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We report the case of an eight-year-old patient referred by his primary care physician for chronic headache. Bilateral papilledema was observed along with right sixth cranial nerve palsy, leading to the diagnosis of intracranial hypertension. Head CT showed no mass lesion. Lyme serology was positive by both Elisa and Western blot. Anti-Borrelia antibodies were positive in the cerebrospinal fluid, with intrathecal synthesis confirming neuroborreliosis. Clinical response to ceftriaxone and acetazolamide was favorable. Intracranial hypertension is rarely caused by Lyme disease. Ophthalmologists should be aware of this clinical presentation, since the presenting clinical signs may be purely ophthalmologic. In addition, early diagnosis may avoid optic nerve atrophy or disease spread.

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Two cases of internal herniation through a defect in the broad ligament of the uterus are described. Both were successfully treated laparoscopically. This rare condition should be borne in mind when a middle-aged woman presents with colicky lower abdominal pain. The cause is unknown, but both congenital and acquired origins have been proposed. As far as emergency situations are concerned, laparoscopy has proven to be both a diagnostic and a therapeutic tool.

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OBJECTIVES: To examine the suitability of a laparoscopic approach for treatment of perforated peptic ulcer. DESIGN: Retrospective non-randomised study. SETTING: District Community Hospital. METHODS: 30 patients who presented with perforated peptic ulcers between November 1992 and October 1997 INTERVENTIONS: 16 patients were operated on laparoscopically, and 14 by open operation (as there was no surgeon available with laparoscopic experience). MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The laparoscopic operation was successful in all but one patient, whose operation was converted to an open procedure because we could not see the ulcer adequately. Duration of operation and postoperative nasogastric aspiration, analgesic requirements, hospital stay, morbidity, and mortality were similar in the two groups. CONCLUSIONS: Laparoscopic repair of a perforated peptic ulcer is safe in selected patients in whom a laparotomy should be avoided.

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Notwithstanding its widely perceived advantages, laparoscopic appendectomy has not yet met with universal acceptance. The aim of the present work was to illustrate retrospectively the results of a case-control study of laparoscopic vs open appendectomy carried out at our institution. From Jan. 1993 to Dec. 1999 a total of 457 patients (M:F = 210:247; mean age 25.2 +/- 15 years) underwent emergency and/or urgent appendectomy. Among them, 254 (55.5%) were operated on laparoscopically, while 203 (44.5%) were treated by conventional surgery The choice of technique depended upon the availability or otherwise of a team expert in minimally invasive surgery. The laparoscopic technique conversion rate was 3.9% and was mainly due to the presence of dense intraabdominal adhesions. The major intraoperative complication rates were 0.39% and 0% in the laparoscopic and laparotomy groups, respectively (P = ns). Major postoperative complications occurred in 2 and 1%, respectively (P = ns). The postoperative mortality rates were 0.4% and 0.5% in the laparoscopy and laparotomy groups, respectively (P = ns). The reoperation rate was 1.1% in the laparoscopic group as against 0% in the open surgery group (P = ns). Minor postoperative complications were observed in 0.8% and 7.5% of patients in the laparoscopy and open surgery groups, respectively (P = 0.001) and consisted mainly of wound infections. Resumption of bowel function was significantly more rapid and the hospital stay significantly shorter in the laparoscopically treated patients. The greater diagnostic accuracy of laparoscopy allowed concurrent diseases to be diagnosed in 9% of laparoscopically treated patients with histologically proven appendicitis as against 1.5% of those treated by conventional surgery (P = 0.001). Similarly, among those patients with no evidence of gross and/or microscopic appendicitis, concurrent diseases were detected in 58.4% of the laparoscopic cases as against only 6% of the laparotomy cases (P = 0.0001). Despite the limitations of a retrospective investigation, on the basis of our experience we believe that laparoscopic appendectomy is as safe and effective as conventional surgery, presents a higher degree of diagnostic accuracy and makes for less trauma and a more rapid postoperative recovery. Such features make its use mandatory in female patients of child-bearing age referred for urgent abdominal and/or pelvic surgery.

