Functioningadrenocorticaloncocytomaisveryrareneoplasm.Itisusuallynonfunctionalandbenignandincidentallydetected. Generally,thesetumorsoriginateinthekidneys,thyroid,parathyroid,andsalivaryorpituitaryglands;theyhavealsobeenreported inothersitesincludingchoroidplexus,respiratorytract,andlarynx.Histologically,theyarecharacterizedbycellswitheosinophilic granularcytoplasmandnumerouspackedmitochondria.Wereportedacaseofa44-year-oldfemalewhopresentedwithCushing syndrome for hypersecretion of cortisol due to adrenocortical oncocytoma. Magnetic resonance of abdomen revealed a right adrenalmass.Laparoscopicadrenalectomywasperformedandthetumorwaspathologicallyconfirmedasbenignadrenocortical oncocytoma.Aftersurgicaltreatment,Cushing’ssyndrome resolved.

Background: Splenic cysts are rare disease. Epidermoid cysts of the spleen belong to the primary nonparasitic splenic cysts group. They are an unusual event in surgical practice. Usually, epidermoid cysts occur in children and young female. Most often, they are asymptomatic, but they may present with abdominal discomfort. Case presentation: We are reporting a rare case of a 23-year-old female came to our attention with history of intermittent pain and previously undergone two times to laparoscopic decapsulation of the cyst in others institutions. During hospitalization, serum and intracystic levels of tumor marker CA19-9 increased. Enhanced CT of the abdomen showed recurrent large cyst in the upper pole of the spleen with satellite nodules. Laparotomic total splenectomy was performed. Histopathological and immunoreactive examinations were executed, and they revealed stratified squamous epithelium on the inner surface of cystic wall, which was positive for EMA, CEA, and CA19-9. The diagnosis of epidermoid cyst was confirmed. Conclusions: Recently, the surgical approach is changing towards conservative treatments in order to save the spleen in young patients for immunological reasons. Sometimes, this target is not achievable. In such circumstances, like recurrent large cyst, anomalous anatomical relationship to the surrounding tissues, total splenectomy is safe and necessary.

Objective: Cholelithiasis represents a very frequent health problem with higher prevalence in developed countries. The aim of this chapter is to underline, also by submitting our surgical experience, some diagnostic deceptions and the timing of treatment. Methods: The presentation of 42 patients admitted in our institution (September 2012/September 2014) with the diagnosis of acute pancreatitis allows to identify two different clinical forms of acute biliary pancreatitis: the pancreatic pattern and biliary pattern. Moreover, the evaluation of another 42 patients observed in our institution (September 2014/September 2016) with acute cholecystitis should show our treatment program. Also, we added the analysis of our previous research, regarding acute cholecystitis, already published: difficult cholecystectomy, antegrade dissection in laparoscopic cholecystectomy, postoperative morbidity, laparoscopic approach in cirrhotics, finally the robotic experience. Results: Clinical features, laboratory, and imaging exams should identify, into acute biliary pancreatitis, two clinical forms as biliary pattern and pancreatic pattern for different therapeutic approach. The treatment chosen for acute cholecystitis is early laparoscopic cholecystectomy within 24–72 hours. Severe, complicated acute cholecystitis can require urgent surgical intervention. Conclusion: Acute cholecystitis encompasses clinical forms with various degree of severity and several clinical courses. The treatment is focused on early cholecystectomy with various and different management strategies, suitable to the specific pathological conditions.

AIM: The purpose of this study was to determine if there are different outcomes between the right and left laparoscopic adrenalectomy according to our experience. MATERIAL OF STUDY: From September 2010 to September 2015 forty-two LA were performed. Variables compared include age, body mass index (BMI), ASA score, operative time, estimated blood loss, conversions, gland size, tumor size, postoperative ambulation, postoperative hospitalization, perioperative and postoperative complications. RESULTS: Substantially there are no difference in postoperative results between right and left LA. DISCUSSION: We report difference in the operative time because left procedure is more complex. The difference in the blood loss due to two intraoperative bleeding in right side, can be considered a given accidental. CONCLUSIONS: It's important an adequate learning curve to improve intraoperative and therefore postoperative Outcomes.

