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The use of Unmanned Aerial Vehicles and known under the generic name of drones is increasingly present in different economic sectors, due to the versatility they offer in solving specific problems. The specific problems to be solved, however, raise the need for the technical characteristics of the drones to be optimized according to the specific usage. In the case of drones used in technological processes in agriculture, they must offer a high autonomy, that can be increased by optimizing their weight. The paper proposes the study of the dynamics of the air flow according to the configuration of the drone rotor (2 and 3 rotor respectively) by numerical analysis methods for the further development of a drone that will be used in the phytosanitary treatment process of agricultural crops. The parameters evaluated and compared are the specific parameters for characterizing the airflow: velocity and relative pressure (at different nacelle's section, both in horizontal and vertical directions). The obtained results show that the most constant, dense and homogeneous velocity field was obtained from the 3-blade configuration of the rotor. [ABSTRACT FROM AUTHOR]

Introduction: Periampullary carcinomas represent a group of tumors that develop in a complex area, implying different anatomical structures. The most common histological type of periampullary carcinomas is the adenocarcinoma. The pancreatic type of periampullary adenocarcinomas has the worst prognosis. Immunohistochemical markers, such as ki-67 and p53, can be used in predicting survival. Material and method: we selected the patients with periampullary adenocarcinomas, intestinal or biliopancreatic type, with resectable tumors, and we performed immunohistochemical stains for ki-67 and p53 markers. The overall survival was analyzed according to the expression of immunohistochemical markers, TNM staging, tumor grade and perineural invasion. Results: Sixty-seven patients were included in the study. The median overall survival for the whole cohort was 12 months, with a 2-year survival rate of 25%. High rate of tumor proliferation (ki67 more than 80%) was significantly associated with shorter overall survival (median survival 3 months compared with 17 months for the group with ki67 index less than 80%). A high expression of p53 protein has been associated with low overall survival. The low survival was associated with poorly differentiated tumor grade and lymph node status. Conclusion: Both immunohistochemical expression of ki67 and p53 can be used as prognostic and predictive factors for overall survival of patients with resectable periampullary adenocarcinomas., (Celsius.)

Background: Since the beginning of the COVID-19 pandemic, empiric antibiotics (ATBs) have been prescribed on a large scale in both in- and outpatients. We aimed to assess the impact of antibiotic treatment on the outcomes of hospitalised patients with moderate and severe coronavirus disease 2019 (COVID-19)., Methods: We conducted a prospective multicentre cohort study in six clinical hospitals, between January 2021 and May 2021., Results: We included 553 hospitalised COVID-19 patients, of whom 58% (311/553) were prescribed antibiotics, while bacteriological tests were performed in 57% (178/311) of them. Death was the outcome in 48 patients-39 from the ATBs group and 9 from the non-ATBs group. The patients who received antibiotics during hospitalisation had a higher mortality (RR = 3.37, CI 95%: 1.7-6.8), and this association was stronger in the subgroup of patients without reasons for antimicrobial treatment (RR = 6.1, CI 95%: 1.9-19.1), while in the subgroup with reasons for antimicrobial therapy the association was not statistically significant (OR = 2.33, CI 95%: 0.76-7.17). After adjusting for the confounders, receiving antibiotics remained associated with a higher mortality only in the subgroup of patients without criteria for antibiotic prescription (OR = 10.3, CI 95%: 2-52)., Conclusions: In our study, antibiotic treatment did not decrease the risk of death in the patients with mild and severe COVID-19, but was associated with a higher risk of death in the subgroup of patients without reasons for it.

The multi-elemental composition of three typical Italian Pecorino cheeses, Protected Designation of Origin (PDO) Pecorino Romano (PR), PDO Pecorino Sardo (PS) and Pecorino di Farindola (PF), was determined by Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). The ICP-OES method here developed allowed the accurate and precise determination of eight major elements (Ba, Ca, Fe, K, Mg, Na, P, and Zn). The ICP-OES data acquired from 17 PR, 20 PS, and 16 PF samples were processed by unsupervised (Principal Component Analysis, PCA) and supervised (Partial Least Square-Discriminant Analysis, PLS-DA) multivariate methods. PCA revealed a relatively high variability of the multi-elemental composition within the samples of a given variety, and a fairly good separation of the Pecorino cheeses according to the geographical origin. Concerning the supervised classification, PLS-DA has allowed obtaining excellent results, both in calibration (in cross-validation) and in validation (on the external test set). In fact, the model led to a cross-validated total accuracy of 93.3% and a predictive accuracy of 91.3%, corresponding to 2 (over 23) misclassified test samples, indicating the adequacy of the model in discriminating Pecorino cheese in accordance with its origin.

Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas., Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05., Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication ( p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026)., Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Laparoscopic cholecystectomy is the gold standard procedure in patients with cirrhosis and symptomatic gallbladder disease or acute cholecystitis. In this retrospective study we evaluated laparoscopic cholecystectomy in patients with cirrhosis based on Child-Pugh score as a predictor of morbidity. In the First Surgical Clinic of Iasi, from 01 jan 2010 to 31 jan 2020, we performed 111 laparoscopic cholecystectomies in Child-Pugh A, B, and C cirrhotic patients. Intraoperative difficulty (grade 3 Cuschieri) was experienced in 32 patients (28.8%). Highly vascular sub hepatic adherences have been reported in a quarter of all patients. Intraoperative incidents were more frequent 27 (24.3%) compared to laparoscopic cholecystectomy performed in other patient groups. The conversion rate to open cholecystectomy was 6.3% (7 cases). Mean operative time was 84 min. Mean duration of hospitalization stay was 4.7 days. The morbidity rate was 16.2% of patients and included bleeding, intraabdominal fluid collections and wound complications more common in patients with Child-Pugh Cirrhosis B and C. The results are dependent of the perioperative management of the liver function., (Celsius.)

Background: Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted., Methods: This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018., Results: A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO 2 ) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8., Conclusions: The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Introduction: Abdominal actinomycosis is a rare granulomatous inflammatory disease caused by a Gram-positive anaerobic bacterium Actinomyces israelii, manifesting as inflammatory mass, or abscess formation. Evolution is slow and steady in inflammatory contiguous extension without limit organ that lends itself to confusion with abdominal malignancies. Methods: We performed a retrospective study on the patients with abdominal actinomycosis operated in the First Surgical Clinic, "St. Spiridon" University Hospital Iasi; between 1980 - 2018 there have been 13 cases (4 men and 9 women) with a mean age 44.07 years admitted for abdominal tumors (7 cases) or pelvic inflammatory disease (6 cases). Results: We identified as predisposing factors: IUD maintained over 10 years (6 cases), foreign bodies 2 cases (a toothpick probably perforated colon, gallstones lost in peritoneum), diabetes (3 cases), immunodepression. All cases were operated by laparotomy (9 cases) or laparoscopic approach (4 cases). We describe five of these cases of actinomycosis that had been mimicking a colon cancer: ileo - cecal - 3 cases, transverse colon - one case and on the greater omentum - one case, followed by specific treatment with penicillin, with good evolution. Conclusions: Abdominal actinomycosis should always be included in the differential diagnosis of abdominal tumors. Preoperative diagnosis, difficult but possible, can avoid surgery. Treatment with antibiotics is necessary for the healing of the disease. Postoperative control is mandatory, with relapses possible., (Celsius.)

Background: Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments., Methods: This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study., Results: A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%., Conclusions: The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low., Competing Interests: The data was completely anonymized, and no patient or hospital information was collected in the database. The study protocol was approved by the board of the WSES, and the study was conducted under its supervision. The board of the WSES grants the proper ethical conduct of the study.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Hematoma of the graft is a life threatening complication of liver transplantation (LT) and there has been no overt conclusion in the literature about optimal management except in scarcely reported cases. It may be either intrahepatic or subcapsular, then again it may develop spontaneously or following parenchimal injuries or transhepatic percutaneous invasive manoeuvers. In this report we describe a rare case of large spontaneous graft intra- and perihepatic hematoma. A 62 year-old man underwent a whole graft orthotopic liver transplantation (OLT) for decompensated chronic liver disease due to alcoholic cirrhosis. The surgical procedure was uneventful. During the early postoperative course, routine Doppler ultrasound examination and CT-scan revealed an extrahepatic paracaval hematoma, 7 days after transplantation, which was stable and conservatively managed until the 18-th postoperative day, when rapidly expanding intraparenchimal hematoma involving the right hemiliver, several other perihepatic hematomas, significant right pleural effusion and hemorrhagic ascites were described. The patient was successfully treated conservatively (nonsurgically) with slow recovery of the liver allograft and discharged one month later in good general status., (Celsius.)