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BACKGROUND: By now, laparoscopic surgery has achieved widespread acceptance among surgeons and, generally speaking, by the public. Therefore, we set out to evaluate whether this technique is a feasible method of treating patients with abdominal emergencies, traumatic or not. To assess the routine use of emergency laparoscopy in a community hospital setting, we undertook a retrospective analysis of an unrandomized experience (presence or absence of a surgeon with laparoscopic experience). METHODS: Between January 1993 and October 1998, 575 emergency abdominal surgical procedures were done in our department. In all, 365 (63.4%) were diagnostic and operative laparoscopy procedures (acute small bowel obstruction: 23 cases; hernia disease: one case; gastroduodenal ulcer disease: 15 cases; biliary system disease: 89 cases; pelvic disease: 237 cases). These cases represent almost 56% of all laparoscopic procedures done during the same period at our institution. Laparoscopy was not performed in patients with a history of a previous abdominal approach to malignant disease, a history of more than two major abdominal surgeries, or massive bowel distension; nor was it used in patients whose general conditions contraindicate this approach. RESULTS: The conversion rate was 6.8%. The morbidity and mortality rates were, respectively, 4.1% and 0.8%. A definitive diagnosis was provided in 95.3% of cases, with the possibility to treat 88.2% of them by laparoscopy. CONCLUSIONS: We consider the laparoscopic approach in patients with abdominal emergencies to be feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities. Sparing patients laparotomy reduces postoperative pain, improves recovery of GI function, reduces hospitalization, cuts health care costs, and improves cosmetic results. This approach promises to play a significant role in emergency abdominal situations and will certainly become increasingly important in today's health care environment.

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BACKGROUND: This is a retrospective review of our experience using a laparoscopic approach in the treatment of acute and chronic small bowel obstruction (SBO). MATERIALS AND METHODS: Of 136 patients hospitalized in our institutions for acute (94 cases: 69.1%) and chronic (42 cases: 30.8%) SBO, from January 1994 to March 1998, 63 (46.3%) were approached laparoscopically. The etiology was accurately diagnosed in 58 cases (92%), and it was possible to treat it laparoscopically in 82.5% (52 of 63 cases). In the remaining 11 cases (17.4%), a formal laparotomy was needed for bowel resection, due to an ischemic small bowel or for malignant disease. RESULTS: Overall, 82.5% of our cases were successfully treated laparoscopically. CONCLUSIONS: We conclude that, in experienced hands, laparoscopy is an excellent diagnostic and, in the majority of cases, a therapeutic surgical approach in selected patients with acute or chronic SBO.

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Colonic perforation is a dangerous complication of colonoscopy, both diagnostic and therapeutic, and its management has become controversial. The question of conservative vs operative treatment is still under debate. Despite the recent expansion and wide acceptance of laparoscopy by surgeons, the feasibility of this technique as a means of treating abdominal emergencies has also been questioned. Of 575 patients admitted to our institution for abdominal emergencies between 1993 and 1998, 365 were treated via a laparoscopic approach. Two of these patients were treated for colonoscopic perforations, one after a diagnostic procedure and one after an operative procedure. Our technique employs an open umbilical approach with two other trocars introduced in the right iliac fossa and left flank. In the first case, a diverticular perforation of the subperitoneal rectum was suspected. The abdomen was copiously irrigated with saline solution and a drain was left in the pelvis. In the second patient, localized peritonitis was found in the left iliac fossa due to a microperforation of the sigmoid colon. It was repaired with a single absorbable suture. The postoperative course was unremarkable in both cases. In patients with an emergency abdomen due to a postcolonoscopy perforation, we consider the laparoscopic approach feasible and safe in experienced hands. It allowed us to avoid an unnecessary laparotomy and other time-consuming and expensive diagnostic investigations. This approach represents an excellent means of managing this type of emergency abdominal situation.

