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The natural evolution of laparoscopy seems to be the use of miniature instruments and, where possible, a reduction of the number of trocars used. We report the results of our experience with all 5-mm instrument three-trocar cholecystectomy vs. the conventional laparoscopy approach. From July 2002 to July 2005 a total of 518 patients underwent laparoscopic cholecystectomy: 268 of them (51.7%) were operated on with a 5-mm three-trocar approach. The primary end point was the feasibility rate of the technique. Secondary end points were safety and the impact of the technique on the duration of laparoscopy. There were two conversions to laparotomy--one in each group--while a conversion to the classical approach for the three-trocar group was registered in 9.3% of the cases. Occurrence of minor complications was 3.6% (9 cases) with the conventional approach as against 3.7% (10 cases) with the three-trocar approach. The present experience shows that 5-mm three-trocar cholecystectomy is a safe, easy, effective and reproducible approach for gallbladder disease. Such features make the technique a challenging alternative to conventional laparoscopy in the treatment of cholecystopathy, in both the acute and elective setting.

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OBJECTIVE: An ideal mesh should produce slight foreign-body reactions and be compatible with the human organisms. Studies focusing on these aspects indicate that the use of mesh with less nonabsorbable material may reduce postoperative complications, insofar the web structure and its rigidity play an important role in compatibility. We evaluated retrospectively the patients of the past 1 year, who underwent laparoscopic transabdominal preperitoneal (TAPP) hernioplasty (without the use any trocar and/or instrument of 10 mm in diameter) focusing attention on the feasibility of the technique and on the incidence of complications, especially those possibly related to the new type of mesh implanted. METHODS: Between June 2004 and September 2005, 76 patients have been operated on by using TAPP hernioplasty (bilateral or unilateral) without any 10 mm instrument/optic/trocar, and by applying a lightweight composite mesh fixed by "glues" (fibrin sealant and N-butyl 2-cyanoacrylate). RESULTS: The mean overall operative time was 55.57 (+/-15.2) minutes. All the procedures have been performed on a day surgery basis. We have registered any kind of major or minor morbidity (early or late), relapse, prosthesis rejection, and/or infection. We have registered no severe pain at 10 days; whereas a mild pain is still reported in 10.5% of our cases at a 3-month follow-up. The mean follow-up is 12.4 (+/-5.1; range 4 to 19) months. CONCLUSIONS: On the basis of this our initial experience, TAPP hernioplasty with a lightweight composite mesh is feasible, effective, and easy to perform by experienced hands, with good results. The well-known characteristics of a mini-invasive and gentle approach, together with the type of mesh implanted and its fixation of related glues, might explain the encouraging results of our experience.

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BACKGROUND: Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment - exploration to identify the causative pathology and performance of an appropriate operation - can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution. METHODS: From January 1992 and January 2002 a total of 935 patients (mean age 42.3 +/- 17.2 years) underwent emergent and/or urgent surgery. Among them, 602 (64.3%) were operated on laparoscopically (of whom 112 -18.7% - with peritonitis), according to the presence of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than two previous major abdominal surgeries or massive bowel distension were not treated Laparoscopically. Peritonitis was not considered contraindication to Laparoscopy. RESULTS: The conversion rate was 23.2% in patients with peritonitis and was mainly due to the presence of dense intra-abdominal adhesions. Major complications ranged as high as 5.3% with a postoperative mortality of 1.7%. A definitive diagnosis was accomplished in 85.7% (96 pat.) of cases, and 90.6% (87) of these patients were treated successfully by Laparoscopy. CONCLUSION: Even if limited by its retrospective feature, the present experience let us to consider the Laparoscopic approach to abdominal peritonitis emergencies a safe and effective as conventional surgery, with a higher diagnostic yield and allows for lesser trauma and a more rapid postoperative recovery. Such features make Laparoscopy a challenging alternative to open surgery in the management algorithm for abdominal peritonitis emergencies.

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Mucosal stomal prolapse is a frequent complication of end colostomies. We describe here an original mucosal colostomy prolapse repair technique using a circular stapling device. This technique stems from the recent introduction of stapled muco-haemorrhoidectomy and was employed on a 68-year-old male patient who had undergone a Miles abdominoperineal excision 17 years earlier. On clinical inspection the patient presented a 5-cm. mucosal stomal prolapse on straining. The surgical procedure was performed under i.v. sedation with midazolam and propofol. After draping the abdomen, the stomal mucosa was gently everted with the aid of three Allis forceps, and a 1.0 prolene purse string suture was created 4-6 cm. cephalad to the cutaneous rim of the stoma. The head of a 33-mm circular stapler was introduced and the purse string suture was tied. The mechanical stapler was prepared and fired, thus obtaining a resection anastomosis of the prolapsed stomal mucosa. No bleeding occurred. A 24-F bladder catheter was placed cephalad to the stapled line and removed on postoperative day one. The patient was discharged from hospital the day after surgery. During a 16-month follow-up neither complications nor relapses have so far been observed. Our technique appears to be simple and safe. We believe it is indicated only for mucosal stomal prolapses, while full-thickness stomal prolapses should be managed by conventional techniques. A larger cohort of patients is needed to confirm our preliminary results.

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The authors report their experience with the treatment of hemorrhoid disease and circumferential mucosal rectal prolapse with the use of a mechanical suturing device, according to the Longo technique. Over the period from March 98 to December 2000, 106 patients were treated with the above-mentioned procedure (100 patients for haemorrhoids and 6 for circumferential prolapse). Twenty-one patients had grade 4, 77 grade 3 and only 2 grade 2 disease. One hundred patients were followed up over a median period of 16.5 months (for the group with haemorrhoids) and 19 months (for the prolapse group). In 81% of cases the procedure was one-day surgery. Mucohaemorrhoidectomy with a stapler was well tolerated in terms of severity of postoperative symptomatology: in 42% of the patients operated on there was no need for any analgesic treatment. The time to return to work was 9.9 days for self-employed subjects and 15.6 days for the others. Refinement of the procedure and better patient selection may improve the results achieved with this technique. Stapled haemorrhoidectomy may be regarded as a sound technique that should be part of the surgeon's armamentarium. We suggest an "eclectic" approach whereby the stapling procedure may be included among the possible therapeutic options, with a view to optimising the choice of therapy for each individual patient.

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