Eva Intagliata

Portal Vein Thrombosis After Laparoscopic and Open Splenectomy

INTRODUCTION Portal vein thrombosis (PVT) could be a life-threatening complication after splenectomy if not diagnosed promptly and treated properly. Risk factors of PVT are not completely clarified. Spleen size and underlying hematologic diseases are main potential risk factors for this complication. Laparoscopic surgery might increase the risk of developing PVT, as it reduces the blood flow in the portal system due to the pneumoperitoneum but, on the other hand, it seems to be associated with less postoperative modifications of coagulation parameters than open surgery, thus preventing PVT itself. The authors reviewed their series on open and laparoscopic splenectomies, pointing out their experience on PVT and discussing their surveillance and prophylaxis programs to prevent this complication. MATERIALS AND METHODS In this series, the authors report their experience on postsplenectomy PVT in 162 patients who have been splenectomised (102 operated on laparoscopically and 60 by open surgery). RESULTS PVT was clinically observed in 1 case out of 60 open splenectomies and in 3 cases out of 102 laparoscopic procedures. Patients were treated with conservative anticoagulation therapy. In one case, additional ileal resection was needed. Mortality was 0%. CONCLUSION Low-molecular-weight heparin should be administered to all patients who have been splenectomised, especially if they are at high risk of PVT. If symptoms appear, patients need to be treated with high-dose heparin followed, after at least 3 weeks, by oral anticoagulant therapy.

Long-Term Results After Splenectomy in Adult Idiopathic Thrombocytopenic Purpura: Comparison Between Open and Laparoscopic Procedures

BACKGROUND Only a few studies have addressed long-term results comparing laparoscopic and open splenectomy in idiopathic thrombocytopenic purpura (ITP). We analyzed the 1-year results comparing age, sex, length of preoperative steroid therapy, diagnosis-to-splenectomy interval, and preoperative platelet count in relation to postoperative response after open and laparoscopic splenectomy. SUBJECTS AND METHODS Data collected from two groups, treated by laparoscopic and open splenectomy, respectively, of 20 patients each were retrospectively reviewed. Positive response to splenectomies, evaluated according to the International Working Group guidelines reported by the American Society of Hematology, was statistically related through Students t test and the Pearson correlation test to the above-mentioned factors. RESULTS Positive response to splenectomy was observed in 80% and 85% of patients, respectively, in the laparoscopic and open groups (P > .10). No statistical differences were observed comparing each of the studied factors between laparoscopic and open splenectomy responder patients (P > .10). When percentage increase of postoperative platelet count was related to diagnosis-to-splenectomy interval, a positive correlation was found in the laparoscopic group (r = 0.544, P < .05). In addition, a significant negative correlation in both groups was observed comparing preoperative platelet count and percentage postoperative platelet increase, with a greater increase of postoperative platelet count in patients with a lower preoperative platelet count (laparoscopic group, r = -0.663; open group, r = -0.656; P < .01). CONCLUSIONS In this series long-term results after laparoscopic splenectomy in ITP patients were as effective as after the open approach. Higher postoperative platelet percentage increase was achieved in both groups in patients with a lower preoperative platelet count. Finally, laparoscopic splenectomy in this study seems to be superior to the open approach in patients with a longer diagnosis-to-splenectomy interval.

Conservative Laparoscopic Treatment of a Benign Giant Ovarian Cyst in a Young Woman

Giant ovarian cysts are very rare. Recently, laparoscopic treatment, with extirpation of the giant cyst and associated oophorectomy, has been reported. In this article, we describe the first case of complete laparoscopic enucleating of a giant serous cystoadenomyoma with preservation of residual ovarian parenchyma in an 18-year-old girl.

