Mario Solej

Ligation of the Inferior Mesenteric Artery in the Surgery of Rectal Cancer: Anatomical Considerations

Background: No agreement has been found in the literature concerning the safest point of ligation of the inferior mesenteric artery (ima) in order to avoid nerve damage during the surgery of rectal cancer. Study Design: The distance between the origin of the ima and the left paraortic trunk was measured, as was the distance between the left paraortic trunk and the origin of the left colic artery (lca). The measurements were carried out on 20 cadavers and during 22 operations for rectal cancer. Results: The left paraortic trunk always runs posterior to the ima: its distance from the origin of the ima is on average 1.2 cm; the distance of the left paraortic trunk from the origin of the lca is on average 0.4 cm. The point at which the ima and the left paraortic trunk cross varies greatly, but it is never near the origin of the ima. Conclusions: From an anatomical point of view the safest point of ligation of the ima is at its origin. At this point, the left paraortic trunk never runs; so there isn’t any risk to damage the nerve involving it during the ligation of the artery.

Primary duodenal adenocarcinoma

Aims and Background Primary duodenal adenocarcinoma is a rare tumor with a poorly defined natural history and prognostic factors. It presents with nonspecific symptoms, and for this reason the diagnosis is often delayed. It is a serious problem for the surgeon because of the difficulty in obtaining an early diagnosis and standardizing basic tenets for an appropriate surgical approach. The aim of this work was to conduct a review of the literature analyzing the points most frequently debated about this pathology. Methods and Study Design A bibliographic search was carried out on the main search engines to find studies regarding duodenal adenocarcinoma, published in English, from January 1992 to January 2007. Results A total of 19 articles was selected. Results concerning symptoms, location of the tumor, diagnostic examinations, surgical treatment, histopathology of the tumor, survival and follow-up were obtained and discussed. Conclusions All patients who are medically fit to undergo surgery should be given the option of aggressive resection regardless of tumor size, tumor invasion or appearance of positive lymph nodes. Hopefully, an early diagnosis will correlate with improved long-term survival.

Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience

BackgroundAim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables.MethodsWe described our standardized TAPP technique according with Stuttgart technique [1], and we evalutated our teams experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs).ResultsWe retrospectively reviewed our Surgery Divisions experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients.ConclusionsAccording with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.

Laparoscopic appendectomy in the elderly: our experience

BackgroundLaparoscopic appendectomy for acute appendicitis is one of the most common surgical procedures performed in the world. We aimed to compare laparoscopic and open appendectomy in the elderly in our experience.MethodsWe performed a retrospective review of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2006 to the 31st of July 2012. We analyzed 39 appendectomies in elderly patients: 20 procedures were performed using open technique (Group O) and 19 using laparoscopic technique (Group L).ResultsIn the analysis of intraoperative variables there was no statistically significant difference. In this study there was no statistically significant difference also in peri-operative variables.ConclusionLaparoscopic appendectomy is a safe and feasible technique in acute appendicitis also in the elderly.

Laparoscopic repair of wound defects in the elderly: our experience of 5 years

BackgroundLaparoscopic approach for wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments.MethodsWe report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II) from June 2007 to September 2012.We analyzed preoperative and postoperative data for the laparoscopic approach in the elderly.Results and discussionIn our experience there was no significant difference in laparoscopic procedure between normalweight and overweight patients.ConclusionsLaparoscopic repair for primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches.

The mesorectum: hypothesis on its evolution

AbstractBackgroundTwo points are controversial in the anatomy of the mesorectum: (1) its origin; and (2) the existence of the lateral ligaments. We studied these structures in animals and in human fetuses.MethodsDissections were performed on quadrupedal mammals (29 dogs and 32 pigs) and 28 primates (Macaca apes). Moreover, macroslices of Macaca ape and of 182 human fetuses were examined histologically.ResultsIn quadrupedal mammals, we found no traces of any adipose masses comparable to the human mesorectum nor were there ligaments of suspension. In the ape, the adipose tissue in the mesosigmoid forms an adipose cuff that completely surrounds the extraperitoneal rectum. Two dense connective bands were found between the lateral wall of the pelvis and the perirectal tissue. Both the mesorectum and the lateral ligaments were clearly identified in the sections of human fetus only at the end of the fifth month but not earlier.ConclusionsOn the basis of our analysis of 3 animal species, we conclude that the mesorectum and lateral ligaments are absent in quadrupedal mammals but are present in primates. Therefore, we hypothesize that these structures appeared with the attainment of the upright position, even though other hypotheses are possible.

