Dome Down Laparoscopic Cholecystectomy: Our Experience and the State of Art

Introduction: Laparoscopic Cholecystectomy is nowadays the gold standard technique for benign gallbladder disease both in elective and emergency surgery. But it is even true that in very acute cholecystitis when the tissues are inflamed and the anatomy can be difficult to recognize, the classic laparoscopic approach can lead to biliary and vascular injuries. Dome down laparoscopic approach can be used to avoid conversion to open surgery and decrease surgical complications. Methods: A retrospective record of all Cholecystectomy carried out in our unit by experienced surgeons from January 2013 to August 2017 was examined. Cases were divided by surgical technique: Classical laparoscopic technique, Open cholecystectomy, Laparoscopic converted to open cholecystectomy, Dome down laparoscopic Cholecystectomy (DDLC). A systematic literature search was performed using PubMedz and Embase databases. The search was limited to studies on humans and to those reported in the English language between January 2009 and December 2016. Results and discussion: 194 cholecystectomy were performed, among these 163 with laparoscopic technique and 3% of all laparoscopic approached cholecystectomy were performed as DDLC. The mean hospital stay was 5 days (2-11). 1 out of 5 patients needed postoperatory ERCP and endobiliary stent was positioned removed in 30 days with no other complications. Other 4 patients were evaluated after 1 week from dismission with no evidence of postoperative complications. Conclusion: Dome down cholecystectomy is a feasible and safe procedure; it avoids biliary and vascular injuries in difficult cholecystectomy. It can still be improved by the combination with ultrasonic devices or with new surgical techniques such as Single-incision Laparoscopic cholecistectomy

Past, present and future of adjuvant HIPEC in patients at high risk for colorectal peritoneal metastases

EDITORIA

Peripheral lymphadenopathy: role of excisional biopsy in differential diagnosis based on a five-year experience.

BACKGROUND: Peripheral lymphadenopathy can be caused by benign disease, or it could be a manifestation of underlying haematological disease or metastasis of a yet undiagnosed malignant condition. Fine-needle aspiration cytology (FNAC) and image- guided core biopsy usually make up the first line of investigation. There are several disadvantages to these techniques: FNAC is an acellular aspirate that may provide non- diagnostic specimens, while core biopsy may fail in the presence of composite lymphoma, nodal necrosis, and insufficiency or fragmentation of the specimens. Our aim was to evaluate the safety and effectiveness of excisional biopsy (EB) in a large case series. METHODS: 220 consecutive patients underwent lymph node EB under local anaesthesia. All patients underwent complete and systematic physical examination. Any palpable lymph node was evaluated for its location, size, consistency, fixation, and tenderness. All specimens were sent to the pathologist as fresh tissue. RESULTS: The EB materials demonstrated 89 (40.5%) benign lesions, 130 (59%) malignant diagnoses, and one (0.5%) unclear diagnosis. Mean operative time was 42.9 minutes (range 10-120 minutes). Harvested lymph nodes had a mean diameter of 3.3 x 2.3 cm. All patients were discharged within 8 hours. No major complications were reported, with a mean of 1.16 post-operative outpatient visits. Temporary seroma and/or minor lymph leak at the site of the incision occurred in 14 cases (6.4%), haematoma in 7 (3.2%), and dehiscence of the surgical incision in 4 (1.8%), and in 3 cases (1.4%) pain was reported up to 7 days post-operatively. CONCLUSIONS: Excisional biopsy is a diagnostic method that can be applied safely with minimal morbidity and mortality

Laparoscopic splenectomy in malignancies: is it safe and feasible?

BACKGROUND: Laparoscopic Splenectomy (LS) is considered the treatment of choice for benign hematologic diseases of the spleen. However, the role of LS in malignancies is still controversial. Technical difficulties, hemorrhagic risk, the need of pathological characterisation of malignant disease, may be considered contraindications to LS in malignancies. This study aims to verify the efficacy and feasibility of LS for hematologic malignancies. METHODS: 145 patients underwent LS for hematologic disease and were retrospectively shared in two groups: Group A (83 patients) patients with preoperative diagnosis of benign hematologic disease and Group B (62 patients) with malignancies. Bipolar spleen diameter, mean operative time, conversion rate and causes, complications and need of transfusion were evaluated. RESULTS: Median splenic diameter was greater in Group B than in Group A with a statistically significant difference (p<0.005), such as higher were the number of accessory mini-laparotomy (p<0.005) and conversion rate (p=0.024) in the group of patients with a diagnosis of malignancy. The mean operative time was 117.6 min. in group A and 148.1 min. in Group B (p<0.005). Besides, there were no significant differences relative to intra-operative and postoperative transfusions and the incidence of postoperative complications. No peri-operative mortality occurred. CONCLUSIONS: The analysis of our data highlights that LS for hematologic malignancies is effective and feasible even if it associated with higher conversion rate due to splenomegaly and difficult hilum dissection. Besides, no differences in the patient outcome were highlighted. LS may be considered a safe procedure in the treatment of haematological malignancies of the spleen