Combined laparoscopic and endoscopic excision of a gastric gist

We read with interest the article by K. De Vogelaere, Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size, published in Surgical Endoscopy 2012;26:2339–2345. We agree with the authors that the laparoscopic approach can be safely and effectively used to remove gastric stromal tumors irrespective of tumor size. Data from the literature show that the long-term results of the laparoscopic procedure are comparable with those reported after traditional open resection of gastric GIST [1–6]. Concerning the technique described by the authors, we think that for tumor located in the anterior wall, the wedge resection is the best technique to be used. For tumors located in the posterior wall, the technique described in the article is a good option for large tumors. For endophitic small tumors of the posterior stomach wall, however, another laparoscopic approach can be used. We have experienced and published an endoscopic–laparoscopic approach that allowed us to perform a mini-invasive surgery for tumors smaller than 2 cm in diameter located in the posterior wall of the stomach. By our proposed technique, laparoscopic removal of GIST was performed also for a patient with a tumor located close to the esophagogastric junction, which the authors ruled out in their series, probably because these tumors are technically challenging with the laparoscopic approach they reported. The technique we have published was performed using two 5-mm radially expandable trocars inserted through the abdominal and gastric walls to have very small incisions in the gastric wall. An endoscopic polipectomy snare introduced per mouth was maneuvered by an endoscopist, who grasped and tractioned the gastric iuxtacardial lesion. A harmonic scalpel device inserted through the 5-mm laparoscopic trocar was used to remove the gastric tumor with a submucosal resection. The resection of the lesion was accomplished thanks to the traction made by the endoscopist through the polipectomy snare, which allowed an excellent exposure of the dissection site. The specimen then was pulled away from the mouth after its introduction into a small plastic bag. After withdrawal of the expandable trocars, the gastric holes were closed with monofilament nonabsorbable sutures. A nasogastric tube was left in place for 2 days. The postoperative phase was uneventful. This laparoscopic–endoscopic technique made possible a complete resection of the submucosal GIST, which otherwise could have been more challenging with marked intraoperative risk of complications (e.g., perforation), considering the iuxtacardial location of the tumor. Our technique allows all the advantages of the laparoscopic surgery, avoids the gastrotomy, and at the same time satisfies the principles of oncologic surgery. In addition, GIST located in the iuxtacardial region may be resected safely and with less morbidity than with other laparoscopic or open approaches.

Solitary subcutaneous hydatid cyst: review of the literature and report of a new case in the deltoid region.

BACKGROUND Solitary subcutaneous hydatid cyst is not frequent and the only symptom is generally a silent growing mass. Total excision remains the mainstay of treatment. Aim of the study was to present a case surgically treated and perform a statistical analysis reviewing previous published works in order to define a correct approach to diagnosis and treatment. METHODS 264 documents from Medline database were considered for primary subcutaneous hydatid cyst cases. Data concerning geographic region, gender, age, job, location, evolving time, history and physical, mobility, diameter, laboratory, imaging, locularity (uni- or multilocular cyst), fine-needle aspiration, preoperative diagnosis, neoadjuvant chemotherapy, treatment, spillage, adjuvant therapy, follow-up and recurrences were ordered in a database and analysed performing t-test, Fishers test and Pearsons test. RESULTS 23 cases, included ours, resulted suitable for our study. Lower extremities were involved in most cases (60.9%) and the thigh represented the most common site (34.8%), whereas upper extremities were the rarest location (8.7%). Patients with head and neck located cysts were younger than those with upper extremities cysts (P=0.037). Patients who underwent multiple imaging approach received a significantly correct first diagnosis (P=0.001) and ultrasonography, unlike other techniques, appeared to be essential (P=0.013). CASE REPORT A 68-year-old man who lived and worked in his farm in Sicily (Italy) presented with a 30-year-growing mass in the deltoid region measuring 10 cm. Ultrasonography and magnetic resonance imaging strongly suggested hydatid cyst. Therefore the cyst was excised and pathology confirmed the diagnosis. CONCLUSION Solitary subcutaneous hydatid cyst must always be considered in the differential diagnosis of silent growing mass in soft tissues. History and physical associated with ultrasound and magnetic resonance imaging are sufficient to achieve a correct preoperative diagnosis.

Laparoscopic splenectomy coupled with laparoscopic cholecystectomy.

Background and Objectives: The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases. Methods: Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients. Results: The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred. Conclusion: Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.

