The Impact of Body Image and Self-Perceived Physical Ability on the Well-Being after Mastectomy without Reconstruction

Introduction: Mastectomy has well-known effects on both physical health status of the patients as well as on their mental life (self-image, daily activities, social integration, lifestyle, etc.). The aim of this study was to identify the physical and psychological factors associated with post-mastectomy distress. 
Material and Methods: Thirty-one women aged 39 to 69 years old (mean age 57 +/- 7.85 years old) who underwent surgery for tumour excision responded to questionnaires on their current physical and psychological well-being following surgery. 83.33% of the patients underwent mastectomy, 10% lumpectomy, and 6.67% both interventions. Age at the time of surgery ranged from 33 to 67 years old (mean 48.30 +/- 7.54). Fifty percent of the patients had no family cancer history, 30% had a family cancer history, and 16.67% were not aware of their family antecedents. 
Results: Over half of the women were satisfied with their arm and trunk mobility and the ability to perform strenuous or prolonged exercise; 60% of patients were satisfied and very satisfied with the postoperative scar. 78.56% feel comfortable when making short trips (weekend). A higher depression score was identified in patients who received chemotherapy compared to those who received hormonotherapy, radiation therapy or targeted therapy. 
Conclusions: The quality of life of mastectomized patients is influenced by the level of satisfaction with body image, perceived physical state, and independence in activities of daily living, and type of therapy. The age at the time of surgery, time passed since surgery or educational level, had no influence on the quality of life.


Background
Malignant melanoma arises by malignant transformation of the normal melanocytes. Distribution of malignant melanoma includes cutaneous (91.2%), ocular (5.3%), mucosal (1.3%), and unknown primary site (2.2%) [1]. Because of rarity and clinical challenges arising from different anatomic location, our understanding for the optimal management of mucosal melanoma remains limited. Malignant melanoma can arise from the mucosal epithelium of respiratory, alimentary, and genitourinary tracts, all of which contain melanocytes. The most common sites for primary mucosal melanoma include head and neck followed by anorectal, and vulvovaginal regions (55, 24, and 18%, respectively). Rarer sites are urinary tract, gallbladder, and small intestine.
Although melanocytes share same embryologic origin, mucosal melanomas behave more aggressively and have many different characteristics compared to cutaneous melanomas. Mucosal melanomas are multifocal in 20% cases, while cutaneous melanomas are multifocal in 5% [2,3]. 40% of mucosal melanomas are amelanotic, while <10% of cutaneous melanomas [3]. In the following section we described this uncommonly presented entity. 5 year survival for mucosal melanoma is 25%, while that for cutaneous melanoma it is 80.8% [1].

Etiopathogenesis
Mucosal melanoma arises in non-sun exposed parts of the body and risk factors are not properly defined. Incidence increases with age and > 65% of patients are older than 60 years [4]. The difference between white and black population is less pronounced compared to cutaneous melanoma and mucosal melanomas are approximately twice higher among whites compared to blacks [5]. The higher incidence in females compared to males is because of the predominance of genital tract melanomas in females, which account for 56.5% of mucosal melanomas among them [5]. There is no difference in rates between genders for extragenital mucosal melanomas.
For oral mucosal melanoma cigarette smoking has been suggested as a risk factor [6]. Formaldehyde has been implicated in sinonasal mucosal melanoma [7]. Genetic studies identified increased prevalence of c-KIT mutation and lower expression BRAF and NRAS oncogene mutation in mucosal melanoma compared with cutaneous melanoma [8,9].

Diagnosis and Staging
Whole body skin examination and ophthalmic examination are important to exclude possibility of metastatic lesion from primary cutaneous or ocular melanoma and it is more important when diagnosing melanoma in sites, where it occurs uncommonly. To distinguish primary lesions from metastases Allen and Spitz identified junctional or in situ melanoma component with intact epithelium overlaying invasive melanoma as main diagnostic criteria for primary melanoma [10]. As diagnosis of mucosal melanomas is usually delayed and many lesions are ulcerated, this criterion is not easy to assess.
There is no uniformly accepted staging system for mucosal melanoma and varies depending on the primary site. A simplified staging system originally developed for head and neck melanoma can be applied to all cases of mucosal melanoma [11] (Table I).

Mucosal Melanoma of the Head and Neck Presentation
Commonly occur in the nasal cavity (most commonly involving the turbinates and nasal wall) 55%, paranasal sinuses (most commonly maxillary and ethmoid sinuses) 15%, oral cavity (most commonly involving the hard palate and upper alveolus) 25% [12]. Uncommonly, it arises in pharynx, larynx, or esophagus [13][14][15]. Sinonasal mucosal melanomas present with nasal obstruction, epistaxis, or loss of smell [16]. Mucosal melanoma of the oral cavity presents as painless bleeding mass, an ulcerated area, mucosal discoloration, or ill-fitting dentures [17]. Regional lymph node involvement has been estimated to be present in 25% of oral cavity lesions and 6% sinonasal mucosal melanoma. Any suspicious lesion should undergo biopsy.

Staging
Workup includes clinical examination with endoscopic inspection for paranasal disease, CT and/or MRI of the primary site and CT and/or PET imaging to assess for lymph node involvement or distant metastases.

Treatment
Primary goal is to perform a sphincter preserving negative resection margin (R0) excision. Ross et al reviewed 32 patients with melanoma treated with either APR or local resection and concluded that local recurrence was lower in the APR group compared to local excision (29% vs 58%), however there was no difference in overall survival (19.5 months vs 18.9 months) [27]. Retrospective studies also confirmed comparable overall survival between APR and local excision [29,30]. Resection status and tumor stage were significantly associated with prognosis, but the type of resection (abdominoperineal resection or local excision) was not significant. Patients with positive surgical margins suffer inferior survival. Abdominoperineal resection is reserved for patients with bulky local disease, involved anal sphincter, anal incompetence and for selected patients with local recurrence. Inguinal lymphadenectomy is performed for clinically apparent disease in inguinal lymph nodes. Adjuvant RT has not shown improvement in overall survival. 5-year survival for R0 resection is 19% and for cases with involved margins is 5%. Factors adversely affecting prognosis in localized disease include perineural invasion, tumor size and thickness, and the presence of amelanotic melanoma.

Vulvovaginal Melanoma Presentation
It occurs primarily in vulva (95%) and vagina (3%). Urinary bladder, urethra, or cervix is rare sites. Although vulvar melanoma is <1% of all melanomas, they represent 10% of all malignant tumors of the vulva [31].Chronic inflammatory disease, viral infections, chemical irritants, and genetic factors have been implicated as risk factors [32]. Vulvovaginal melanoma commonly presents with pruritus, vaginal bleeding, a vaginal discharge, dyspareunia, or a mass.

Staging
Work-up includes clinical assessment with a pelvic examination, CT and/or MRI of the primary site and CT and/or PET imaging for distant metastasis. Vulvar melanoma is staged according to AJCC TNM classification for cutaneous melanoma [33]. No staging system has demonstrated prognostic accuracy for vaginal melanoma. Previously described simplified clinical staging system can be used for the purposes of standardization (Table II); however its prognostic utility is limited.

