Giornale di Chirurgia最新文献

Trichilemmal ovarian carcinoma is very rare. A 52-years-old woman was admitted to University Hospital Department suffering from pain in the left iliaca fossa lasting for three months. Uterus was normal in size, painless as well as right adnexum. On the left site ovary was increased in volume and slightly sore. Transvaginal ultrasounds showed a 97x65x86 mm mixed vascularized unilocular mass. CT scan detected a pelvic expansion with a heterogeneous density due to the presence of different structures varying from fat to bone tissue. A proper informed consent was obtained and a suprapubic transversal laparotomy according to Pfannenstiel was carried out. Ovarian mass and ipsilateral tube were removed with no rupture. The anatomical extemporaneous result was of benign dermoid cyst. The postoperative course was uneventful and after three days the patient was discharged in regular conditions and was recommended to come for final anatomical result. Following a month, the final histological answer was of 15 mm trichilemmal malignant tumor in a context of a large benign dermoid cyst. The neoplastic lesion appears to be entirely contained within the limits of the swollen mass. The outer surface was with no lesions. A case of trichilemmal malignant tumor involving ovary has not been published so far.

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Encapsulating peritoneal sclerosis (EPS) is a rare clinical syndrome characterized by an acquired, inflammatory fibrocollagenous membrane encasing the small intestine, resulting in symptoms of bowel obstruction. It is still unclear whether early surgical intervention has an advantage over conservative management, but, in most reviewed case reports, it is preferred to preserve the surgical management in patients not responding to conservative measures, or when bowel ischaemia is occurring. We report a case of a 58-year old patients, affected by chronic renal failure, on treatment with peritoneal dialysis, in which a late diagnosis of encapsulating peritoneal sclerosis was made, and where surgical intervention was not sufficient to guarantee survival due to the late diagnosis.

Background: Laparoscopic adrenalectomy is the standard management of benign adrenal tumors. Open adrenalectomy is still the gold standard surgical treatment for adrenocortical carcinoma and malignant pheochromocytoma, while the role of minimal invasive surgery is still controversial. Laparoscopic adrenalectomy is associated with low morbidity rate, short hospital stay and rapid recovery to work. The aim of the study is identifying the advantages of laparoscopic adrenalectomy in comparison to open adrenalectomy.

Methods: We present a retrospective study of 21 adrenal tumors that underwent surgical resection at Misurata Cancer Center from April 2013 up to April 2018. We compared: age, sex, marital status, past medical history, function and size of the tumor, type of surgery, duration of surgery, estimated blood loss, preparation of patient for surgery, post-operative complications, post-operative discharge day and mortality.

Results: There were 21 adrenal tumors, 61.9% were females and 38.1% were males, median age 41 years. 61.9% were hypertensive patients, 71.4% functional tumors and 28.6% nonfunctional tumors. 71.4% benign tumors and 28.6% malignant. Laparoscopic adrenalectomy was done in 15 cases (71.4%), open adrenalectomy in 6 cases (28.6%), and 4 cases (19%) were converted to open surgery. Morbidity was 19%, and 30 days mortality rate was 4.7%.

Conclusion: Surgical treatment of adrenal tumors consists of laparoscopic and open adrenalectomy. The type of surgery depends on the size of the tumor and suspicious of malignancy in imaging study. Laparoscopic adrenalectomy is safe and effective for benign tumors with decreased operative time, less post-operative pain, and decreased hospital stay.

We present a very rare case of a 49-year old woman suffering from Nuck canal cyst reaching and compressing femoral vein. Nuck canal cyst is very uncommon event because the pouch accompanying the gubernaculum during intrauterine descent of ovaries usually obliterates, whereas when it persists a cystic cavity containing citrine fluid develops. A gravid 0 para 0 49 old woman was admitted to Catania University Surgery Department owing to suspected lymphatic tumor compressing right femoral vein and causing groin pain with ipsilateral leg partial stasis. Patient believed right venous stasis was due to fibromatous uterus. Ultrasounds and computed tomography (CT) scan defined size (7.1 × 4.2 × 1.5 cm), structure (cystic) of mass and its relation with femoral vein, although they were not diriment for diagnosing its nature. Color Doppler detected circulatory function of compressed femoral vein. Surgery was challenging and Nuck cyst was removed after accurate separation from the right femoral venous walls. A case of Nuck cyst involving femoral vein has never been reported so far.

