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Total mesorectal excision is a valuable technique in preventing local recurrences cancer. However the use of the word “mesorectum” is inaccurate anatomically, and the implication that total excision of all the perirectal fat contained within the perirectal fascia in all patients with rectal cancer will minimize local recurrences remains contentious. The term extrafascial excision of the rectum is more accurate. He may contribute as well to a better understanding of the surgical technique allowing all surgeons to improve their own results. [Copyright &y& Elsevier]

Gastro-intestinal stromal tumors associated with Recklinghausen’s disease should be considered in the current concept of the stromal tumors with reference to recent advances in immuno-chemistry. In this setting, there is an high potetial of maluignancy. For the treatment of these lesions, surgery is the main tool. Frequency of malignant digestive diseases associated with Recklinghausen disease should be kept in mind. [Copyright &y& Elsevier]

We describe one case of intra-scrotal hernia of the right ureter. The anomaly was recognized on a pre-operatory urogram. It was an extra-peritoneal ureteral hernia. There are two types of ureteral hernia: the para-peritoneal hernia with a peritoneal sac; the extra-peritoneal type with only a fatty hernia. The mecanism of the latter illustrated by our case is a prolapse of the retro-peritoneal fat. It is not possible to practice an urogram before the cure of every inguinal hernia, so the prevention in this rare situation of the damage of ureter is to be cautious in the resection of huge lipomas and sliding fat when operating on inguinal hernias. [Copyright &y& Elsevier]

Study Aim: The aim of this study was to analyse our vaginal hysterectomies performed for prolapsed uterus and non prolapsed uterus with benign disease. For the latter indication, a comparison was made with abdominal hysterectomy., Patients and Methods: From february 1986 to december 1998, 1008 vaginal hysterectomies were performed in our department: 219 for prolapsed uterus and 789 for non prolapsed uterus with benign disease. During the same time, 217 abdominal hysterectomies were performed for non prolapsed uterus with benign disease., Results: Intra-operative and post-operative complications had the same rates in the two groups. Owing to the low number of abdominal hysterectomies, we cannot draw a valuable conclusion. The study of the literature shows in this field an advantage for the vaginal hysterectomy; mean time hospitalization was shorter in the vaginal group., Conclusion: Advantages of vaginal hysterectomy are multiple: aesthetic, shorter hospitalization, quicker recovery. The low rate of vaginal hysterectomy on non prolapsed uterus with non malignant disease is linked with the lack in training of surgeons for the vaginal approach. In these cases, a rate of 70% is a realistic one in a well trained hospital center.

The transvaginal sacrospinous fixation, called Richter operation was initially aimed to cure vaginal vault prolapse after hysterectomy. The results are as good as those of the abdominal promontory fixation with the well known advantages of the vaginal route. Indications way be extended to V3 U3 R3 prolapse and cure of elytrocele with good results in our practice. In few cases remnant cystocele may be a trouble some problem.

Localized ischemic lesions of the caecum should be classified among ischemic colitis. However, a separate study is justified to their original clinical presentation due to the fact that these lesions are, on one hand small, and on the other hand, sit in the right lower quadrant of the abdomen. For each of an appendicitis, operation will be performed quicker than in ischemic colitis in their usual presentation. The treatment is variable, including abstention, localized excision-suture, right hemicolectomy. Results are usually good. Coelioscopy in the future may have a place as in one of our three observations and must be evaluated.

Segmental infarction of the great omentum is a possible aetiology of acute abdominal pain. The diagnosis was difficult before operation and, generally the patient was operated upon with the diagnosis of appendicitis, or less often by laparotomy. The laparoscopy appears to be nowadays the ideal way of diagnosis, as this was the case in two of our patients. The treatment is also possible by laparoscopy (one of our patients). Generally speaking the laparoscopy should be of great help in the diagnosis of some acute abdominal pain, and could reduce the number of the so called non specific abdominal pain.

Though very different, aberrant bile ducts and cysto-hepatic ducts are often confused. Aberrant bile ducts are abnormal ducts which do not drain any segment or sector of the liver. They are filled of bile counter-flow and can be injured not only in the gallbladder bed, but also elsewhere on the surface of the liver. Cysto-hepatic ducts are normal ducts, draining segment or sector of the liver, but because of an embryologic sliding, their branching is on the gallbladder or on the cystic duct. All these ducts can be injured during cholecystectomy, and it would be of importance to recognize the true type of duct one has to deal with, by radiologic explorations. The management is different as aberrant bile ducts need only to be ligated, instead, the cysto-hepatic ducts may require a reimplantation in the common bile duct or Roux en y loop. We discuss all these problems on the basis of 1200 traditional cholecystectomies where 1 aberrant bile duct, 3 cysto-hepatic ducts, and 3 external biliary fistulas were encountered.

Massive hiatal hernia is a lesion at risk of incarceration, volvulus, and obstruction. The true paraesophageal type is a very rare condition and probably often mistaken with end-stage slidind hernia. Furthermore reflux and oesophagitis are always possible. In this case report a small bowel loop was incarcerated with a massive hiatal hernia. This association was only possible because of the existence of an associated transverse mesocolis hernia giving way to the small bowel. An emergency operation was necessary. The need of surgical treatment of such lesions is stressed, if possible before acute complication, even if they are asymptomatic at the time of diagnostic, which is a quite common condition.

Owing to the wide diffusion of the coelioscopic cholecystectomy some problems are worth studying. From a technical standpoint they are important changes: use of monopolar current for coagulation, suppression of intra-operative cholangiography, absence of suture of the gallbladder bed, systematic retrograde dissection. Theoritically these modifications are important enough to increase the biliary risk. As a matter of fact, comparison with traditional cholecystectomy data as well as results of preliminary studies on coelioscopic cholecystectomy does not confirm such a risk. This operation appears safe, at least if indications are limited to non complicated cholelithiasis.

A patient with hepatocaval injuries was treated successfully by direct suprahepatocaval hemostasis, and right lateral sectoriectomy after elective extrafascial clamping of Glisson's capsule. Anatomical conditions favorable for clamping were assessed from data in the published literature, and a personal series in which this technique was employed. A Gans' incision of at least 20 mm in length conditions the possibility of direct control of the right lateral pedicle, and was performed in 65 to 80 p. cent of cases. The proximal part of the incision reveals only the anterior border of the lateral pedicle where as the distal portion uncovers the first important right anterior pedicle of the segment VI, this being observed most frequently. At this level, extrafascial isolation of the lateral pedicle is usually rapid and precise (approximately 70 p. cent of cases). Adaptation of treatment of lesions of the homonymous sector is then possible under controlled surgical conditions of comfort and safety.

Early detection of residual stones in the main biliary pathways during external drainage following surgery has, until recently, required a repeat operation with all its associated technical and psychological problems. Currently, however, Burhenne-Mazariello's nonoperative extraction technique is a very reliable therapeutic measure, as shown by results in 8 cases and those reported by the authors. Furthermore, this technique can be applied by a surgeon isolated in a small centre with the minimum of material, with a high probability of success. Other conservative techniques, particularly instillations through the external drain, are still valid and can be complementary to Burhenne's method, which for the authors, however, remains the therapy of choice.