Treatment
Vulvar Melanoma: Wide local excision with negative margins is the adequate treatment and it has replaced the more radical surgeries. Melanomas <1 mm thick should be treated with at least 1 cm skin margins and for thicker melanomamargins can be extended up to 2 cm [34]. The excision should incorporate all layers of skin and subcutaneous tissues and extends upto muscular fascia below. Radical vulvectomy is reserved for large tumors and inguinal lymphadenectomy is done in the presence of nodal disease. Even after extensive surgery prognosis is poor in advanced cases.
Vaginal Melanoma: achieving wide local excision with negative margins can be difficult without pelvic exentration because of multifocality and anatomical constrain. Whenever possible, wide excision with negative margins is adequate. There may be a role of adjuvant RT in selected cases.
Patients with vulvar melanoma have 5-year survival rates of 24-The American Joint Committee on Cancer (AJCC) staging system for head and neck is used for this subset of disease and staging starts at stage III reflecting poor prognosis (Table II) [18].

Treatment
Wide local excision is the treatment of choice if R0 resection can be achieved. The surgical approach is same as for other common malignancies of that particular site. Local resection is followed by appropriate reconstruction. Therapeutic neck dissection is indicated in the presence of lymph node metastasis. Elective neck dissection in the presence of local disease only is not indicated. Sentinel node biopsy doesn't have an established role in the management of head and neck mucosal melanoma. Local recurrence occurs in 29-79% of cases even after despite aggressive surgical treatment [19][20][21][22].
Malignant melanoma are relatively radioresistant, but some studies have shown benefit [20,21].Temam et al found local control rates of 26% with surgery alone and 62% with postoperative radiation therapy in 69 patients with mucosal melanoma [22]. Several series have reported improvement in local recurrence with adjuvant RT but no improvement in survival [23]. Role of RT has not been established in trails. Postoperative RT is usually indicated for positive surgical margins or narrow surgical margins and recurrent disease. Some centres routinely use postoperative RT if palpable lymph nodes or extracapsular extension present. RT is not used if lesions are close to the eye or central nervous system. Primary RT is applied to patients who are not candidates for resection and when adequate resection margin is not possible.
Prognosis of the head and neck mucosal melanoma is usually poor with 5 year survival rate of 12-30%. 10% have distant metastasis at presentation. Local recurrence occurs in 40% of nasal cavity lesions, 25% of oral cavity lesions, and 32% of pharyngeal tumours. Overall local recurrence occurs in 55% -66% and nodal recurrence in 16%-35%. Most of the recurrences occur within first 3 years [24]. Nodal involvement reduces median survival time of 18 months and multiple local recurrences are the most common cause of treatment failure. As per Memorial Sloan-Kettering Cancer Centre study independent prognostic predictors include stage at presentation, tumor thickness >5mm, vascular invasion, and distant failure are the only independent predictors of outcome of mucosal melanoma of the head and neck [18]. In localized lymph node negative primary mucosal melanoma microstaging according to invasion into tissue compartments are found to be a significant and independent predictor of poor survival (Table III). 16. Moreno MA, Roberts DB, Kupferman ME, DeMonte F, El-Naggar AK, et al.

Introduction
Medicine is an ever-changing and ever-growing field where day after day and year after year new things are invented, applied for the treatment of various diseases. In the line of treatment, surgery has been one of the feared treatment options for most of the patients; therefore surgeons try to provide the patients with the best possible surgical treatment options. The best possible surgical option has always been the one with the lesser complications intra and postoperatively, wellcontrolled pain, less stay at hospital etc. Both doctors and patient don't want to maximize hospital stay as one study stated that extended hospital stay has been associated with increased incidence of hospital acquired infections, which causes further increase in morbidity and mortality [1]. One of the greatest achievements in the history of surgery has been evolved from open surgical techniques to the operative video-laparoscopy Acute appendicitis is one of the most common cause of acute abdomen and one of the most common surgical emergencies. Appendectomy for acute appendicitis is one of the most commonly performed surgical procedures [2]. The surgical technique of first open appendectomy (OA) was performed by Dr. Charles Mcburney in and this approach has not significantly changed in the last 1 century [3]. In 1983, Dr. Kurt Semm, performed first minimally invasive laparoscopic appendectomy, thereafter LA has become the standard of practice in uncomplicated appendectomies in most minimally invasive institution [4]. In the past few years of minimally invasive surgery, LESS, NOTES has gained popularity. SILA was first described in 1998 by Esposito and has gained popularity as a method with a concept of ''scarless'' abdomen [5]. While Pelosi in 1992 performed the first SILA for acute appendicitis [6]. Innovative methods such as NOTES (Natural Orifice Tran luminal Endoscopic Surgery) and single incision laparoscopy (SIL) have demonstrated promissory results in various surgical procedures, appendectomy among them [7]. According to a recent study, SILA resulted in faster recovery than conventional 3-port LA [8]. However in some other studies it has also been reported that SILS is associated with a longer operative time and higher postoperative pain scores, and that patients need more analgesics to feel comfortable [9]. NOTES, SILS, and robotic surgery do not constitute techniques, rather they are concepts, hence regarded as transitions from laparoscopic surgery to unknown fields of minimally invasive therapeutic modalities [10]. SILS was recommended as a possible alternative of the traditional laparoscopic surgery via four ports for the biliary tact by Navarra et al. [11]. With NOTES having a diminished success, because of the inability to find a clean site for access, thereby increasing the chances of intra-abdominal spillage or infection from the incision [12] increased interest has been seen in SILS. SILS occupies a space between NOTES and standard laparoscopy [13]. There have been several studies regarding comparison between the SILA and 3PLA and to evaluate the possible advantage and disadvantages between them. Therefore the purpose of this article is to review and asses the outcomes and results related to SILA and 3PLA thus have an idea that whether SILA can be replacement for 3PLA in coming years.

Discussion
Minimal invasive surgery has continued to evolve, with a focus on improving cosmetic results and others potential benefits regarding *Corresponding author: Ji Zhen Ling, Department of General Surgery, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China, Tel: 008613705153488; E-mail: zlji@vip.sina.com/zlji@me.com pain needs to be less. Less post-operative pain also allows less use of analgesics. In the study conducted by Carter et al. [20] showed the SILA patients reported a mean pain score of 4.4 of 10 in the first 12 hours after surgery, compared with 3.5 for 3-port patients. A visual analogous scale was used from 0-10 in which 0 refers no pain whereas as 10 refers to severe pain in ascending order. In another study Post-surgery pain was measured using the VAS scale (0-10), with higher readings for SILS with a statistically significant difference, SILA=4, 3PLA=3.3 [23]. In contrary other study by Ahmed et al. [25] showed patient have slightly less pain following SILA; comparison to 3-PLA. However, this was not statistically significant in which SILA group required less morphine in recovery. Another two study reported significant difference on pain score in favor of the SILA group during the first 24 h [21,22]. Teoh et al. [16] described no significant differences in pain score when evaluated at rest but a decrease in this score in the CLA group during coughing and standing. As many patients felt pain after surgery, it is difficult to conclude precisely on whether or not there is less post-operative pain. More study is required in this area.  [14,16,19,21] showed patient complications were similar between groups the results for SILA and 3PLA groups revealed no significant difference despite some fewer complications in each groups.