We report a case of a 32-year old woman with severe pelvic abscess formation who was readmitted to the hospital after ten days of postoperative caesarean course. The patient had undergone emergency caesarean section (CS) for acute foetal sufferance during expulsive period and following three days had been discharged regularly. Enterococcus Faecalis was isolated from purulent material. A prompt antibiotic therapy was carried out, therefore clinic condition did not improve. A percutaneous Computed Tomography (CT)-guided drainage of the abscess was planned. Under local anesthesia abscess was drained. The hospitalization stay allowed monitoring the patient's clinical condition and laboratory blood panel until normalization of all parameters.

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

We present a case where a toothpick perforation in both the large and small bowel was intra-operatively diagnosed. A 45-years-old man presented with 48 hours abdominal pain associated with fever. The abdomen was tender at the McBurney point with signs of localized peritonitis. We suspected an acute appendicitis. The patient underwent a diagnostic laparoscopy. During the operation we exposed a toothpick perforating both sigmoid and small bowel. The toothpick was removed and a direct suture of the two perforations was performed. No faecal contamination or purulent peritonitis was showed. The patient was given 5 days of intravenous antibiotics and recovery was uncomplicated. Perforations caused by foreign body ingestion are often non-specific and misdiagnoses such as diverticulitis or acute appendicitis are common. The diagnosis is most commonly made on radiological imaging or intraoperatively. Abdominal X-ray is unlikely to detect a foreign body unless it is high bone density or metal, CT scan has a higher yield. In our patient, although the ultrasound didn't show directly an appendicitis, we didn't decide to perform other diagnostic exams because of the typical clinical feature. 80 to 90% of foreign bodies transit the gastrointestinal tract without causing an associated pathology. However, the distal ileum and recto sigma tract are risk areas for impaction and perforation due to their caliber. There are no guidelines for the management of foreign bodies in the lower gastrointestinal tract. Case reports describe managing patients non-operatively with antibiotics or with surgery, as in this case.

Overuse myositis ossificans is considered an extremely rare diagnosis, with only a few cases reported so far. A case of a 54-year-old firefighter, involved regularly in training exercises, with bilateral myositis ossificans of the triceps, is presented. The patient had a 4 year history of painful masses at the posterior region of both arms. He never experienced any traumatic event, while physical examination revealed firm masses extending longitudinally within the lateral head of the triceps, bilaterally. The patient had painful restricted range of motion at both sides. Plain X-ray views of the humerus showed linear lobulated heterogeneous masses posterolateral. Surgical resection of both masses, which extended intramuscularly through the whole lateral triceps' head, was performed. Histological examination confirmed the diagnosis of myositis ossificans. Myositis ossificans represents a benign, relative rare clinical entity, defined as heterotopic ossification of the soft tissues. Only 5 cases of myositis ossificans due to overuse have been described so far. The present case is unique, since it is the first one describing bilateral appearance of two masses which extended through the whole length of the lateral head of the triceps. A detailed medical history, as well as imaging examination seem to be necessary in order to establish the diagnosis. Treatment should be decided upon the stage of the lesion. For mature lesions surgical treatment is advised.

Aim: We present a novel approach to a Littré hernia case.

Case report: A 62-year old male presented at our department with a painless mass in the inguinal area and was successfully treated for an inguinal Littré hernia. A Lichtenstein tension-free mesh repair was used without performing simultaneous diverticulectomy.

Discussion: Resection of an asymptomatic Meckel's diverticulum remains a controversial issue. In adult population, leaving an accidentally found silent Meckel's diverticula in situ could reduce the risk of postoperative complications without increasing late complications. Mesh-based techniques provide lower recurrence rates compared to non-mesh techniques.

Conclusions: Management of asymptomatic Littré hernias presents a challenge for the operating surgeon. Treatment guidelines should be developed for the optimal management of these patients.