Voluntary and involuntary ingestion of foreign bodies is a common condition; in most cases they pass through the digestive tract, but sometimes they stop, creating emergency situations for the patient. We report a case of meat bolus with cartilaginous component impacted in the cervical esophagus, with a brief literature review. Case Report: A 64-year-old man came to our attention for retention in the cervical esophagus of a piece of meat accidentally swallowed during lunch. After a few attempts of endoscopic removal carried out previously in other hospitals, the patient has been treated by us with a cervical esophagotomy and removal of the foreign body, without any complications. We checked the database of PubMed, Scopus, and the Cochrane Library from January 2007 to January 2017 in order to verify the presence of randomized controlled trials, clinical trials, retrospective studies, and case series regarding the use of the cervical esophagotomy for the extraction of foreign bodies impacted in the esophagus. Conclusions: The crucial point is to differentiate the cases that must be immediately treated from those requiring simple observation. Endoscopic treatment is definitely the first therapeutic option, but in case of failure of this approach, in our opinion, cervical esophagotomy could be a safe, easy, viable, durable approach for the extraction of foreign bodies impacted in the cervical esophagus. Our review does not have the purpose of providing definitive conclusions but is intended to represent a starting point for subsequent studies.

The complications of biliopancreatic surgery have a very variable range of incidence showing surgical procedures with low incidence of complications such as simple cholecystectomy and complex or very complex procedures such as pancreatic resections followed by high incidence of postoperative complications. The purpose of this editorial is to examine a number of specific complications unique to biliopancreatic surgery such as: pancreatic fistula in relation to the different types of pancreaticdigestive anastomosis and biliary injuries after biliary surgery. Pancreatic and biliary surgical complications include a large range of conditions with overlapping clinical presentations and diverse therapeutic choices. The true incidence of pancreatic and biliary complications is difficult to determine due to selection and reporting bias. The treatment of these complications continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques.

The use of imaging modalities and minimally invasive surgery plays an important role in the current management of adrenal tumors. Ultrasonography frequently allows for the incidental diagnosis of adrenal masses. The most frequent adrenal pathologies encountered are hypercortisolism (Cushing’s syndrome), primary hyperaldosteronism (Conn’s syndrome), and pheochromocytomas. Clinical presentation of these adrenal tumors can often be non-specific, or such lesions may present as “incidentalomas” in patients who undergo imaging for clinical reasons unrelated to the adrenal glands. Adrenal malignancy is suggested by morphologic characteristics found on imaging studies: increased size, irregular borders, local invasion, and large necrotic areas. The risk of malignancy increases for larger adrenal masses. Minimally invasive surgery has become the initial choice for the treatment of adrenal tumors with retroperitoneal and transperitoneal approaches. This chapter describes the surgical indications and compares the various minimally invasive surgical approaches for the therapeutic management of adrenal masses.

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery.

AIM: We report an unusual case of broken adenosarcoma located in the omentum that has procured a clinical situation of acute abdomen in a patient. CASE REPORT: A 79 year-old woman went to the emergency room for growing abdominal pain and then transferred to our department. In previous years the patient had removed endo-cervical and endometrial fibro-glandular polyps and subsequently to a total laparoscopic hysterectomy with bilateral oophorectomy was performed for another endometrial fibroglandular polyp; other vaginal recurrences were then removed. We performed a computed tomography thanks to which we made a diagnosis of moderate hemoperitoneum. RESULTS: The patient underwent to a laparotomy. After abdominal blood removal was evidenced the presence of a damaged big cystic formation starting from the epiploon, containing blood and necrotic debris treated with omentectomy. The subsequent histopathological examination revealed that this tumor was an adenosarcoma. DISCUSSION: Rarely adenosarcoma can grow in extrauterine locations. The simptoms are related to the localization. Even during an emergency surgery it is important to respect the criteria of oncological radicality. You must avoid the tumor dissemination in order to reduce late recurrences, and to achieve a better final histologic diagnosis should avoid intraoperative extemporaneous histological examination. CONCLUSIONS: This case is an example of how many diagnostic pitfalls you can hide in emergency surgery, but in conclusion it remains a doubt about our experience: it is not possible to know if this tumor was a primary extra-uterine neoplasm or a recurrence of fibro-glandular polyps removed years before already in malignant transformation?