Conversion (to additional port or Open)
During the course of surgery every surgeon wants to finish the surgery without any complication or difficulty but due to some unavoidable circumstances surgeon need to convert the operation for example difficult and unclear anatomy, intra operative bleeding that can't be tackled by existing procedure etc. In one study by Ahmed et al. out of 33 patients in SILA group 3 patients in the required an additional port, 2 patients underwent standard three port laparoscopic surgery, and 1 patient was converted to an open operation. While out of 34 patients the 3PLA group, 2 patients required an additional port and 2 patients were converted to an open operation. Another study Carter et al. showed 1 case of SILA need to be converted which required 2 additional port due to intra operative complication. While in 3PLA group this is no any conversion. Others studies Sozutek et al., Teoh et al. and Frutos et al. [14,16,21] regarding conversions reported that there was not significant difference in the conversion rates among two groups. Sozutek et al. [14] in their studies stated that considering results of patients with complicated appendicitis treated with SILA and 3PLA, both methods may be applicable in experienced hands. As in all laparoscopic operations, insufficient exposure due to severe inflammation or dense adhesions is always the main indications for open conversion or additional port. Conversion should be considered as a surgical decision and not a complication.

Cost
Although not many studies have clearly stated about the cost difference between SILA and 3PLA, one meta-analysis conducted by postoperative outcomes and to reduce surgical trauma. Both technique have their own advantages and disadvantage. A comparison of outcomes between both techniques is required to be looked into.

Cosmetic
One of the commonly seen advantages of SILA over 3PLA is the reduction in incisions needed. Where in SILA there is a single about 2 cm intraumbilical skin incision from which SILS port is inserted while other two 10-mm and two 5 mm trocars were inserted from the same port. While in 3PLA there is need for three incisions; two 5 mm ports and one 10 mm port [14]. In a study of scar comparison by both SILA and traditional 3-port by Ceci et al. [15] it was concluded that the former was found to reduce scars, thus it is advantageous from cosmetic improvement. Another study by Teoh et al. [16] concluded that the LESS approach resulted in better cosmetic scores and satisfaction scores than 3-PLA. Most researchers found that the cosmetic scores given by patients undergoing SILA was higher than that given by patients undergoing the 3PLA [17,18]. Conversely, according to study conducted by Lee et al. [19], reported that the cosmetic satisfaction score and postoperative pain scores were not significantly different between SILA and 3-port LA. According to these studies, patients were more satisfied with the cosmetic appearance of SILA over 3PLA.

Operative time
As SILA is considered to be a relatively less used technique, it is essential to understand the learning experience of the surgeons and how the operative time changes with experience. According  [16,18,[20][21][22][23] the results showed that SILA was associated with significant longer operative times than 3-port LA. More time is needed for performing SILA than 3PLA may be due to the characteristic single incision of SILA technique would increase its technical difficulty because all surgical procedures have to be performed in one working channel [18,24]. However in the study conducted by Ahmed et al. [25] showed that SILA which took 74 minutes to complete the operation was quicker than traditional 3-port which took 89minutes with the total operation time being 15 min shorter. The shorter operating time observed in SILA may be due to more experienced surgeons in the SILA group. Interestingly though, in another study conducted by Mutter et al. [26] stated that even though the surgeons with experience performed more rapidly, there was no significant difference. But the study by Tay et al. [27] reported that a second surgeon showed faster improvement on mentoring from the first surgeon. Overall, the learning curve is said to be quite short [28]. The technical change from conventional to single-port LA requires a learning curve of at least 10 surgeries for a basic handling of SILA [29]. Therefore with more experience, the time required for the operation significantly decreases.

Length of hospital stay
Shortening the stay in the hospital is one main concern of the patient and patient party and is beneficial to both hospital and patient, as it reduces costs also. As one study by Adolfo et al. [30] showed the mean postoperative hospital stay was shorter in the SILA group than in the 3PLA group but the difference was not significant. Other studies though, didn't find a much significant difference in hospital stay [20,23,31,32]. However some studies regarding SILC was said to have a significantly shorter stay in the hospital [33]. This was supported by a few other studies [34,35]. So among different studies done the LOS between SILA and 3PLA has not much difference.

Post-operative pain
Pain is one of the main concerns for patients after surgery. In order for patients to return back to their daily activities, postoperative Jun Gao et al. [17] reported that the use of additional device makes SILA more expensive than 3PLA.
In a comparison of costs, it is said that SILC is more expensive than traditional 4 port laparoscopic cholecystectomy [38,39]. In another study Bucher et al. [40] surgeons tried to reduce the cost by reusing material. According to the study conducted by Lee et al. cost was significantly lower in the SILA group compared with the CLA group because of using a unique ''single-port'', that could reduce the number of trocars, generally 3 trocars were needed for CLA and 1 trocar for SILA [41]. However, it must be noted that the surgical techniques differed among the included studies in terms of the type of umbilical port (triport vs. "homemade") and straight versus curved instruments. These differences impact the cost of SILA significantly [42]. The study conducted by Seung Min Baik et al. [43] showed no any significant difference in the cost comparisons between the two groups. (SILA $1,527 ± 218.3 and 3PLA $1,549 ± 119.8)

Conclusion
In the current era of modern surgery SILS represents a new technique in minimally invasive surgery and has been applied to various abdominal operations aiming to reduce the trauma of surgical access and improving cosmesis. Paul Buckley 3rd et al. [44] in their study concluded that Single-incision laparoscopic (SILS) surgery has emerged as an alternative to 3-PLA, with some advantages in terms of patient satisfaction and cosmesis and SILA performed by experienced surgeons have shown similar postoperative outcomes as 3PLA. SILA is a safe technical alternative to 3PLA for patients with appendicitis. Some studies have shown that SILA has the advantage of shorter hospital stay and it can achieve comparable operative time, blood loss, postoperative recovery, postoperative pain and complications with 3 port laparoscopic [45]. SILA is feasible technique and represents a possible alternative to conventional laparoscopic appendectomy as it does not increase the rate of complications. However Jun gao et al. [17] in their study reported that SILA should not yet be considered the gold standard for appendectomy as long term data on outcome are lacking.
Hence, SILA is a procedure still in the progress of being superior to traditional 3 port in the field of minimally invasive surgery for the treatment of acute appendicitis and many more studies should be conducted in large scale to see if SILA can replace 3PLA in future.

Background
Endometriosis is a painful and chronic gynecologic disorder, characterized by the presence of ectopic endometrium outside the endometrial cavity. Under this situation endometrial cells are implanted ectopically, that lead to retrograde menstruation via the fallopian tubes into the pelvis [1]. Endometriosis affects at least 6.3 million women and girls predominantly of reproductive age in the United States, 1 million in Canada, and millions more worldwide. It is associated with pelvic pain and infertility [2]. Peritoneal endometriosis, ovarian endometriosis and DIE are the three clinical presentations of endometriosis that have been described before [3]. Furthermore, several classifications of DIE have been proposed. In one classification, three different types of DIE are distinguished [4]: (I) A large lesion in the peritoneal cavity, infiltrating conically with the deeper parts becoming progressively smaller is designated as type-1; (II) In type-2, the bowel is being retracted over the lesion, and becomes deeply situated in the rectovaginal septum without infiltrating it; (III) Spherically shaped lesions, situated deep in the rectovaginal septum, and are often only visible as a small typical lesion at laparoscopy or often not visible at all. In the year 1995, Donnez and Nisolle have proposed only two types of DIE, first being caused by the invasion of a very active peritoneal lesion deep in the retroperitoneal space. In cases of lateral peritoneal invasion, utero-sacral ligaments can be involved as well as the anterior wall of the recto-sigmoid bowel junction resulting in a retraction, adhesions and secondary obliteration of the cul-desac. A second type is pseudo-DIE where the lesion originates from the rectovaginal septum tissue and consists essentially of smooth muscle with active glandular epithelium and scanty stroma [5].
Today it is believed that endometriotic lesions can penetrate deep either into the retroperitoneal space or into the walls of the pelvic organs [6]. However, the mechanism is not clear and little is known about the impact of the different types of surgery in the treatment of DIE on complications, pain, patients' quality of life (QOL), recurrence rate and pregnancy rate or fertility. The aim of this review is therefore to evaluate the quality of life improvement after the different surgical modalities for management of DIE based on the above-mentioned parameters.