Introduction: During the past decades, the safety of pancreatoduodenectomy has improved, with low mortality and reduced morbidity, particularly in centers with extensive experience. Emergency pancreatoduodenectomy is an uncommon event, for treatment of pancreaticoduodenal trauma, bleeding, or perforation. We herein present a single center experience concerning nontrauma emergency pancreatoduodenectomy for pancreaticoduodenal bleeding., Methods: From January 2007 to December 2015, from a population of 134 PD (70 males and 64 females, mean age 62.2, range 34-82), 5 patients (3.7%; 2 males and 3 females, mean age 64, range 57-70) underwent one-stage emergency pancreatoduodenectomy for uncontrollable nontrauma pancreaticoduodenal bleeding in our tertiary center., Results: All the 5 patients underwent a backwards Whipple with a morbidity of 60% and a mortality of 20% (1/5). The other 4 patients were recovered and discharged with a median postoperative length of stay of 17 days (range 14-23)., Conclusion: Emergency pancreatoduodenectomy is a definitive life-saving procedure allowing for a rapid control of bleeding when other less invasive approaches (transcatheter arterial embolization or interventional endoscopy) are exhausted, unavailable, or unsafe. It should be particularly considered in neoplastic disease and tailored by surgeons with a high level of experience in pancreatic surgery.

Introduction: Pancreaticoduodenectomy (PD) is the procedure of choice in patients with tumors of pancreatic head or periampullary region. Hepatic artery anatomic variants (HAav) are frequently encountered during PD., Aim: To evaluate the incidence of HAav in a series of PDs and their consequence on technical tailoring and outcome., Material and Methods: Forty-five patients with HAav were identified in a consecutive series of 140 PDs for periampullary and pancreatic head tumors performed between January 1, 2007 and December 31, 2015. The groups with or without HAav were compared in terms of operative approach, complications and survival., Results: All patients underwent Whipple procedure, with right posterior approach for those having HAav. HAav was spared without damage in 41 cases. Four patients in whom the HAav were either sacrificed (2) or damaged (2) required arterial reconstruction., Conclusions: HAav are frequently encountered during PD. Its safeguarding is mandatory but in malignancy it can be damaged or sacrificed, hence arterial reconstruction is required. HAav have no negative impact on surgical morbidity and outcome.

Unlabelled: The abdominal cystic lymphangioma (CL) in adults is a rare benign tumor of the lymphatic system., Methods: We report a retrospective study from January 2002 to Decemberr 2014 concerning 18 patients who underwent surgical removal of a CL, 9 patients with laparoscopic approach included. The localization, size, and number, diagnostic, treatment and results have been reported for patients approached laparoscopically., Results: There were 8 women and 1 man with median age at diagnosis was 35,6 years (range 20-51 years). Clinically, the main symptom was an abdominal pain found in 8 patients (88.8%). Physical examination revealed an abdominal mass in 5 patients (55.5%). The CL was asymptomatic in four patients; the discovery of CL was performed preoperatively during an ultrasound for another pathology (n=3) or intraoperatively (n=1). US exam CT scan usually allow the preoperative diagnosis. The most common site was shared equally between the mesentery (n = 3; 33%) and left retroperitoneum (n = 3;33%), followed by the right retroperitoneum and the posterior cavity of the lesser omentum and great omentum, each one case. The most common procedures performed were: laparoscopic total cystectomy of a closed cyst in two patients and evacuation of larger cysts followed by total cystectomy in seven patients. No conversion, no mortalities and no morbidity was noted. Mean hospital stay was 3.4 days. No recidive after 28 months in the average after treatment., Conclusions: The laparoscopic approach is the gold standard in the treatment of intraabdominal CL.We recommend complete surgical excision to avoid recurrence., (Celsius.)

Background: To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression., Methods: The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study., Results: Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4., Conclusions: WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