Aims: This study presents our experience in the laparoscopic management of simple hepatic cysts (SHCs) and the polycystic liver disease (PCLD). Study Design: Retrospective institutional study. Place and Duration: Department of Medical and surgical Science, University of Foggia, Foggia, from January 2004 to December 2014. Methodology: Laparoscopic deroofing was performed in 20 consecutive patients. There were 15 cases with SHCs and only 5 cases with PCLD (Gigot’s type I). In SHCs group, cyst was single in 10 cases and multiple in 5. Cysts were located in both hepatic lobes in 4 cases. The two groups were homogeneous for age, sex and ASA score. Preoperative investigations include routine laboratory tests, ultrasonography and the use of computed tomography in order to make diagnosis ad to rule out parasitic and neoplastic liver cysts. CT scan was performed in all cases to assess the characteristics, dimensions, and exact position of the lesion. Surgery was planned for all patients because of evident and persistent symptomatology, characterized of the presence from no less of 6 months of typical symptoms such as nausea, vomiting and epigastric pain. In our series, 6 cases of cholelithiasis were associated. Results: The analyzed outcome variables included surgical procedure, operative time, blood loss, length of hospital stay, complications, and medium follow-up period. All the patients underwent laparoscopic deroofing of the larger cysts and puncturing of the smaller cysts. There were no conversions. The mean operative time was estimated twice in the group PCLD than SHCs (110 min vs 60 min). The histological examinations revealed the typical pattern of the simple liver cysts in any case, without evidence of malignancy. No significant blood loss was found. The total morbidity recorded was 25% (5/20), 2 cases in the group of SHCs (13,3%) and 3 cases in the PCLD one (60%) and was characterized of 2 cases of ascites through trocar insertion sites after removal of drainage tube and 3 case of pleural effusion. There were no significant group differences in term of length of hospital stay. The follow-up period (a mean of 22 months) confirmed that all the patients remained free of symptoms and relapse of the disease. Conclusion: The technical feasibility and the good short- and medium-term results made the laparoscopic approach the procedure of choice for the management of symptomatic liver cysts.

Background: The management of common bile duct stones still remains an area of controversy. Over the years, numerous authors have proposed various solutions: based on the time of cholecystectomy treatment can be preoperatively or intra and post-operative (in singlestage and two-stage). Methods: We have selected and compared several studies that make a compare between one-stage management [Laparoscopic Cholecystectomy (LC) Plus Laparoscopic Common Bile Duct Exploration (LCBDE) or Intra-Operative ERCP) and two-stage management [laparoscopic cholecystectomy preceded or followed by Endoscopic Retrograde Cholangio Pancreatography (ERCP)] in secondary choledocholithiasis, adding our personal experience in two stage management of CBDS. Results: In accordance with relevant randomized trials, we can say that the clinical outcome after one-stage laparoscopic/endoscopic management of bile duct stones is no different to the outcome after two-stage management. Conclusion: Our evaluations indicate that the best treatment of choice for any patient with CBDS must be based on locally available expertise, experience of the multidisciplinary team and standardization of the technique (endoscopic, laparoscopic and surgical), as determined by success rates, rates of morbidity and mortality, costs, and patient preference.