Material and Method
In this review we have searched The PUBMED (March 2005 to July 2015) for relevant articles. Heading terms "deep infiltrating endometriosis, quality of life" (n1=33) and "deep infiltrating endometriosis" (n2=402) were used. All pertinent articles were retrieved without any language restriction. To ensure the relevance of the publications, additional inclusion criteria were applied. We have included only those studies that contained a clear explanation of the surgical technique, an effectual evaluation of pain and an explicit description of post-operative QOL. To ensure a complete review of the preoperative evaluation of DIE, we have also included some of the most relevant studies regarding this subject, without any restriction.

Specific Symptoms of DIE
DIE exhibits a broad spectrum of clinical manifestations. DIE can be completely asymptomatic, or can become a disorder where quality of live is heavily compromised, as DIE is defined by the presence of endometrial implants, fibrosis and muscular hyperplasia under the dyschezia, gastrointestinal symptoms, and noncyclical pelvic pain and the anatomic locations of deep infiltrating endometriosis. They found a direct correlation between symptoms and location of DIE, as painful defecation was associated with vagina involvement and dyspareunia with uterosacral ligament localization. Other manifestations such as: GI symptomatology and lower urinary tract symptoms were correlated with bowel, respectively with bladder extension. It was also noticed that severe dysmenorrhea was more frequent in patients with adhesions in the Douglas pouch [16]. In a study by Chapron et al., 300 women were evaluated in order to assess the type and severity of pain symptoms and correlate them with intraoperatory findings. Endometrioma associated to severe pelvic pain strongly correlates with the presence of DIE, thus making preoperative extensive evaluation of endometriotic lesions mandatory for planning the surgical intraoperative strategy [17]. As a consequence, it is crucial to conduct additional investigations in order to map out DIE lesions accurately before surgery. The best time to conduct additional investigation is either during menstruation or just before/after the menstruation. Pelvic exam should always be associated with transvaginal ultrasound (TVUS), which is definitely the most important and widely available tool in evaluating endometriosis. Existing preliminary results need to be confirmed, but is a common view that TVUS should be conducted systematically at first intention [18]. Transrectal ultrasonography (TRUS) is one of the most reliable and widely accepted methods of diagnosing for infiltration of the bowel wall [15,[19][20][21][22]. Infiltration of the bowel wall is an essential point of preoperative investigation as it affects the way the surgery is performed. One must consider following factors while opting for TRUS: (1) preexistence of rectal bleeding (2) possible bowel infiltration (3) possibilities of painful menstrual bowel functional symptoms in the absence of rectal bleeding and (4) possibility of a large posterior lesion. Among other methods, few clinicians also adopt cystoscopy and ureteroscopy in order to determine urinary tract mucosal infiltration, especially when bladder endometriosis is suspected [23][24][25]. This method allows the position of the lesion relative to the ureteral meatuses to be established. This is an important factor to consider especially when deciding on the surgical technique.
Regarding preoperative staging, the revised American Society for Reproductive Medicine (rASRM) score is the most widely used classification of endometriosis. The Enzian classification, also revised in 2011 and mainly used in the German-speaking countries, was developed as a supplement to the rASRM score, in order to provide a morphologically descriptive classification of deeply infiltrating endometriosis [26].
Magnetic resonance imaging (MRI) is another means of preoperative evaluation that provides complete and simultaneous descriptions of the anterior and posterior compartments of the pelvis [27]. Complete and simultaneous preoperative evaluation is important, as DIE lesions are most often located in the posterior compartment of the pelvis [10,28]. Posterior compartment of the pelvis is an area that transvaginal ultrasonography does not explore well. One drawback of MRI is that it is less sensitive for the diagnosis of bowel infiltration [29,30].
Virtual modified colonoscopy is a single investigation that can visualize all affected organ systems in the pelvis and abdomen (multifocal bowel lesions, urinary tract lesions, reproductive organ lesions, and distant organ lesions such as liver involvement). The LSD/ MURO Scale is a new preoperative classification designed specifically for this method in an attempt to quantify the severity of rectogenital disease and disseminated endometriosis [31]. Further studies are essential to establish novel way of diagnosing bowel infiltration and to define the respective places of the various additional means of investigation. If the intestinal infiltration is known or suspected to exist, the bowel must be prepared preoperatively. peritoneum [7]. It may also involve, in descending order of frequency, the uterosacral ligaments, the rectosigmoid colon, the vagina and the bladder. DIE may cause severe dysmenorrhoea. However, pelvic pain may be more common in women with deep, infiltrating implants postsurgery. It is reported that, DIE induced pain is due to compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants [8]. However, the intensity of pain in woman with DIE correlates well with the depth and volume of infiltration [9]. DIE induced painful symptoms is very organ specific, being present in precise anatomical locations. However, multifocality is also a major characteristic of DIE Lesions [9]. DIE induced pain can thus be described as organ and location specific pain. Rectovaginal endometriosis accounts for 5% to 10% of women with DIE [9]. It is characterized by the presence of palpable endometriotic nodules deep in the connective tissue of the pelvis. This shows profound fibrosis and fibromuscular hyperplasia [9].

Surgical versus Conservative Management
Surgery is the primary mode of treatment in most of the infiltrating diseases. Surgical treatment is very effective in relieving painful defecation, pelvic pain and dyspareunia [10]. In principle, deep endometriotic lesions should be ignored some time and should not be always treated because of its passive impact (and effect). However, intestinal and ureteral foci that cause progressive stenosis constitute indisputable reasons for operating. Otherwise, it is not necessary to opt for asymptomatic DIE surgery and should not be considered mandatory in all cases. In case there is no response to medical therapies or there is a symptom, which requires urgent surgical procedure, surgery should be the primary mode of DIE treatment. In addition, the location of the DIE lesions must dictate the choice of operating technique. Since endometriosis is located primarily on the pelvic organs, laparoscopy should be the preferred technique for diagnosis, especially in multifocal cases. It is ideal to obtain consent for surgical resection of DIE, if surgery is performed for diagnosis.
Normally, the mean number of lesions is significantly correlated with the location of the main lesion, as the percentage of isolated DIE lesions that is located on a single, varies between 29 and 83% [10]. During speculum observation, a bluish lesion is observed which is normally located in the upper third corner of posterior vaginal wall. These are normally pathognomonic for DIE diagnosis. Under such situation, a detailed medical investigation in the posterior vaginal fornix should be made for irregular appearance or for a stiff and thickened area. During this process, existence of a nodule must be sought during the vaginal touch. Even though, most clinicians sought for nodular lesion (a most standard form observed), it is not a must-to-follow rule [11,12]. It is also true that the outcome of clinical examination varies per the physical location of the lesion. However, signs like lateral deviation of the cervix [13] or asymmetry of the uterosacral ligaments instead of a nodule are also evident [14,15]. With a close examination with the speculum that finds lesions evocative of endometriosis, the upper third of the posterior surface of the vagina is infiltrated. Nevertheless, this proportion is significantly far lower in cases where the bowel or uterosacral ligaments are involved [11]. On the same note, lesions affecting vagina results in more frequent palpation of a nodule or painful infiltration during the vaginal touch [11]. So, the surgical practice must systematically include a rectal touch.