Vascular Anatomy of the Rectal Stump After Total Mesorectal Excision

PurposeFor many years, poor vascularization of the short rectal stump has been considered the main cause of leakage. The purpose of this study was to evaluate the vascularization of the rectal stump after total mesorectal excision.MethodsWe studied the iliac vascularization on 28 volunteers with healthy rectum to have an anatomic basis. Then, we studied the vascularization of the rectal stumps after total mesorectal excision by using angio computed tomography at seven and three months after operating on 22 patients; we validated this technique by studying the vascularization using angio computed tomography in 18 rectal specimens from cadavers.ResultsBoth in healthy rectums and in rectal stumps after total mesorectal excision, there is good vascularization substained by middle and inferior rectal arteries. The former is more important and frequent as described in previous literature.ConclusionsThe vascularization of the short rectal stump is generally well represented even after total mesorectal excision.

Meso-pancreatectomy for pancreatic neuroendocrine tumor.

We report a case of a meso-pancreatectomy performed on a pancreatic glucagonoma in a 58 years-old woman. MP is a conservative surgical treatment consisting in a resection of the body of the pancreas with the aim of reducing postoperative hormone insufficiency. This approach is curative in benign or low-malignant neoplasm of the central part of the pancreas.

Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly.

INTRODUCTION Inguinal hernia surgery is one of the most common surgical procedures performed worldwide. Some studies demonstrated clear advantages of laparoscopic approach in terms of chronic pain, recurrence rate and daily life activities Aim of this study was to compare short and long-terms outcome of tacks and fibrin glue used during laparoscopic transabdominal hernioplasty (TAPP). METHODS This is a retrospective study conducted by our division of General Surgery. From May 2008 to May 2013 we performed 116 hernioplasty with TAPP technique. We compared two groups of patients: a group of 59 patients treated with fibrin glue and a group of 57 patients treated with conventional tacks and the two subgroups of patients over 65 years old. We evaluated: perioperative outcomes, early and late complications. RESULTS There were no significative difference about length of postoperative stay, time to return to work, recurrence rate and complications. DISCUSSION This study demonstrates that fibrin glue are same tolerated than tacks by patients and that the glues lead to the same good results during initial follow-up and in long term data also in the elderly. Meticulous preparation of the groin with preservation of spermatic sheet is in our opinion necessary to provide effective pain reduction and a good result in every TAPP procedure.

Decreased Expression of Stem Cell Factor in Esophageal and Gastric Mucosa After Esophagogastric Anastomosis for Cancer: Potential Relevance to Motility

Background: Esophageal replacement with gastric tube is a well-established reconstruction of the alimentary tract after esophagectomy in cancer patients. The resulting molecular events in the transposed gastric tube and residual esophagus have yet to be investigated. Stem cell factor (SCF) was recently shown to be critical for signaling in gastrointestinal motility. SCF expression is here correlated with changes in mucosal morphology, acid and biliary reflux, and motility in the residual esophagus and gastric tube.Methods: Thirteen patients surgically resected for squamous esophageal carcinoma with gastric tube replaced by esophagogastric anastomosis underwent upper endoscopy, esophageal manometry, 24-hour pH monitoring, and bile reflux detection. Esophageal and gastric mucosa samples were examined for SCF expression by immunohistochemical and semiquantitative reverse transcriptase-polymerase chain reaction analysis and for SCF serum levels by enzyme-linked immunosorbent assay.Results: All patients showed severe residual esophagus hypoperistalsis and no gastric tube motor activity. The 24-hour pH monitoring was positive in most; 24-hour bile detection was mostly negative. SCF levels in the residual esophageal and gastric tube mucosa were dramatically decreased compared with those of normal subjects. The correlation between SCF and slow-wave activity was positive.Conclusions: Hypomotility of the residual esophagus and gastric tube seems closely associated with disruption of the SCF/c-kit signaling pathway. However, the absence of notable relations between mucosal changes after chronic exposure to acid, biliary gastric content, and SCF expression indicates that this analysis cannot be considered part of endoscopic follow-up.