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Laparoscopic hernia repair has already become as accepted a technique as the conventional ones and is routinely used in those centres where this kind of surgery is normally performed. The two most commonly used laparoscopic techniques (transabdominal and total extraperitoneal) have been shown to produce good results in terms of post-operative course and recurrence rates, but still present the disadvantages of high cost and the need for general anaesthesia. We report here a retrospective analysis of our early experience with laparoscopic treatment of inguino-crural hernias. The positive results achieved (no cases of conversion to an open technique; no recurrences to date; 4.7% major morbidity) allow us to consider this approach a valid alternative to the traditional ones in selected, well-informed patients.

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BACKGROUND AND AIM: The wide diffusion and increasing use of laparoscopic surgery prompts the authors to broaden discussion to its validity and diagnostic-therapeutic use in emergency abdominal surgery. The aim was to evaluate the efficacy of laparoscopic surgery in the light of reports in the international literature and in relation to the situation in our hospital. METHODS: From April 1994 to May 1998, out of 1016 emergency abdominal operations performed at our hospital, 783 (77.5%) used a laparoscopic approach for diagnostic and therapeutic purposes: intestinal occlusion: 26 cases; gastrointestinal ulcer pathology: 15 cases; hepatobiliary pathology: 398 cases; "pelvic" pathology: 305 cases; colic pathology: 39 cases. These represent 24.4% of all laparoscopic procedures carried out during the same period. We preferred to use immediate laparotomic access in patients with the following characteristics: anamnesis of previous surgery for malignant pathologies; anamnesis of more than two major abdominal operations; massive intestinal distension; patients whose general conditions were a contraindication to a laparoscopic approach. RESULTS: The conversion rate was 6.2% (49 cases) with morbidity of 3.4% (25 cases) and a mortality rate of 0.2% (2 cases). A final diagnosis was made in 763 patients (97.4%) with the possibility of treating 719 of them (94.2%), again using a laparoscopic approach. CONCLUSIONS: It is right to regard the laparoscopic approach in emergency abdominal surgery as a feasible and safe model, offering a high potential for diagnosis and therapy if appropriately performed by an expert and well coordinated team. The increased experience of mini-invasive surgery and the improved range of instruments available make the laparoscopic approach a valid alternative to laparotomy, even in the event of emergency abdominal pathologies.

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BACKGROUND AND METHODS: The authors report their experience with thrombolytic therapy in seven cases of graft thrombosis managed successfully with low-dose i.v. rt-TPA. In six patients the cause was an anatomical one and so, after the successful lysis, there was enough time to confirm a correct diagnosis and plan the "right" and "less extensive" surgical procedure, obviating it in one case with a "functional" cause of thrombosis. RESULTS: No complication directly attributable to rt-TPA infusion occurred, and no systemic fibrinogenolysis was registered in any cases. Judging from this experience, i.v. rt-TPA appears safe and effective in patients with graft thrombosis, proving to be a good adjunctive therapeutic mode. CONCLUSIONS: Further studies are needed do delineate more clearly safe indication and the validity of this method.

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The authors report their experience with the femoral-to-distal in situ saphenous vein bypass. Evaluation of the distal circulation, the adequacy of the saphenous vein, and routine follow-up after bypass, along with the operative procedure and technical problems (A-V fistulas, valvulectomy, etc.) are described. Overall the in situ saphenous vein bypass provides a natural, compliant endothelial-lined conduit that allows an optimal revascularization to below-knee arteries.

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The authors report their experience with 9 patients, affected by pancreatic and periampullary carcinoma, treated using pancreaticoduodenectomy with pyloric preservation. They analyse the physiopathology of this technique, by the light of the international reports, and note the advantages that this technique allows about the nutritional status and the quality of life of the patients operated on.

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The paper reports the study of 35 patients affected by pancreatic and periampullary carcinoma. The authors analyse the results of six patients treated using pancreaticoduodenectomy with pyloric preservation and compare the results to those achieved using Whipple's operation.

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