Background: Several laparoscopic approaches to the adrenal gland have been described. We prefer the lateral transabdominal approach. The aim of this study is to evaluate prospectively the presence of any anatomical and dynamic changes in the spleen after laparoscopic transperitoneal left adrenalectomy (LTLA), which can cause an increased risk of early and late complications. Methods: We have evaluated 21 patients before and 6 months after surgery in order to verify the possible presence of a wandering spleen. A clinical and instrumental follow-up [ultrasound (US), magnetic resonance (MR)] were performed. During US protocol, in supine, right lateral, and orthostatic position, the longitudinal and anteroposterior diameter of the spleen and the resistive index within 3 cm of the origin of the splenic artery in three different measurements averaged were measured. MR protocol evaluated, in supine and right lateral position, the splenic volume and its distances from the diaphragm dome and the lateral margin of the costal arch. Results: p Values calculated for each parameter were not statistically significant. Our results confirm the absence of any anatomical and dynamic changes in the spleen after LTLA. Conclusions: The most common complications after laparoscopic adrenalectomy are well known and widely described. Our experience does not exclude the occurrence of a wandering spleen, but allows us to state that a rightful mobilization of the pancreaticosplenic block can avoid this event, and in agreement with other authors, the presence of a wandering spleen remains an isolated complication.

Haemorrhoidal disease affect between 4.4% and 36.4% of the general population. The common symptoms are: bleeding, prolapse, pain, discharge, itching and hampered anal hygiene. There is no correlation between specific symptoms and anatomic grading. Apparently severe looking haemorrhoids can cause relatively few symptoms. Open haemorrhoidectomy, as described by Milligan, has been accepted worldwide as the best choice for treatment of symptomatic haemorrhoids. In 1998, Longo proposed a procedure for haemorrhoidectomy with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. His technique presented a new notion for treating haemorrhoids as he proposed circumferential rectal mucosectomy that results in mucosal lifting (anopexy). His aim was not excision of the haemorrhoidal tissue but rather restoring anatomical and physiological aspects of the haemorrhoidal plexus. The grading system described by Goligher, is the most commonly used and is based on objective findings and patient history. Stapled hemorrhoidopexy is performed for grade III and IV, for grade II in case of major bleeding. In lithotomy position and spinal anesthesia and after taking all aseptic precautions, the procedure of stapled hemorrhoidectomy was performed according to Longo’s technique. After this surgical procedure, the need to manually reduce prolapse will have been cured in approximately 90% of patients and the overall preoperative symptoms will be much reduced in the great majority. There should be no anal pain. Bowel habits should have returned to a normal pattern without urgency. One year follow-up or longer 11% of patients had remaining or recurrent prolapse, the reintervention rate is about 10%.

AIM: The purpose of this study is to communicate our experience about the results and effectiveness in the use of the Ttube biliary drainage during pancreaticoduodenectomy. MATERIAL OF STUDY: In accordance whit Whipple we perform the gastric antrum resection during pancreaticoduodenectomy. We have treated 42 patients with pancreaticoduodenectomy, 25 males and 17 females with a mean age of 62 years (range: 53-79 years), and in each of them we have placed a biliary T-tube. RESULTS: Pancreatic fistula was the most common complication and occurred in 10 patients (23.81%), all of these were low-flow fistula (<200 ml) and required only medical treatment. DISCUSSION: Resection of the pancreas is considered a major operative procedure. Pancreatic fistula is the most common complication after pancreaticoduodenectomy, and it was also the most frequent complication observed by us. In pancreaticoduodenectomy T-tube allows lesser risks of complications due to pancreatic fistula and it makes its faster healing. In all cases the treatment was not invasive. CONCLUSIONS: T-tube biliary drainage can make a positive contribution concerning all the complications that can occur after pancreaticoduodenectomy, especially against the pancreatic fistula.

Complication rates from total thyroidectomy are low, at present mortality for this procedure is around 0% and overall complication rate is less than 3%. Major complication includes wound infection, hematoma, recurrent laryngeal nerve palsy, hypoparathyroidism. Tracheal injury associated with thyroidectomy is rare,but when it occurs it can be very dangerous.Tracheal perforation is generally not considered a complication as such, but rather atechnical occurrence during surgery that requires expeditious attention. Tracheal perforation, if encountered, needs to be managed appropriately incenters of expertise for high volume of thyroidectomy.