Preoperative Evaluation
Pelvic exam still represents an important step in the initial evaluation of DIE, as it offers the first perspective of preoperative assessment. Studies have demonstrated that results vary depending on DIE involvement, having low sensitivity and specificity, especially when referring to multiple localizations: ovaries, bladder, rectum, ureters etc. Fauconnier et al. in a study on 255 women evaluated the correlation between specific symptoms such as: dysmenorrhea, dyspareunia, In conclusion, TVUS / TRUS provide accurate information about the presence and extent of the lesions. Moreover, TVUS with or without prior preparation of the colon, can be alone an accurate non-invasive method for preoperative detection of deep-infiltrating endometriosis (DIE) involving the rectosigmoid. Ultrasound evaluation of DIE lesions is very similar to that performed laparoscopically in concordance with Enzian classification. However, involvement of the USL, pelvic and vaginal wall is difficult to assess by ultrasound only. MRI proves its worth in the correct classification of doubtful cases, in case of extrapelvic localization and abdominal adhesions. Both ultrasound and MRI are accurate diagnostic methods, with no differences in terms of disease staging. Transvaginal ultrasound is the first choice investigation if clinical suspicion is present and for rectovaginal septum evaluation. Enzian classification and rASRM score supplement each other in terms of morphological description and have common potential for classifying endometriosis. Preoperative staging permits the creation of a treatment plan and provides an early stage prognosis [26,[32][33][34][35].

Choosing the Best Surgical Approach
The overall goal behind designing the best surgical approach is to achieve complete resection of all symptomatic DIE lesions during a one-step surgical intervention. To accomplish this, several surgical procedures must be associated. Operative laparoscopy based partial cystectomy is a standard method for bladder DIE. For vaginal DIE, numerous authors have demonstrated that operative laparoscopy using various techniques like electrosurgery, sharp dissection or laser CO 2 ; exclusively laparoscopic procedure or laparoscopically assisted vaginal surgery is highly efficient. For DIE infiltrating the uterosacral ligaments, it has been shown that laparoscopic surgical resection is efficient.
In principle, the location of the endometriosis governs the choice of operating technique. Despite a huge number of available publications, there is no definitive answer available for a best possible surgical procedure that is recommended for women presenting with DIE. Previous studies show at least two widely used (and accepted) surgical approaches that are employed: (1) colorectal resection removing the rectal segment affected by the disease, and (2) nodule excision. Nodule excision may be performed by shaving the rectum. Alternatively, nodule excision is performed by removing the nodule along with the surrounding rectal wall. Again, the best surgical procedures to treat DIE lesions can be further divided into two concepts of surgery: conservative and radical. Conservative surgery is otherwise known as "nodulectomy" where intestinal DIE implant is resected. Nodulectomy is accomplished by rectal shaving [36-39] or mucosal skinning [40]. Rectal shaving allows an incomplete excision of microscopic implants, and lead to cyclic pain or digestive complaints. However, as cyclic pain may be controlled by post-operative hormonal treatment, they should not lend support to an argument for a more aggressive surgical approach. In case of bladder endometriosis, partial cystectomy is the surgical treatment of reference. This operation has been conducted by operative laparoscopy as described elsewhere [41,42]. Moreover, clinicians use laparoscopic surgical resection in cases of deep endometriosis infiltrating the uterosacral ligaments [43][44][45][46][47]. In this case, it is necessary to conduct ureterolysis to be able to execute the uterosacral ligament (USL) nodule completely without any risk of ureter injury. Decision on laparoscopic surgery is totally dependent upon the nature of USL. A bilateral surgery is conducted if a nodule affects both USLs. However, a healthy contralateral ligament should not be resected if the USL lesion is unilateral.
Approaching an advanced stage of endometriosis disease can be a real challenge, as it should take into consideration the real extent of infiltration and all possible complications that may appear. Angioni et al. demonstrated that incomplete surgery of DIE can eventually lead to higher rates of pain recurrences and even to repeated surgery accompanied by medical therapies [48].

Determining Quality of Life Improvement after Surgery for DIE
Quality of life (QOL) and health-related satisfaction of DIE patients can be assessed with the Medical Outcomes Survey Short Form 36 (MOS-SF-36). Available in several languages, MOS-SF-36 is the most widely used generic instrument to evaluate health-related quality of life and offers a simple tool to help clinicians select and inform patients who might benefit from DIE surgery [49]. Previous study shows that preoperative assessment of QOL with the SF-36 questionnaire can predict the QOL improvement after laparoscopic resection for endometriosis [50]. It is very important to emphasize patient's pain during the preoperative examination, which normally has a higher impact on the other components of QOL [51]. However, conservative surgeries in young women have a higher rate of pain recurrence [52]. Same study has demonstrated that in the absence of bowel resection in women with DIE, intestinal endometriosis is the factor most strongly associated with the actuarial recurrence rate [52].
One flip side of this questionnaire is that, SF-36 contains 36 items and thus places a considerable burden on both patients and investigators [53]. To overcome this issue, Ware and colleagues, therefore, decided to develop a substantially shorter questionnaire-the SF-12-reducing the number of items from 36 to 12 [54]. Clinicians found that the SF-12 summary measures are highly correlated with the SF-36 summary measures. In addition, SF-12 items explained about maximum variation of the SF-36 summary measures. SF-12 also reproduces eightscale profile with fewer levels than SF-36 scales and yields less precise scores, as would be expected for single-item and two-item scales [50]. However, for large group of studies, confidence intervals are largely determined by sample size and hence these differences are not as important.
Previous studies have evaluated the impact of surgery on quality of life using visual analogue scale (VAS) [55,56]. From a group of patients with endometriosis, a significant negative correlation between VAS rating and quality of life has been evaluated by using MOS SF-36 questionnaire [57]. In addition, the same group has found a relation between hyperalgesia to pressure pain threshold measured and the impairment of SF-36 physical function as well as mental health parameters. All these interesting facts emphasize the systematic use of MOS SF-36 questionnaire as a tool, especially to identify patients who may have a benefit of surgery. On the same note, Abbott et al. and HRQOL data from the 36-item Short Form (SF-36) questionnaire and concluded that radical excision of DIE is safe and is associated with significant improvement in QOL, especially in terms of pain [62]. Another study by Angioni et al. demonstrated that complete surgical excision of deep endometriosis is associated with better long-lasting improvement in quality of life. They encouraged surgeons to completely excise DIE implants when possible, as administration of GnRHa is followed by only a temporary improvement of symptomatology when incomplete surgery is performed [48]. In a study published by Ruffo et al., long-term outcome after laparoscopic bowel resections for DIE was evaluated on a number of 900 cases. Bowel resection for endometriosis is associated with an acceptable postoperative complication rate and significant improvement in symptoms (except for rectal bleeding and dysuria). Unfortunately, the median follow-up was just 54 months, which can be considered as a bias, so further studies need to be done in order to confirm the results  [66].
A pilot study on 20 patients with DIE and colorectal infiltration who benefited from osteopathic manipulative therapy, showed an improvement of the quality of life evaluated by the SF-36 questionnaire. Further randomized studies are required to correctly evaluate the benefits and outcomes of this technique [67].

