Mauro Valentini

Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative.

BACKGROUND Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. In this article, we describe the initial experience with laparoendoscopic single-site surgery (LESS) cholecystectomy. PATIENTS AND METHODS Between February and April 2009, patients referred for cholecystectomy to the General Surgery Unit of our institution who agreed to undergo LESS were included in a prospective study. All operations were performed by the same surgical team that was specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing LESS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. RESULTS The LESS and standard cholecystectomy groups included 19 patients each. LESS was successfully performed in all patients and none required conversion to an open procedure or a conventional laparoscopic cholecystectomy by adding more entry ports. The median operating time of 62 minutes in the LESS group was not significantly different than that in the standard laparoscopic cholecystectomy group. CONCLUSIONS LESS cholecystectomy was technically feasible, safe, and represents a reproducible alternative to standard laparoscopic cholecystectomy.

Single-incision versus standard laparoscopic cholecystectomy: comparison of surgical outcomes from a single institution.

BACKGROUND Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy. METHODS Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. RESULTS The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046). CONCLUSIONS SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.

Long-term Control of Gastroesophageal Reflux Disease Symptoms After Laparoscopic Nissen-Rosetti Fundoplication

Laparoscopic fundoplication is the gold standard surgical treatment for gastroesophageal reflux disease, although some patients develop recurrence or collateral symptoms related to surgery. The aims of this study were to describe the long-term symptoms control in patients undergoing laparoscopic fundoplication, to analyze the patterns of failure and to correlate postoperative symptoms with anatomic and physiologic findings. Extensive preoperative and postoperative work-up including symptom questionnaire, barium meal, endoscopy, manometry, and 24-hour pH-metry were performed in 130 consecutive patients undergoing laparoscopic fundoplication. Mean follow-up was 52 months. After laparoscopic fundoplication, 117 patients (90%) were asymptomatic with Visick grade I and II symptoms reported by 124 patients (95%). On evaluation, 119 (92%) patients were satisfied and willing to repeat surgery. Two failure patterns, anatomic abnormalities (wrap migration into the chest or down onto the stomach with or without repair disruption) and functional (incompetence of antireflux mechanism), were reported in 17 patients. Reflux can be controlled in up to 90% of patients with gastroesophageal reflux disease with relatively few complications and a high degree of patient satisfaction. The most common cause of recurrent symptoms is an anatomic failure of the fundoplication.

Total extraperitoneal (TEP) hernioplasty with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia.

We describe the first clinical case of a total extraperitoneal hernioplasty combined with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia. The patient was a 94-year-old woman admitted to the emergency room with signs and symptoms of acute small bowel obstruction. Diagnosis of a strangulated left Richter femoral hernia was only possible during the initial exploratory laparoscopy. The extraperitoneal approach for mesh positioning was performed gaining access through an infraumbilical 12 mm trocar incision, and assistance of two 5 mm laparoscopic ports at the hipogastrium and right flank. Laparoscopy was resumed and segmental intestinal resection with primary anastomosis was performed. The patient recovered without complications and was discharged home at the fourth postoperative day. The total extraperitoneal approach for acute hernia repair was successful in our particular case. However, factors such as laparoscopic surgical experience, careful patient selection, and correct preoperative diagnosis must be considered before studies in the emergency setting.

Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution.

Background: Laparoscopic adrenalectomy by 3 or 4 trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. Methods: Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. Results: There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In 1 case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 80 (20) minutes in the SILS group and 75 (8) minutes in the conventional laparoscopic adrenalectomy group (P=0.150). No intraoperative or postoperative complications occurred. Differences between the 2 study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conn syndrome, Cushing adenomas, nonfunctioning adrenal tumors), and length of hospital stay were not observed. Conclusions: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and seems to have results similar to a conventional approach in our initial comparison.

Pheochromocytoma as a rare cause of arterial hypertension in a patient with autosomal dominant polycystic kidney disease: A diagnostic and therapeutic dilemma.

Highlights • Pheochromocytoma is a rare but treatable cause of hypertension among patients with polycystic kidney disease; it may be suspected in patients with refractory hypertension.• Considering that PCC is much more commonly associated with von Hippel Lindau disease, this alternate diagnosis must be ruled out.• Treatment of PCC is surgical; when there is cystic affectation of the liver in addition to the kidneys, retroperineoscopic surgery is the approach of choice.

Aplicación de sellante de fibrina en pacientes operados por cáncer diferenciado de tiroides. ¿Qué mejoramos?