Totally Laparoscopic Repair of an Ileal and Uterine Iatrogenic Perforation Secondary to Endometrial Curettage

Small bowel perforation is a unique, serious complication during endometrial biopsy. The authors report a case of a double uterine-ileal perforation totally managed by primary laparoscopic repair. A 63-year-old female was admitted with acute abdomen 2 days after an endometrial curettage. Abdominal X-ray shows signs of pneumoperitoneum. Emergency diagnostic laparoscopy was performed and a uterine-ileal perforation was identified. Repair was accomplished by a totally laparoscopic intracorporeally suturing of the 2 breaches. Postoperative course showed only a delayed ileus and the patient was discharged after 5 days with no complications. When acute abdomen arises following uterine biopsy, a potential iatrogenic intestinal laceration always has to be ruled out. Laparoscopic approach is a quick and safe technique in these cases. Totally laparoscopic primary closure of the iatrogenic ileal laceration may be accomplished with low morbidity.

Laparoscopic Surgery in the Elderly: Personal Experience in 141 Cases

INTRODUCTION As life expectancy increases, the number of elderly patients presenting with surgically correctable diseases will rise as well. For advantages, which are well recognized in young patients, laparoscopic surgery has been proposed also for older patients. Because of underlying chronic diseases, however, elderly patients have been considered at high risk for the laparoscopic approach. Several studies have pointed out the risks related to cardiac, respiratory, or general comorbidities when elderly patients are proposed for laparoscopic treatment of their surgical disease. PATIENTS AND METHODS In this study, we reported our experience in 141 patients older than 65 years who were submitted to laparoscopic procedures for several indications. According to American Society of Anesthesiologists (ASA) score, patients were classified as ASA I in 70.9% of cases, ASA II in 27.6%, and ASA III in 1%. RESULTS No mortality has been reported. Conversion rate was 5.3% for bleeding in 4 cases or intraoperative hypotension in 2 cases. Mean hospital stay was 5 days. Postoperative complication was reported in 1 case and consisted of a hearth attack. CONCLUSIONS Laparoscopic surgery in the elderly is a safe procedure, if preoperative selection of the patients is accomplished. An experienced surgical team and multidisciplinary approach are mandatory.

Laparoscopic Colorectal Surgery for Cancer: What Is the Role of Complete Mesocolic Excision and Splenic Flexure Mobilization?

Laparoscopic colorectal surgery for cancer is nowadays routinely performed worldwide. After the introduction by Heald of total mesorectal excision for rectal cancer, also a complete mesocolic excision has been advocated as an essential surgical step to improve oncologic results in patients with colon cancer. The complete removal of mesocolon with high ligation of the main mesenteric arteries and veins and the mobilization of splenic flexure are well-known but still debated in western surgical society. The authors reviewed the literature and outlined the rationale and the results of splenic flexure mobilization and complete mesocolic excision in laparoscopic surgery for colorectal cancer.

Mini-invasive tension-free surgery for female urinary incontinence.

The Authors describe the techniques they perform of prepubic, retropubic and transobturator mini-invasive anti-incontinence surgical procedures and point-out some technical details. The state of art and the results of these three main surgical procedure are compared and discussed. Data from the Literature have been reviewed in order to evaluate the efficacy of the techniques. A Medline search has been performed, and 65 relevant articles from 1996 to 2012 were selected. Literature showed similar cure rates among retropubic (71,4-91%), trans-oburator (77,3-95%) and prepubic (81-87,2%) anti-incontinence procedures. Cystoscopy was considered necessary in the retropubic, optional in transobturator and in the prepubic techniques. Intra-operative cough stress test was believed useful only in the retropubic and prepubic procedures. Obstruction symptoms prevailed in the retropubic, were rare in the transobturator and missing in the prepubic technique. Erosion rate was very low and similar for all the three techniques. Intra-operative vascular and perforating risks prevailed in the retropubic technique, due to the danger present in the retropubic space, whereas late infective complications overcame in the transobturator procedure. Severe complications in the prepubic procedure were not reported, but the procedure is performed only in few centers.