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Robotic surgery is gaining more space in every country at every level. Wall surgery is one of the fields in which technology can help the surgeons and can give more opportunities to the patients. One of the biggest differences between laparoscopic surgery is that the use of the robot provides excellent 3D VISION of the abdomen and can ease the surgeon, during difficult and tricky situation mostly. One of this wall affection is diastasis recti. It affects about 1/3 of women after childbirth, yet it is still little talked about today. Often underestimated or confined to a cosmetic problem, most of the times abdominal diastasis is a functional problem primary and must be addressed in the correct way. In this video, we report a case of diastasis recti associated with a primary umbilical hernia in a multipara woman. She was 45 with a BMI of 26.4 kg/m2 and she came to our attention after a long period of discomfort and pain. She told us that her umbilical hernia was growing fast in the last months and that the condition of her abdomen was getting worse, with pain and digestive difficulties. At the physical examination we found an umbilical hernia of 3 cm of diameter and a diastasis recti of 6 cm of width. Due to the conditions of the patient, the young age and the will not to have children anymore, we decide to perform a robotic transabdominal retromuscular umbilical prosthetic (rTARUP) «bottom-up approach» (the patient never underwent abdominal surgery).

Background and aim Near infra-red/indocyanine green imaging fluorescence (NIR/ICG) technology is showing promising results in several fields of surgical oncology. However, the clinical value of NIR/ICG technology in the surgical treatment of advanced gastric cancer (AGC) is not clearly established. Indeed, although lymphadenectomy is one of the main steps in curative-intent surgery for gastric cancer and lymph node status is the most important prognostic factor for survival, several questions have risen in literature on considering the overall number of harvested lymph nodes as the best indicator of the NIR/ICG technology clinical value. At present, no data exist regarding the ability of NIR/ICG technology to modify the surgical conduct at the moment of lymphadenectomy. Methods This is the ‘iGreenGO’ (indocyanine Green Gastric Observation) study protocol: an international, prospective, multicentre study. Study population will be a cohort of Western patients undergoing preoperative upper gastrointestinal endoscopy with submucosal peritumoral ICG injection followed by curative-intent minimally invasive gastrectomy with D2 lymphadenectomy for locally AGC. High-volume western academic and non-academic hospitals will be allowed to participate in the study. The primary endpoint will be the ‘change of the surgical conduct’ (CSC) at the moment of intraoperative NIR/ICG technology activation after completing a D2 lymphadenectomy ‘with the naked eye’. Key secondary endpoints will be the identification of preoperative clinical variables potentially associated with CSC, the number of additional LNs retrieved and pTNM stage migration using NIR/ICG technology, abdominal fluorescence location according to patient’s and tumor’s characteristics. Results The sample size was calculated by considering the estimated incidence of intraoperative change of the surgical conduct when using NIR/ICG technology. Data from the literature indirectly suggest an approximate rate of such event around 17%. A sample size of 350 patients will be necessary to obtain a measurement with an estimated precision of 4% with a confidence level of 1-alfa = 95%. Conclusion The iGreenGO study will be the first western study to investigate the intraoperative clinical role of NIR/ICG technology in surgical treatment of AGC in a large cohort of Western patients. Results from the present study can further clarify the role of the NIR/ICG technology in helping the surgeon during lymphadenectomy for AGC.

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 diameter15 cm and by weight400 g. Thirty patients had splenomegaly. The outcomes with spleens15 cm and spleens15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens15 cm required longer operating time and were associated with greater blood loss (P0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

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.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.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.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.

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.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.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.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 activity of Italian alienists during the year 1913 has not been very extensive in range, but it is nevertheless considerable, especially in view of the complexity of the subjects which have been selected, and of the antecedent fitness which the different authors showed they possessed for their thorough treatment.

Resume LE PROBLEME DE LA CRIMINALITE CHEZ LES ENFANTS On montre que la soi-disant criminalite ou delit chez les enfants n'est que le resultat de certaines tendances naturelles qui n'ont pas ete bien dirigees a cause d'un manque de conditions favorables a la maison ou a cause d'un manque entier de vie familiale. Il paraǐt que le meilleur remede est de donner a ces enfants l'occasion de faire sortir les tendances naturelles sous la direction, pleine de tact, d'un certain type de personnalite dont la comprehension, la bonte, et une foi intelligente sont les qualites essentielles.