Fabrizio Lazzara

Single-Access Laparoscopic Rectal Resection Versus the Multiport Technique A Retrospective Study With Cost Analysis

Background. Single-access laparoscopic surgery is not used routinely for the treatment of colorectal disease. The aim of this retrospective cohort study is to compare the results of single-access laparoscopic rectal resection (SALR) versus multiaccess laparoscopic rectal resection with a mean follow-up of 24 months. Methods. This retrospective cohort study enrolled 42 patients. Between January 2010 and June 2012, 21 SALRs were performed. These patients were compared with a group of 21 other patients who had undergone multiport laparoscopic rectal resection. This control group had the same exclusion criteria and patient demographics. Short-term outcomes were reassessed with a mean follow-up of 2 years. Statistical analysis included the Student t test and Fisher’s exact test. Finally, we performed a differential cost analysis between the 2 procedures. Results. Exclusion criteria, patient demographics, and indication for surgery were similar in both groups. The conversion rate was 0% in both groups. There were no intraoperative complications or deaths. Bowel recovery was similar in both groups. No interventions, readmissions, or deaths were recorded at 30 days’ follow-up. At a mean follow-up of 24 months, all the patients with a preoperative diagnosis of cancer are still alive and disease free. Considering the selected 3 items, the mean cost per patient for single-access laparoscopic surgery and multiple-access laparoscopic surgery were estimated as 7213 and 7495 Euros, respectively. Conclusion. We think that SALR could be performed in selected patients by surgeons with high multiport laparoscopic skills. It is compulsory by law to evaluate outcomes and cost-effectiveness by using randomized controlled trials.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BackgroundRe-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an “open” access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.Methods and designThe LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.DiscussionThe study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon’s experience.Trial registrationCurrent Controlled Trials ISRCTN93729016

Single-access laparoscopic subtotal spleno-pancreatectomy for pancreatic adenocarcinoma.

Abstract Laparoscopic distal or subtotal pancreatectomy can be performed safely and effectively unless there is a clear reason why not to do so. With the aim of reducing postoperative trauma and improving the cosmesis, single-access laparoscopic surgery has been introduced into daily practice. We report the first case of distal single-access laparoscopic pancreasectomy for an adenocarcinoma. The procedure was carried out in 170 minutes without postoperative complications. Despite some technical difficulties, we think that a single-access laparoscopic approach could be adequate for a pancreatic resection. However, an adequate analysis of cost-effectiveness as well as regarding the reproducibility should be carried out.

Pseudodiverticular defecographic image after STARR procedure for outlet obstruction syndrome

Dear Editor: Outlet obstruction syndrome (OOS) is a defecation disorder more common in women. Patients refer to coloproctologists complaining of constipation and other typical symptoms ranging from incomplete and fragmentized evacuation to rectal bleeding. This syndrome may be caused by functional and/or anatomical alterations. A correct etiological classification can help the clinician to predict the best treatment strategy. Non-operative treatment, mainly based on dietary changes and biofeedback, is usually suggested as the first or unique treatment option when symptoms are caused by an uncoordinated inhibitory muscular pattern. Conversely, patients not responsive to conservative treatment most likely can benefit from surgery. Nevertheless, traditional techniques, aimed at restoring normal anatomy, are often time-consuming, technically demanding, burdened by serious complications, and, sometimes, under particular circumstances, can be ineffective or can even worsen symptoms. In 2003 Stapled Transanal Rectal Resection (STARR) was described by Longo as an effective new option for the cure of OOS. Since its introduction, STARR has become an accepted surgical procedure even if some criticisms have been raised due to possible serious complications. Recently, a case of rectal diverticulum after STARR procedure has been reported. Here, we describe a similar case, its related diagnostic and treatment modalities. A 60-year-old woman, who had previously undergone unsuccessful medical treatment, was submitted to STARR in our service for obstructed defecation syndrome caused by an anterior and posterior rectocele associated with a posterior rectal wall prolapse. The technique, described elsewhere, follows the same steps as standardized by Longo. In the present case, at the end of the procedure, the stapled line was carefully inspected. As routinely performed, the mucosal band connecting the two edges of the anastomosis was cut both anteriorly and posteriorly. Stitches were then applied at the anastomotic level in order to avoid the risk of postoperative bleeding. The postoperative course was uneventful, and patient discharged on the third postoperative day. One month later, the patient presented at our outpatient visit complaining of recurrence of symptoms with tenesmus, constipation, a sensation of incomplete evacuation, painful and unsuccessful efforts, urge to defecate, anal incontinence, with need of digital assistance. Defecography showed a diverticular cavity on the right rectal wall (60 mm diameter) and an incomplete evacuation of barium. This lateral diverticulum, filled up by impacted stools, shrank the rectal pouch lumen during straining and defecation. The patient refused clinical examination and endoscopy because of intense pain and an examination under spinal anesthesia was then planned. The exam revealed the presence of a bridge of rectal mucosa, 2 cm wide, on the posterior wall. This bridge caused deformation of the rectal profile creating a diverticular cavity full of impacted stools. After mechanical emptying of the diverticulum the mucosal bend was cut with restoration of normal anatomy. Two months after this procedure, the patient had significantly improved defecation with complete resolution of symptoms. Defecography, performed 3 months postopInt J Colorectal Dis (2009) 24:1115–1116 DOI 10.1007/s00384-009-0666-6

Spleen and Pancreas

Splenectomy is a surgical treatment for hematologic diseases like platelet dysfunctions and autoimmune anemia; it is used for lymphoma stadiation and for splenic neoplasms. Laparoscopic surgery for spleen diseases is widely adopted among surgeons as a safe and feasible alternative to open surgery.

Kidney, Adrenal Gland, Ureter, and Varicocele

From early nephrectomies carried out in 1990s, radical nephrectomy nowadays reaches a high diffusion between surgeons and finds specific indications. In 2014 The European Association of Urology built a Renal Cell Carcinoma Guideline Panel and created evidence-based recommendations [1]. Laparoscopic radical nephrectomy has the same oncological outcomes of open approach, and it is the gold standard for T2 renal tumors.

New teaching models for the medical school of medicine: comparison between oral an online classes. The experience of the Genoa school of medicine

The authors have created and tested a tool for performing online classes (AulaWeb, online e-learning of the Genoa school of Medicine). Described here are the results obtained from the pilot project that was performed. Two groups of 50 students each were created among the students who voluntarily signed up for the ADE on the theme of laparoscopic surgery. Each group was further divided into 2 smaller groups of 25 students, which followed respectively classic oral classes or on line classes. The experiment was divided into 2 parts. While the oral classes were the same for the 2 parts of the experiment, the online classes were characterized by the delivering of videos in the 1st part and videos and interactive web teaching in the 2nd part. Standardized questionnaires were distributed to the students, at the beginning and at the end to evaluate the effcacy of the system used to deliver the information. Both groups of students greatly improved their scores answering the questionnaires, but the on line groups expressed greater satisfaction in particular because of the fruition of free didactic contents. In conclusion we can confrm that, when used properly, the web is a fantastic learning tool for students because, not only it delivers information in a stronger way, but it also provides a faster and more enthusiastic way of learning.