[Crural hernia after inguinal hernia repair. A technical note]

A case of femoral hernia following repair of an inguinal hernia with the Shouldice method is presented. The authors discuss the pathogenesis, suggest the use of ultrasound for a precise preoperative diagnosis, and propose the "plug" technique of Lichtenstein as the method of choice for the repair. This method offers a minimally invasive approach, without disturbing the previous inguinal repair and it is very simple to perform.

[Infected pseudoaneurysms of the upper limb. A case re-evaluation]

The authors report a case of infected pseudoaneurysm of the brachial artery in a drug addict, treated with aneurysm excision and brachio-brachial bypass with inverted saphenous vein. They review the literature on the subject and management options.

[The Knight-Griffen technique in colorectal surgery]

The use of stapling devices has changed the practice of colorectal surgery. The authors report their experience with the "double stapling" technique introduced by Knight and Griffen in 1980 for the performance of low colorectal anastomosis. They treated 42 patients, with a mean age of 63.2 years. In 34 surgery was performed for rectal adenocarcinoma, while 8 patients were being reoperated on for closure of a colostomy after Hartmann's operation. In one patient a diverting colostomy was fashioned because of poor bowel cleansing, secondary to a stenosing rectal carcinoma. Mortality was nil. There were no clinical anastomotic leaks. There were 2 cases of late postoperative anastomotic stenosis that responded to endoscopic pneumatic dilatation.

[Rectal foreign bodies. Principles of therapy]

The authors report their experience with the treatment of endorectal foreign bodies (EFB). They review the literature on the subject and examine the various therapeutic options. Considering the possible complications of leaving an EFG in place for prolonged period of times in the hope of spontaneous delivery, they suggest that immediate removal is always indicated. They describe various technical modalities for endoscopic removal, that can avoid laparotomy in the majority of cases.

[Local anesthesia in anal surgery. Technical note and immediate results]

The authors report their experience with the use of local anesthesia in anal surgery (hemorrhoids, anal fissures and fistulas). They describe their technique in detail, stressing the importance of thorough knowledge of the neuroanatomy of the anal canal and of a stepwise blockage of all sensory and motor fibers to the area. They report their results on 300 anal procedures performed under local anesthesia, with good patient acceptance.

[Subacute Budd-Chiari syndrome treated with rTPA. Considerations on a case]

The authors report on a case of hepatic vein thrombosis or Budd-Chiari syndrome (BCS) successfully treated with recombinant Tissue Plasminogen Activator (rTPA). They briefly outline the etiology and symptomatology of this disease as well as the various surgical procedures used for treatment. Medical therapy has been so far poorly effective in treatment BCS, but recently various reports seem to indicate that rTPA may have a role. The authors suggest that rTPA may be used as the only therapy in selected cases, or in treating patients that are not candidates for surgical intervention, or as a temporizing measure to improve symptoms in patients awaiting surgery.

[Calculosis of the cystic duct]

The authors report on three cases of cystic duct syndrome, a fairly uncommon complication of cholelithiasis, consisting in migration of a large gallstone from the gallbladder to the common bile duct, resulting in the formation of a common cavity between cystic, hepatic and common bile ducts. They review the pathogenesis of this entity, as well as the diagnostic modalities best suited to a precise diagnosis. They stress that surgical therapy must be chosen on a case by case basis, trying to restore a functional extrahepatic biliary tree.

[Caroli's disease associated with cholangiocarcinoma. A case of our own observation]

The authors report a case of Caroli's disease associated with cholangiocarcinoma. The patient presented with pain and jaundice and ultrasonography disclosed multiple common bile duct stones, cystic dilatation of the extrahepatic biliary tree and a mass in the right lobe of the liver. At operation, after a frozen section demonstrated cholangiocarcinoma, a common bile duct exploration, right hepatic lobectomy and hepato-jejunostomy were performed. They review the literature on the subject and stress the fact that hepatic tumors are associated with Caroli's disease in 7% of cases. Therefore, in these patients, when a stenosis of the biliary tree is found, multiple diagnostic manoeuvres are indicated in order to exclude the presence of malignancy.

Spontaneous rupture of the liver

A case of spontaneous hepatic rupture associated with bacterial cholangiohepatitis, an entity not previously described as an etiologic factor, is reported and the literature reviewed. Awareness of the pathophysiology of this process and avoidance of certain procedures are important parts of the surgical armamentarium.

[Modified radical mastectomy in local anesthesia]

The authors report their experience on the use of local anesthesia for modified radical mastectomy. They have used this modality in five patients who could not undergo general anesthesia because of underlying severe medical illness and in a sixth one who adamantly refused general anesthesia. They describe in detail the technique used, stressing the importance of a thorough knowledge of regional neuroanatomy. There were no complications in their small series. The authors conclude by stating that the use of local anesthesia may expand the indications for "toilet mastectomy" to include patients in poor medical condition, unsuitable for general anesthesia.

[Surgical treatment of toxic megacolon]

After an introduction on the various aetiological factors involved in toxic megacolon, its onset, medical treatment and indications to surgery, the paper describes personal experience with seven cases. The report highlights the importance of medical treatment which is recommended as the appropriate initial therapeutic approach. Then after a review of evolving surgical techniques, it is suggested , again on the basis of personal experience, that the surgical approach should be neither excessively aggressive (total proctocolectomy with permanent ileostomy) nor excessively conservative (multistoma decompression). According to this report, the operation of choice is currently subtotal colectomy plus ileostomy and sigmoidostomy which combine modest morbidity and mortality with the possibility of future reconstruction.

[Acute intestinal infarction. Diagnostic and therapeutic problems]

The authors report their experience in thirteen cases of mesenteric infarction. They emphasize the difficulty in diagnosing and treating this entity, considering also the impossibility in most centers of performing emergency selective angiography of the superior mesenteric artery (SMA) When feasible, mesenteric rivascularization should always be attempted, followed 24 hours later by a "second look" procedure.

[Inguinal hernia surgery under local anesthesia. Technical note and immediate results]

The authors report their experience on local anesthesia for inguinal hernia repair in 164 patients. They describe the neuroanatomy of the inguinal region as well as the technique of loco-regional anesthesia. The Shouldice repair was most frequently employed, followed by the Bassini repair. Local anesthesia was very well tolerated by the patients, sometimes with the addition of mild sedation. The postoperative course was definitely shortened by the use of local anesthesia, and all patients were able to take a regular diet and to walk few hours after surgery.

[Spigelian hernia: its echotomographic diagnosis and surgical treatment]

A case of Spigelian hernia recently observed gives the chance to review the anatomic features of this pathology. Spigelian hernia is seldom suspected, owing to its rare incidence. Currently, ultrasonography seems to resolve diagnostic problems with an accuracy of 86%. Consequent surgical treatment such as simple hernioplasty is easy, and the risk of recurrence is very small.

[Idiopathic and torsion-induced omental infarct: case reports and a review of the literature]

The authors review nosologic problems related to the infarction of the greater omentum on the ground of two cases (one idiopathic, the other by torsion) recently observed. Omental infarction, far from being a real diagnostic or surgical problem, is an unusual cause of acute abdomen; resection of the affected omentum is curative in 100% of cases.