on laparoscopic surgery of the stomach have been conducted so far, yet they have not provided surgeons with criteria for gradual and safe training with this technique. The results of gastric surgery with 30 patients operated on by laparoscopic approach are hereby described. The aim of this issue is to provide surgeons with guide lines for progressive training, respectful to patients, complying with oncologic criteria and useful to reduce conversion rate or drawbacks at the start of the experience., Methods: The Authors made a retrospective analysis on 30 patients affected by gastric lesions, 5 benign chronic ulcers and 25 neoplasms of the stomach. Our guide lines suggest that the training begin with the treatment of benign lesions, followed by early gastric cancer (EGC) and by advanced gastric cancer (AGC) of the antrum. Our experience started with 4 laparoscopic subtotal distal gastrectomies (LSGs) for benign ulcer; independent of the guidelines hereby proposed 1 laparoscopic total gastrectomy (LTG) was done after the intraoperative finding of a benign ulcer of the lesser curve penetrating into the left hepatic lobe. The beginning of training included also 1 LSG for distal stromal tumor (GIST). Subsequently 13 early gastric cancers (EGC) were operated on: echoendoscopy could demonstrate 12 T1 m and 1 T1 sm and no evidence of nodal involvement. The diameter of EGCs was 1,3 cm on average ( range 0,7-4 cm), all were marked by Indian ink to allow performance of 10 LSGs and 3 LTGs. Moreover, 8 LSGs for advanced gastric carcinoma (AGC) of the antrum were carried out. The training in malignancies progressed with LTG for 2 non-Hodgkin gastric lymphomas; 1 lymphoma required conversion to laparotomy due to infiltration of the diaphragmatic crus. A D2 lymphadenectomy was associated to gastrectomy in adenocarcinomas., Results: The feasibility of laparoscopic gastric surgery was confirmed by this study, with operating time of 240 minutes (range 150-360), intraoperative blood loss was 180 ml (range 100-250), and only 1 patient required blood transfusion for postoperative bleeding. The specific morbidity rate was 10% owing to duodenal leakage in 3 cases in the early phase of this study (3/30): 1 required laparotomy. The mortality rate was 3% due to 1 serious postoperative bleeding and acute hepatic failure in a patient with post-alcoholic cirrhosis. The conversion rate was 3% (1/30). The nasogastric tube was removed on the 4(th) postoperative day, and the oral intake started on the 6(th) postoperative day after a barium follow-through examination. The mean postoperative hospital stay was 16 days (range 10-25). The number of nodes retrieved was 18 on average and it improved with the experience: from the minimum of 9 nodes in benign ulcers, it grew to 20 in EGCs and to 25 in AGCs, so that this data confirmed the guide lines proposed in this issue . The histologic examination of EGC confirmed the data of echoendoscopy about nodal status., Conclusions: Laparoscopic surgery is a safe and feasible procedure both for benign and for malignant lesions of the stomach. The results analysed hereby suggest that at the start of training be treated patients affected by benign lesions, followed by patients with EGC and then by patients with AGC. For gastric cancers, the average number of 18 nodes harvested from each patient was adequate, complying with the requirements suggested by the latest TNM classification. This choice of progressive selection of patients for training represents a good means to get an optimal performance level, especially in view of the oncologic requirements, and can prevent surgeons from elevated conversion rates and disappointing outcomes at the beginning of experience.

Background: Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis., Methods: A single-center experience of 103 patients treated for Hinchey I-III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection., Results: Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedure-related morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed., Conclusions: Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis.

Aim: The outcome of surgery in gastric cancer differs in Japan and Western countries and the extension of lymphadenectomy may play a crucial role in survival. In Japan the choice of performing extended (D2) and superextended (D4) lymphadenectomies is based on retrospective studies, and a prospective randomized study comparing D2 and D4 is still in course. In Western countries the randomized trials comparing D1 and D2 could not provide definite indications, D2 is not yet performed as a routine procedure and D4 is accepted only by few surgeons. We report our experience and discuss indications and results., Methods: Since January 2000 through December 2002 we performed 27 superextended lymphadenectomies for the radical treatment of advanced gastric cancer. Early gastric cancers and patients over 80 years of age received conventional D2 gastrectomies. Selection of patients for D4 was made after laparotomy, when intraoperative peritoneal lavage cytology could rule out the presence of malignant cells, while D2 was done in case of peritoneal micrometastases., Results: Every patients had 39.5 nodes removed on average (range 17-94), and micrometastases in tier 16 were found in 7 cases (26%). Early post-operative surgical morbidity was 18% (5 patients) and mortality was 3.7% (1 patient). As much as 30% of patients complained of diarrhea as a late complication. The follow up could demonstrate a 3 year overall actuarial survival of 76%. Actuarial survival was 100% for N- and 70% for N+. A remarkable data was that 4 out of 5 patients who died from recurrence in the follow-up, were N4+. Actuarial survival at 3 years for N4+ patients was 34%, and the difference in survival between N4+ and other N+ was statistically significant (p<0.05)., Conclusions: Superextended lymphadenectomy in gastric cancer is feasible with postoperative morbidity and mortality rates not exceeding the rates of other lymphadenectomies. Actuarial survival at 3 years with D4 was better than in previous personal experience with D2, although the patients who underwent D4 were selected by intraperitoneal lavage cytology, while D2 patients had not been selected. The prognosis for N4- patients was better than for N4+ with micrometastases in tier 16. The presence of N4 micrometastases worsens the prognosis, but it is still uncertain whether D4 does improve survival: it is undoubtedly a new means of more accurate staging in gastric cancer surgery. The newer TNM classification regards the number of nodes removed as an indicator of radicality. Every surgeon should consider that superextended lymphadenectomies could comply with R0 radicality, and perform it within the ranges of low morbidity and mortality, until randomized trials with definitive results are available.