Identifying Patients Most Likely to Benefit from Surgery
The latest review on the subject clearly concludes that surgery should be indicated only in the following situations: patients who present with significant dyspareunia and dyschezia that results in major impairment of quality of life (evaluated by VAS . 7), patients who present with signs of bowel obstruction, and patients who have failed previous in vitro fertilization (IVF) cycles [68]. Therefore, a thorough preoperative diagnostic investigation and careful detailed counseling are of major importance to understand which patients are most likely to benefit from DIE surgery. A good understanding of family history and physical examination of the patients helps predicting clinicians to evaluate the risks and benefits of surgery on an individual basis. Patients with prior information of the intestinal and urologic systems are the good candidates to schedule intraoperative consultation. Laparoscopic visualization remains the gold standard for diagnosis of endometriosis and preoperative imaging may also help guide therapeutic approaches, enabling patient counseling prior to surgery. Patients with pain should undergo a trial of empiric hormonal treatment, especially those who fail to benefit from laparoscopy. Patients with unsatisfactory preoperative function are most likely to improve, especially those with worse preoperative imagery. However, patients with a previous family history of DIE are less likely to gain functional improvement. Previous studies report a worse preoperative physical function as a strong predictor of functional improvement. This is true for patients who especially fall under upper quartile of the change in SF-36 function score [69]. One must consider predictive variables and operationalize into a clinical scoring tool to identify patients who are most likely to benefit from DIE surgery in terms of a clinically meaningful improvement in SF-36 function score.

Conclusion
A delay between onset of symptoms and diagnosis of DIE is mainly attributed to insensitivity of specific signs and available diagnostic tests. There is a clear need for a comprehensive preoperative evaluation of the disease with precise description of the morphologic extension. This mandatory step can provide the necessary surgical planning and predict possible future quality of life improvements. Patients should be precisely informed and counseled about treatment options and expected results.

Introduction
Breast cancer is the most common form of cancer diagnosed in women (23% of all cancer cases) and the leading cause of cancer death, accounting for 14% of all cancer deaths [1]. Studies show that breast surgery, regardless of type, mastectomy or lumpectomy, has a major impact on both health and psychosocial life, affecting patient's femininity, body image and indirectly her behaviour and social integration [2].
The impact of mastectomy is strongly reflected on body image during the first 3-12 postoperative months [3]. Thirty percent of the women with breast cancer require mastectomy, of which 8-10% undergo immediate or delayed breast reconstruction. Many studies have confirmed its psychosocial benefits; however, the research conclusions are not generally valid [4][5][6][7]. Boughton showed that most psychological consequences of conservative breast cancer surgery mostly depend on individual personality and not on the type or technique of surgical procedure [8]. The psychological echo of mastectomy is generated by stress and feeling of disfigurement due to breast loss, to which the anxiety generated by the disease that threatens the vital prognosis adds up [9].
The ultimate goal of modern medicine is to overcome lifethreatening obstacles and offer better chances of survival to certain categories of persons who would otherwise have tragic destinies. This idea is more easily understood by people who have to deal with patients with similar diagnoses [10].
According to the WHO definition, the concept of "quality of life" (QoL) implies the absence of disease on the background of physical, social and mental well-being [11]. Ensuring QoL is assumed by a multidisciplinary team of physicians, psychologists, social workers, nurses, who must work together to improve the physical, mental and social well-being of patients. The WHO definition of health emphasizes not only the physical well-being, but also the idea that health represents a balance between physical, mental and social wellbeing in an environment that promotes good health. Consequently, the health status is the expression of individual's capacity to adjust adequately to his environment, so that a harmonious balance between the psychophysiological states, body resources and environmental circumstances to be established. Currently, there is no universally accepted definition of health, but a plurality of definitions, due to the extensive medical knowledge gained, cultural specificity and to the fact that health is an evolving concept. As advances in medicine have led to highly improved therapeutic methods aimed at delaying as much as possible the complications and death, logically, those who are assessing the health status should consider the idea of not only saving lives but also of improving its quality.

Medical variables
The synthesis of medical data of patients included in the study is shown in Table I. About half of the investigated patients (46.67%) had various associated diseases (other cancers, hypertension, diabetes), 46.67% answered that they did not have associated diseases, while 6.67% said they were not aware of diseases other than the one they were operated for.
Fifty per cent of patients declared not having a family cancer history, 30% had a family cancer history (parents, siblings or extended family), and 16.67% said they were not aware of such a diagnosis in their close relatives. More than half of the patients, 53.33%, declared that prior to diagnosis they had various family problems (financial, relational, stressful life events etc.) (Table I).

Psychometric characteristics of QoL-M questionnaire
Data in Table II summarize the correlations between the 6 dimensions of the questionnaire, overall QoL score and Cronbach alpha value, calculated on the study sample. The values show in the first place, appropriate levels Cronbach alpha index, from 0.79 to 0.94. As expected, the correlations between overall score of QoL and the six dimensions are relatively high. However, the correlations between questionnaire dimensions are relatively small, indicating a sufficient level of mutual independence. (Table II)

Analysis of Satisfaction Level with some QoL Indicators Measured by qol-M Questionnaire Satisfaction with physical state
The items aimed at identifying the level of satisfaction with the ability to perform strenuous or prolonged exercise, arm and trunk mobility, variables considered only in relation with the performed surgery and its consequences. Responses were assessed on a scale of 1 to 4 (where 1=very little satisfied, 2=little satisfied 3=satisfied and 4=very satisfied) and the results are as follows: 1. Capacity to perform strenuous physical exercise, with mean of 2.28+/-1.15; of all responses, 25% of patients were very little satisfied, 7.14% little satisfied, 53.57 satisfied, and 7.14% very satisfied with their ability to perform strenuous exercise; in the collection of self-report QoL data; (d) aggressive therapy may result in improved QoL; (e) pathological symptoms are associated with quantifiable disruptions in QoL; (F) CV pre-treatment QoL may be predictive of may be predictive of on-treatment QoL and of survival [12]. The breasts are attractive in many cultures and losing a breast by mastectomy is considered to be extremely demanding mentally compared to other forms of cancer therapy [13]. In this context, surgeons hope that breast preservation or reconstruction would help the affected women to regain psychological well-being, resume daily life activities, and have sexual relationships and better sexual functions after breast cancer diagnosis and treatment [14].

Study sample
In the interval October 2014 -January 2015, a total of 31 women from Northeast Romania who were diagnosed with breast cancer and underwent mastectomy answered a QoL-M questionnaire developed by the first author of this study. The relatively small study sample is mainly explained by the surprisingly numerous difficulties encountered in identifying and approaching the patients operated for breast cancer. Most patients (93.1%) were from urban areas, and 6.9% from rural areas and their age ranged from 39 to 69 years old, with a mean of 57.22 +/-7, 85 years old. The time elapsed since surgery ranged from 1 to 21 years, with a mean of 8.25 +/-4, 89 years. The age at the time of breast cancer surgery ranged from 33 to 67 years old, with a mean of 48.3 +/-7, 54 years.
Fifty per cent of the patients had higher education, 30% high school education, 6.67% secondary education and 13.32% primary education or unschooled. As to marital status, 6.45% were unmarried, 54.84% married, 25.81% divorced, and 12.9% widows. A percentage of 12.9 had no children, 41.94% had one child, 38.71% had two children, and 6.45% had three children.

