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Aim of the present study is to propose a clinic-therapeutic course for the treatment of hemorrhoidal disease able to combine radical anatomic surgery with a painless postoperative path.The present study is based on the evaluation of 20 selected patients who underwent radical hemorrhoidectomy for very high grade hemorrhoidal disease. The clinical course was characterized by careful bowel cleansing, hemorrhoidectomy according to Milligan-Morgan using LigaSure, intraoperative perianal infiltration of Ropivacaine and postoperative use of analgesic drugs.A low postoperative pain may descend from a scheduled timing of clinical procedures. Preoperative bowel cleansing delays the first postoperative evacuation, thus avoiding the perianal nerve stimulation. The use of LigaSure allows to perform surgical excision in a perfect way: lack of hemostatic stitches, less tissue trauma, very low early morbidity. A rational and scheduled intra and postoperative drug administration offers a highly significant contribution to the pain control. The intra and postoperative use of drugs makes it possible to perform the so-called "preventive anesthesia with activation of the pain memory" and postoperative evacuations with low pain perception. All patients, in fact, reported low and well tolerated pain, satisfaction and return to normal activities in a short period.Radical hemorrhoidectomy with LigaSure and attention to pre, intra and postoperative protocol makes the procedure painless, safe and with low morbidity.Hemorrhoidectomy, LigaSure, Painless procedure.Gli autori propongono una procedura clinica, che consente di praticare un intervento anatomico di emorroidectomia radicale ben sopportato dal paziente, in funzione del dolore molto contenuto nel periodo post operatorio. Come è noto, negli interventi di emorroidectomia, in tutte le tecniche chirurgiche praticate, il dolore è legato alla complessità dell’intervento e, quindi, allo stadio di malattia. Per tale motivo abbiamo valutato nel nostro studio, i risultati relativi ad un gruppo selezionato di 20 pazienti con malattia emorroidaria avanzata ed sintomatica. Il protocollo clinico è stato caratterizzato da: accurata pulizia dell’intestino, emorroidectomia sec. Milligan- Morgan eseguita con LigaSure, infiltrazione intraoperatoria di Ropivacaina, uso postoperatorio di farmaci analgesici. La pulizia preoperatoria del colon, con assenza di evacuazione postoperatoria nelle successive 24-30 ore, evita in tale periodo una stimolazione nervosa perianale. L’uso del LigaSure consente di eseguire l’intervento in maniera ottimale: assenza di punti aggiuntivi per l’emostasi, minore trauma dei tessuti, morbilità immediata praticamente assente. Una programmata e razionale utilizzazione di farmaci in sede intra e postoperatoria permette un efficace controllo del dolore. L’uso di farmaci intraoperatori consente, inoltre, di attuare la “analgesia preventiva con attivazione della memoria del dolore” (paziente asintomatico sino alla prima evacuazione), mentre la somministrazione post operatoria permette di avere evacuazioni intestinali con bassa percezione del dolore. Applicando il protocollo descritto, abbiamo ottenuto, nei 20 casi selezionati, i seguenti risultati: tempo operatorio contenuto, assenza di sanguinamento intra e postoperatorio, assenza di ano fibroso o stenosi nei controlli a distanza, ritenzione urinaria, nel 35% dei soggetti, transitoria e reversibile (una singola cateterizzazione), dolore postoperatorio contenuto e ben tollerato in tutti i pazienti, rapido ritorno alla normale attività e vita di relazione, con buona soddisfazione dei pazienti.

The aim of this paper is to present the results of the Italian Society of Colorectal Surgery [or Società Italiana di Chirurgia Colorettale (SICCR)] Logbook of adverse events (AE) occurring in relation to emerging technologies in coloproctology (ETCs), over a 3-year period.A total of 245 AE were reported (patients age: mean = 49.6 years, range = 20-75 years; gender: 155 = F, 90 = M). The "observations" originated from the same institution of the AEs in 44 cases (18.0%), while 201 patients (82.0%) had been operated on somewhere else.The three most reported ETCs were: Procedure for prolapsed haemorrhoids (PPH) (n = 120-48.9%), stapled transanal rectal resection (STARR (n = 96-39.2%), and transanal haemorrhoidal dearterialization (THD) (n = 11-4.5%). PPH, STARR, and THD together accounted for n = 227 (92.6%) observations. For the three main reported ETCs, the various AEs are listed. Chronic pain after PPH was 46/120 (38.3%), and after STARR of 21/96 (21.9%). The overall re-operation rate was n = 135 (55.1%) versus n = 110 (44.9%) no reoperation. In particular, for the three main reported ETCs, n = 68/120 (56.7%) following an AE after PPH, n = 47/94 (50.0%) following an AE after STARR, and n = 6/11 (54.5) following an AE post-THD. The various types of treatment to solve AE after each of the three most observed ETCs are reported in the text.Our results do not allow us to draw statistical conclusions; however, this was not the aim of our survey. ETCs are important, yet they are not without major risks. Manufacturers should help colorectal surgeons to convey the right message to patients.

Aim of this retrospective study is to report personal experience in the surgical management of substernal goitres emphasizing the guidelines for preoperative planning of sternotomy in selected cases.Medical records of all patients (n=355) submitted to thyroidectomy for struma in our Operative Unit, between 1993-2003, were analysed. A substernal goitre was defined as a goitre having a significant retrosternal extension (50%) requiring mediastinal dissection.A total of 18 out of 355 patients undergoing thyroidectomy for struma in our Operative Unit had substernal goitres. The most common symptoms, at presentation, were the presence of neck mass and respiratory disorders. Standard cervical incision was adequate to achieve total thyroidectomy in 17 cases while, in one patient with computed tomography images showing the presence of a huge goitre extending below the aortic arch, a sternotomic approach was inevitable to ensure safe removal. No major morbidity or perioperative deaths occurred. One patient with scleroderma experienced bilateral paralysis of laryngeal nerves for two months, with full recovery thereafter.While removal of the majority of substernal goitres can be achieved by means of cervical incision, this approach is not always safe. In a selected number of cases with an iceberg shaped substernal goiter and with70% of the volume lying below the thoracic outlet, a sternotomic approach is inevitable. Preoperative diagnostic work-up should, thus, include chest X-ray and computed tomography. Overall results in the present patient population, have been excellent since morbidity has been minimal and mortality absent, and all patients are symptom free.