Objective: An emerging body of evidence supports a role for dysfunctional purinergic neurotransmission in mood disorders. Adenosine agonists have been shown to have properties similar to those of dopamine antagonists; there is a well-characterized interaction between adenosine and dopamine receptors in the ventral striatum, and increasing adenosinergic transmission has been demonstrated to reduce the affinity of dopamine agonists for dopamine receptors. Allopurinol increases adenosine levels in the brain, and hence is hypothesized to reduce the symptoms of mania. Two randomized, placebo-controlled trials administering add-on allopurinol to manic patients showed significantly greater improvements in Young Mania Rating Scale (YMRS) scores for drug compared to placebo, while a more recent, relatively small, add-on study showed negative results. Based on these data, our objective was to examine the efficacy of allopurinol as add-on treatment to mood stabilizers and/or antipsychotic agents in manic patients with bipolar disorder., Methods: We performed a large, well-powered, multicenter, six-week, randomized, placebo-controlled trial of allopurinol added to mood stabilizers and/or antipsychotic agents in 180 patients with bipolar disorder in an acute manic episode., Results: Both groups showed improvement on the YMRS (effect size of 1.5 for placebo and 1.6 for allopurinol), with no difference observed between groups on YMRS scores (t = 0.28, p = 0.78). There was no difference in the proportion of patients who responded to treatment (defined as showing at least 50% improvement in YMRS score) between the two groups (p = 0.92), or in dropout rates (p = 0.84)., Limitations: None of our patients received lithium. However, the side effects of lithium and its narrow therapeutic index made the use of lithium less common and, therefore, our study results reflect common current clinical practice. In the present study, we used a variety of antipsychotic and/or mood stabilizing treatments, to which we added allopurinol; one might hypothesize that add-on allopurinol has a different effect in combination with different antipsychotic agents or mood stabilizers., Conclusions: The findings of this large, well-powered study do not support add-on allopurinol as a treatment for acute mania. This study did not test the efficacy of allopurinol as monotherapy., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Necrotizing colitis (NC) is a rare complication of the obstructive cancer of the left colon and it is the result of intramural ischemia due to impairment of blood supply secondary to increased endoluminal pressure., Case Presentation: A 70 years old patient with significant comorbidities (ASA 4) was admitted for intestinal obstruction.The extensive necrosis of the entire proximal colon secondary to an obstructive sigmoid colon cancer has been diagnosed intraoperatively. Total colectomy and terminal ileostomy have been performed. The postoperative course was uneventful and the ileostomy closure with ileo-rectal anastomosis was performed 7 months later. A review of the literature discussing the epidemiology, pathogenesis, diagnosis and therapeutic approach of this type of colitis, was performed., Conclusions: NC implies diagnosis and therapeutic difficulties,especially from point of view of surgical strategy. We advocate of large colic resections, beyond the macroscopic limits of the necrosis in order to avoid the postoperative complications. We also consider seriate surgical procedures as a good choice for the high risk patients.

Background: The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis., Material and Methods: We retrospectively analyzed the patients operated in the First Surgical Unit Iaşi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed., Results: 219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate., Conclusions: RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

Unlabelled: The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax., Material and Methods: There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iaşi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology., Results: Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981., Conclusions: Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.

Background: Pancreaticoduodenectomy is the treatment of choice for periampullary and pancreatic head tumors. In case of hepatic artery abnormalities, early pancreatic transection during pancreaticoduodenectomy may prove inappropriate. Early retroportal lamina dissection improves exposure of the superior mesenteric vessels and anatomic variants of the hepatic artery, where safeguarding is mandatory., Method: We describe our early retroportal lamina approach in patients with anatomic variants of the hepatic artery before pancreatic transection., Results: This approach was used during 42 pancreaticoduodenectomies with a hepatic artery anatomic variant which was spared in 40 patients. Arterial reconstruction was performed in 2 patients. Five patients with a hepatic artery variant and adenocarcinoma involving the portomesenteric junction required venous resection and reconstruction., Conclusions: Early retroportal lamina dissection during pancreaticoduodenectomy in patients with hepatic artery anatomic variants enables easier exposure, avoiding injuries that might compromise the liver arterial supply. When the portomesenteric vein is involved, this approach facilitates en bloc "no touch" venous resection and reconstruction.

The classic apprenticeship model for surgical training takes place into the operating theater under the strict coordination of a senior surgeon. During the time and especially after the introduction of minimally invasive techniques as gold standard treatment for many diseases, other methods were developed to successful fulfill the well known three stages of training: skill-based behavior, rule-based behavior and knowledge-based behavior. The skills needed for minimally invasive surgery aren't easily obtained using classical apprenticeship model due to ethical, medico-legal and economic considerations. In this way several types of simulators have been developed. Nowadays simulators are worldwide accepted for laparoscopic surgical training and provide formative feedback which allows an improvement of the performances of the young surgeons. The simulators currently used allow assimilating only skill based behavior and rule-based behavior. However, the training using animal models as well as new virtual reality simulators and augmented reality offer the possibility to achieve knowledge-based behavior. However it isn't a worldwide accepted laparoscopic training curriculum. We present our experience with different types of simulators and teaching methods used along the time in our surgical unit. We also performed a review of the literature data.