QoL-M questionnaire
The questionnaire consisted of 64 items with response scales (four levels of intensity), developed by studying the literature and based on the results obtained from personal interviews and focus groups of mastectomized patients. Items are based on a 5-dimensional structure: functional (e.g. satisfaction with arm mobility), physical state (e.g. frequency of arm pain); relational (e.g. family relationship); mental disposition (e.g. good mood); sexual life (e.g. frequency of intercourse).
The following socio-demographic variables were taken into account: age, area of residence, education level, marital status, number of children, depression level, data on surgical intervention, aspects of the doctor-patient relationship, family history, comorbidities, diseaserelated data (diagnosis, time passed since surgery), treatment, type of surgery, ways of informing the patient about the possibility of breast reconstruction, source of information and reasons for not having breast reconstructive surgery until the time of questioning. The relationships between these variables and responses to the QoL-M questionnaire will be analysed in a further step of this The main objectives of this research were: 1. preliminary assessment of QoL-M questionnaire psychometric characteristics;

2.
Analysing the collected data about the QoL of mastectomized patients and the relationship between QoL and the level of depression.
The research was approved by the Ethics Committee of the Iaşi "Grigore T. Popa" University of Medicine and Pharmacy. The questionnaire was completed after the patients were instructed and signed the informed consent. Data were processed with SPSS 22.0.   The statistical significance of the above presented percentages was subjected to chi-square test goodness of fit, to analyse the deviation of the answer values profile from the null hypothesis (equal frequency of each answer level). A non-significant p-value for an item means that the answers profile for that item significantly departs from equal frequency profile, and therefore that item capture a significant preference for the observed levels responses. The associated phi-Cramer index is the effect size measure of each chi-square test. The greater effect size index, the greater the intensity of preference for the chosen answer values for that question. The results are summarized in (Table III).

Type of Surgery
As can be seen, in all cases the profile of responses deviates statistically significant the null hypothesis (equal percentages for the four possible answers). Even more important than statistical significance is the phi-Cramer index of effect size, which was high and very high (over 0.40) in most situations. The lowest value of this index was for postoperative scar (0.29), which is characterized by an effect size only slightly exceeding the average. These data support the conclusion that these questionnaire indicators are relevant in for the level of QoL in mastectomized patients.

Satisfaction with self-perceived physical appearance
The questionnaire included items related to the comfort to wear clothes, bra included, and satisfaction with the perceived body image. Over half of the questioned patients said they were satisfied and very satisfied with the way clothes fit them (40.74% and 18.52%, respectively), while 25.93% were little satisfied and 14.81% very little satisfied As to satisfaction with the self-perceived body image over 35% were very little or little satisfied, 25% were satisfied and 39.29% very satisfied physical. Over 40% of the patients who responded to the questionnaire said that wearing a bra is uncomfortable, and were very little satisfied (14.81%) and little satisfied (25.93%) with the need of wearing it, while 59.26% felt very comfortable wearing a bra.

Satisfaction with daily or leisure activities
The items aimed at identifying the level of satisfaction with the ability to cope with household, work-related and leisure activities, or ability to make shorter (weekend) or longer (vacations) trips. These variables were taken into account only related to performed surgery and its consequences. The answers were assessed on a scale of 1 to 4 (where 1=very little satisfied, 2=little satisfied 3=satisfied and 4=very satisfied) and the obtained results were distributed as follows: 1. Ability to cope with household activities, with a mean of 2.92 +/-  Table IV.
The significance of the percentages obtained to questions about daily and leisure activities was also subjected to chi-square test goodness of fit test (Table V).
As with physical state, the profile of answers to these questions had a statistically significance (p<0.05). Also the values of effect size index exceed the "large" effect threshold, showing that patients feel a strong positive effect of mastectomy in terms of physical state. However, although high, effect size levels for physical and leisure activities were significantly lower than those obtained for physical state (Table II). Also, it is interesting to note that satisfaction with the ability to perform short trips is noticeably higher (0.91) than the satisfaction with the ability to make long journeys (0.39).

Relationship Between Quality of Life and Depression
The level of depression was measured with BDI (Beck Depression Inventory), composed of 21 items related to symptoms of depression,

Items
Chi-square p phi-Cramer    such as hopelessness and irritability, perceptions of guilt or of being punished, or physical symptoms, such as fatigue, weight loss or loss of sexual desire. The study identified an average score of depression of 6.7 +/-6.29.

Goodness of fit
The relationship between QoL and depression was studied on dimensions level and overall QoL scoring and on elementary-level indicators of the questionnaire. For the first level, the results are summarized in Table VI, which presents the Pearson r correlations between overall QoL score, its dimensions and BDI questionnaire score. The obtained results show that a low level of overall QoL score and its mental and somatic dimensions is associated with statistically significant higher levels of depression (Table VI).
For a better understanding of the relationship between QoL and depression the responses to QoL indicators were correlated with depression level. Given the small size of our study sample, it was not surprising that most correlations did not reach statistical significance. As a result, it was more relevant to interpret the correlation coefficients in terms of effect size. According to Cohen's recommendations [15], we refer to the following thresholds: r=0.01 -small, r=0.24 -medium, and r=0.37 -large. Table VII allow us the following conclusions:

The correlations in
Higher levels of satisfaction with postoperative scar are associated with lower levels of depression; Feeling comfortable with wearing a bra is associated with lower levels of depression; Ability to make longer trips correlates with lower levels of depression; The other variables in the table have no relevant correlations with depression (Table VII) Analysing the obtained correlations in Table VIII between depression and self-image in public places, we can draw the following conclusions: Depression levels tend to be higher when the satisfaction with family relationships (spouse, children, and parents) is lower. Although negative, the correlations of depression with satisfaction with extrafamily relationships (friends, colleagues, etc.) remain at a low threshold; A higher level of depression is associated with a lower level of satisfaction with the way the clothes fit and her physical appearance with or without clothes; Regarding sexual life, a higher level of depression is associated with a lower frequency of sexual intercourse and with a poor perception of femininity. No relevant correlations resulted in terms of libido, satisfaction and state of comfort and relaxation during intercourse; A higher level of depression is associated with lower self-confidence in public places, less optimism and good mood, while self-confidence in the family environment showed no relevant correlation (Table VIII).