Background: Cervical lesions from penetrating trauma in the neck are increasing together with other types of trauma especially in big towns. Nevertheless in Italy a Register of Trauma is still lacking and no guidelines are available. Conservative management is also advocated and is still under discussion. Comparison of diagnostic tools and evaluation of different treatments in case of vascular damage is also expected., Patients and Methods: A series of 16 penetrating lesions of the neck including various degrees of severity were treated over a span of 5 year. The penetrating trauma was due to stab wound or similar causes in 11 cases; to gunshot wound in 3 and to traffic accidents in 2 cases. All of them received surgical treatment. In 56% of cases (9/16) of cases vascular structures were involved, in 4 cases the aerodigestive tract was involved (25%), and in 1 the spinal cord was injured (6%) resulting in a Brown-Sequard syndrome. Other patients presented with superficial lesions, and reconstruction of muscles by simple suture or ligature of veins could obtain complete healing., Results: The penetrating trauma brought about death in 2 cases (1 stab wound, 1 gunshot wound), while 1 lesion of carotid artery and 4 lesions of jugular vein were successfully repaired. In 1 case of lesion in zone 3 a serious bleeding from damage to lingual artery was cured in spite of the minimal width of the external injury. Hypopharyngeal lesions could be treated in 2 cases. One was associated with lethal vascular damage. In 1 case of tracheal lesion with cervical hematoma and dyspnea, patency of the airways became the main concern and and a cannula was placed in the trachea. The Brown-Séquard syndrome could improve with rehabilitation therapy in 3 years. All of the minimal cervical lesions healed with uneventful course., Conclusions: The penetrating trauma in the neck may show various degrees of severity: nevertheless, no cervical penetrating trauma should be underestimated in spite of the minimal width of the lesion. Surgical exploration was invariably the preferred treatment in our experience.

The authors have reviewed the literature particularly of the last decade, about surgical indications and timing in chronic ulcerative proctocolitis, also regarding the difficulties and the hazards the surgeon has to face depending on which type of chronic disease is considered. The various solutions for intestinal transit restoration have been reviewed, especially after the indications for terminal and continent ileostomy and for ileo-rectal anastomosis have been put aside, and total proctocolectomy with mucosectomy was advocated, with a special concern for assets and drawbacks of every type of ileal pouch. It is herein discussed the difference between the attitudes towards chronic active and recurrent ulcerative proctocolitis. The active form can't be cured with steroids and shows a greater risk of malignant transformation after 10-15 years of illness, insofar most cases (82%) in the long run need operation with this form that just often permits a one-stage surgery with mucosectomy, though. The commoner recurrent form is quite sensitive to steroids until these prove to be ineffective and surgery becomes mandatory (28% of cases). A two or three-stage surgery is advocated in this form with conservation of the rectum (mucosal fistula) as long as the acute phase is present, permitting only after its remission a restorative procedure with mucosectomy, which would be likely to be jeopardizing during the acute phase. The many designs of ileal reservoir do not differ indeed between each other as much in compliance as in maximum tolerable volume. The quadruple loop reservoir affords a volume approaching highly the original rectal volume, with better compliance and lesser frequency of bowel evacuations compared to other pouch designs. Some authors maintain that the functional outcome is independent of the reservoir shape. The anal continence basically depends upon the integrity of the internal sphincter, on the conservation of the anal inhibitory reflex and on the resting pressure. Muscular cuff is also mentioned with reference to anal function. Circular staplers have been employed for pouch-anal anastomosis 1-2 cm above the dentate line without mucosectomy. The stapled pouch-anal anastomosis entails a damage to the internal sphincter by some authors on the contrary a better sphincter function by others, compared to hand-sewn anastomosis with mucosectomy. Trials are needed to compare the risk of rectocolitis recurrence or malignancy after hand-sewn pouch-anal anastomosis with mucosectomy and after stapled anastomosis without mucosectomy. Postoperative complications are also herein discussed, with a special regard to pouchitis and its various aetiologic factors in early and late postoperative course.

The incidence of intestinal adenocarcinoma in Crohn's ileal disease is reported in the literature to be higher than in the normal population. The authors report two cases of adenocarcinoma observed during the course of Crohn's ileitis and, by comparing these findings with earlier published data, highlight their characteristics. Two patients, a 53-year-old woman and a 62-year-old man, are reported as suffering from Crohn's ileitis. The woman underwent resection of the right colon with ileo-transversostomy due to stenosis twenty years earlier, whereas diagnosis in the male patient dates back to an appendicectomy 11 years earlier. Surgery, which was performed in both due to subocclusion which failed to respond to steroid therapy, showed the typical alterations of Crohn's disease. An adenocarcinoma was also found in both patients in the stenotic zone with highly dysplasic foci. The man presented a monoclonal gammopathy of an IgA-type with light lambda chains and Bence-Jones' proteinuria. Both patients are living and enjoy apparently good health respectively 2 and 6 years after surgery. The authors emphasize that the association between Crohn's ileal disease and intestinal adenocarcinoma cannot be considered casual. In the literature the relative risk is reported to be between 6 and 320 times higher, with approximately 1 out of 350 patients suffering from both diseases contemporaneously. In the series reported earlier, 2 cases of carcinoma were diagnosed in 38 Crohn's patients studied over a period of 12 years out of a total population of 114000 inhabitants, with a frequency of carcinoma of 5.13% compared to 0.3% reported in the literature. The incidence of Crohn's disease was 2.84/100000 per year.(ABSTRACT TRUNCATED AT 250 WORDS)