BACKGROUND In recent years, several publications have shown that new adhesives and sealants, like Tissucol(®), applied in thyroid space reduce local complications after thyroidectomies. STUDY AIMS To demonstrate the effectiveness of fibrin glue Tissucol(®) in reducing the post-operative hospital stay of patients operated on for differentiated thyroid carcinoma in which total thyroidectomy with central and unilateral node neck dissection was performed (due to the debit drains decrease), with consequent cost savings. MATERIAL AND METHODS A prospective randomised study was conducted during the period between May 2009 and October 2013 on patients with differentiated thyroid carcinoma with cervical nodal metastases, and subjected to elective surgery. Two groups were formed: one in which Tissucol(®) was used (case group) and another where it was not used (control group). Patients were operated on by surgeons specifically dedicated to endocrine surgical pathology, using the same surgical technique in all cases. RESULTS A total of 60 total thyroidectomies with lymph node dissection were performed, with 30 patients in the case group, and 30 patients in control group. No statistically significant differences were observed in most of the studied variables. However, the case group had a shorter hospital stay than the control group with a statistically significant difference (p<0.05). CONCLUSION Implementation of Tissucol(®) has statistically and significantly reduced the hospital stay of patients undergoing total thyroidectomy with neck dissection, which represents a significant reduction in hospital costs. This decrease in hospital stay has no influence on the occurrence of major complications related to the intervention.

Los cadáveres en fresco, un antiguo modelo quirúrgico en la cirugía general actual

El pasado 9 de septiembre de 2013, nuestro equipo de Cirugı́a del Hospital Clı́nic llevó a cabo un curso en la Sala de Disección de la Facultad de Medicina de la Universitat de Barcelona sobre la resolución laparoscópica de hernias inguinales complejas. Este curso se basó en la colocación de prótesis tanto con técnica habitual como por acceso TEP laparoscópico. Realizamos el curso con cadáveres en fresco y la valoración de los participantes fue muy positiva, tanto, que ya hemos realizado más, aplicados a otros ámbitos de la cirugı́a. Como cirujanos esta ha sido nuestra primera experiencia trabajando con cadáveres. Ya quedan lejos esas lecciones de anatomı́a aprendidas durante nuestra etapa de estudiantes. Queremos explicar nuestras impresiones y como nuestras expectativas han sido sobrepasadas con creces. No nos centraremos en el objeto del curso sobre hernias sino en el modelo cadáver que tanto nos ha sorprendido. Quiero empezar este escrito dando las gracias a los donantes. Es necesario un reconocimiento a estas personas que dieron su cuerpo por diferentes motivos pero, en el fondo, pensando en su utilidad una vez hubieran muerto. Sin este modelo deberı́amos explorar diferentes maneras de continuar con el avance de la medicina y de la cirugı́a y, en cualquier caso, nunca podrı́amos alcanzar la exactitud de trabajar con cuerpos humanos. Como decı́a antes, lejos quedan nuestros inicios de estudiantes; hemos ido creciendo, madurando, aprendiendo y adquiriendo experiencia. Siempre es interesante volver la vista atrás y volver a hacer cosas olvidadas. Nos sorprendimos con nuestras sensaciones, que fueron completamente distintas a las del estudiante. Como profesionales de la cirugı́a tenemos un objetivo claro y eso cambia la percepción del estı́mulo. Acostumbrados como estamos a diferentes modelos quirú rgicos inertes y experimentales, principalmente animales, lo más destacable fue la casi perfección del modelo para procedimientos quirú rgicos. Esta similitud con el modelo real convierte el modelo cadáver fresco en la mejor manera para avanzar en la implementación de técnicas quirú rgicas, al

Volvulus of the splenic flexure of colon: The coffee bean and whirl signs.

Fig 1. Abdominal radiography showing the coffee bean sing: a double loop of air-distended colon with the two inner bowel wall edges directly opposed to each other, simulating the central crevice of a coffee bean. A 49-YEAR-OLD WOMAN without a previous medical history of illness presented to the emergency department with severe acute abdominal pain and vomiting. On physical examination she was hemodynamically stable with abdominal distension and signs of peritoneal irritation. The leukocyte count and differential were within normal levels. Abdominal radiography evidenced a coffee bean sign (a double loop of airdistended colon with the two inner bowel wall edges directly opposed to each other, simulating the central crevice of a coffee bean; Fig 1). A contrast-enhanced computed tomography (CT) scan showed a whirl sign at the splenic flexure of the colon (a twisting and engorgement of the mesenteric vessels around a central point; Fig 2). A laparotomy with left hemicolectomy and primary anastomosis was performed. Pathologic findings confirmed the diagnosis of volvulus of the splenic flexure of colon with initial ischemic changes. The patient’s recovery was uneventful.

La imagen del mes

La imagen del mes Aneurisma de la arteria esplenica Splenic artery aneurysm Rosa Gomez Espin *, Eduardo Munoz Bertran , Diego Martinez-Gomez b y Enrique Girela Baena c a Servicio de Aparato Digestivo, Hospital Morales Meseguer, Murcia, Espana b Servicio de Cirugia General y del Aparato Digestivo, Hospital Morales Meseguer, Murcia, Espana Servicio de Radiodiagnostico, Hospital Morales Meseguer, Murcia, Espana