Discussions
Breast reconstruction is an important step in breast cancer management. Data in the literature demonstrate that the psychological effects of that procedure depend on a series of variables such as age, psychological traits, patient-surgeon relationship, and relationship with the partner, socioeconomic level, and type of breast reconstruction. The QoL of mastectomized patients can be considerably improved by selecting the most adequate strategy, both medically and psychologically.
Considering the safety proven by conservatory breast surgery procedures, with excellent cosmetic results, it is obvious that they lead to an improved body image, well-being and QoL of the patients and their entourage [16]. However, we are not entitled to neglect the depression symptoms that occur frequently in patients with mastectomy. The answer to this health problem can be provided by reconstructive surgery. Studies analysing the well-being in more and more specific pathologies prove that women who undertake plastic surgery after mastectomy have lower depression levels, as compared with patients who do not choose these procedures [17].
Besides the evolution of oncogenetics and the modern multidisciplinary medical collaborations, we presume that the prophylactic bilateral mastectomy rate will also increase in the years to follow. New genetic discoveries related to breast cancer motivate the risk patients and their close relatives to take regular tests and to have surgery if necessary [18]. It is a known fact that contralateral

Quality of life (QoL-M) Depression (BDI)
Overall score -0.    prophylactic mastectomy is the most effective method of avoiding relapse in the case of hereditary breast cancer patients [19].
The moment of the reconstruction may vary from one particular case to the other. It was proven that the immediate breast reconstruction does not increase the risk of tumour recurrence [16,20]. The patients who were interviewed and asked to explain their reasons for choosing breast reconstruction explained that the procedure allows them to keep the discretion about their disease, to avoid a great shock after mastectomy and to go on with the life they used to live before [21]. For women with mastectomy, a visit to the plastic surgeon is the first step towards breast reconstruction. Health insurance covers these expenses, the patients being fully supported by the law. The therapeutic trajectory is changed due to the more and more advanced cancer treatments. The breast reconstruction can be a strong ally in the fight for survival [18].
There are multiple tools used for measuring the various dimensions of the quality of life. In the studies we analysed (Ireland, China, Australia, Brazil, Poland, France, Great Britain, Italia, Belgium, Sweden, Spain, USA or Canada) most authors admit the fact that a sensitive instrument is the one that measures the research indicator accurately and that its validation is a mandatory condition for the data to be relevant and valuable. The general questionnaires we came across in most researches were EORTC QLQ-C30 [16,17,22], MOS SF-36 [19], FACT-G [23], WHOQOL [24]. It is current practice, though, for researchers to use several questionnaires on the same group of patients, so that the study acquires a specific feature for different researched dimensions. Consequently, for the measurement of depression we apply the BDI [17] or HAD questionnaires [19,25], to which the investigated anxiety component is added, Body Image Scale (BIS) [25], for sexuality, Sexuality Activity Questionnaire (SAQ), for the impact of an event upon the created feelings, Impact of Event Scale (IES) and so on.
Although general tools are still widely used [20,26], specific tools are beginning to gain more and more interest, being conceived for different cultures or groups and targeted at patients. Such questionnaires, conceived for the breast cancer pathology in Europe and the USA are: EORTC-QLQ-B23, BREAST-Q or FACT-B [16,17,22,27]. They include items for dimensions such as: functional state, physical symptoms, emotional states, psychosocial impact, self-perception, sexual life or for the calculation of the global score. The application methods vary from direct application to correspondence by mail or by direct interviews with the patients.
In order to compare pre-or post-surgery results and assess the quality of life we need two or more patient groups. This aspect varied for each particular study. Some researchers compared the results from one group of patients with mastectomy to which they presented the questionnaire in parallel with other patients with similar descriptive data who had breast reconstruction surgery in the same period [16,17,19,[21][22][23][24][25]27]. Other researchers prefer to apply the tool retroactively for the same investigated group for the periods before and after the reconstruction surgery, the data described being provided by the patients from memory. Finally, a third category of researchers evaluated the questionnaire for the same prospective cohort before the intervention and use the same instrument at different times after the surgery. All these methods have their supporters. However, it is obvious that, despite the fact that studies are not very frequently conducted and the patient groups are relatively small, similar outcomes seem to result from all these studies.
The results and conclusions of the studies presented in literature are often similar. Statistic data are spectacular most of the time, if we compare them with the attitude of the patients who we consult or treat regularly. Women who opt for conservative surgery for cancer, for instance, have the same or slightly lower quality of life scores as patients who had reconstruction [16]. However, both methods help in keeping the body image, with high scores on this segment, as compared to patients with mastectomy [23]. This conclusion allows us to refine upon the fact that female patients are confronted with a major negative emotional impact only when they have at least one amputated breast. This aspect can also be explained by the fact that conservative breast surgery is available especially to patients who discovered the disease in an incipient stage with early breast cancer, with higher chances for a long survival and who do not need an aggressive treatment subsequently. The satisfaction final score is higher in patients with breast reconstruction [23]. The fact that they receive or do not receive radiotherapy does not affect the similar groups (as far as the stage of the disease is concerned) [16]. Thus the patients benefit from a less traumatising rehabilitation during the subsequent treatment for breast cancer, with visible physical and psychosocial benefits.
Out of all patients who undergo breast reconstruction surgery the most satisfied are the ones opting for delayed breast reconstruction. The explanation provided by several authors is that they had more time to reflect upon their situation and to adapt to new conditions. The new breast was thus accepted much better. Moreover, the patients who lived for a while without a breast regained their self-esteem after the reconstruction surgery, which determined them to value the new breast even more. This feeling is not shared by women who have two identical breasts before the anaesthetics and have two new breasts when they wake up [24]. Brazilian women, for example, who undergo breast reconstruction surgery, have a high level of satisfaction in the psychic and social relationships fields. Breast reconstruction help patients with mastectomy to improve their quality of life, from a physical, psychic, social, self-perception and integrity viewpoint, their cognitive dimension remaining unaffected [22,24,28].
Patients are fully satisfied with the reconstruction surgery but their satisfaction does not depend on the variables related to their personal life. The longer the period left until the reconstruction is performed, the more their satisfaction decreases. As well as this, it was demonstrated that most of the patients feel that they are involved in choosing their reconstruction method [27]. The basic component that is modified after reconstruction in patients with mastectomy is the psychical one. In one of the studies in which depression was also measured it was shown that patients with a higher level of depression also had a lower quality of life level measured with both general questionnaires and questionnaires specific for breast cancer pathology [17]. Another extremely important component for our target group of patients is the sexual one. Patients usually avoid this subject [21]. Most probably the participants do not feel comfortable talking about this subject, which would be approached more easily on focus group meetings, where several people could open a debate on this subject.
More and more patients opt for immediate breast reconstruction, although the applicability of these procedures is still limited. The reasons can include the fear that planning this intervention might affect the subsequent oncological treatments, the lack of information and knowledge regarding reconstruction surgery and the patients' having other priorities besides reconstruction surgery. More research is needed in the field in order to enable clinicians to recommend and to make the right choices in their multidisciplinary therapeutic behaviour [20].
Patients should be informed about the possible side effects of the reconstruction surgery procedures. Providing fully detailed information is essential in order to create realistic expectations in the patients and enable them to have a good relationship with their surgeon. When women become aware that the techniques and materials available at the present time are less and less invasive, the number of patients who will opt for breast reconstruction surgery is likely to increase [22].

Volume 11 • Issue 4 • 5
Women should be informed regarding the post-surgery psychological risk before they undergo surgery. This information must be considered by the multidisciplinary commissions during the counselling process of such a candidate [19]. Reconstruction surgery combined with psycho-spiritual therapy sessions has already begun to display promising results [28].

Conclusions
In our pilot study we have noticed higher levels of satisfaction regarding the post-surgery scar, which are associated with lower levels of depression; a feeling of comfort in wearing a bra is associated with lower depression levels; the ability to take longer trips is also associated with a lower level of depression, while the other variables did not have relevant correlations with depression.
Analysing the correlations between depression and self-perception in the public space, the following conclusion can be drawn: the level of depression tends to be higher when satisfaction within the family relationship (husband, children, parents, etc.) is lower. Depression is negatively correlated with the level of satisfaction within extra-family relationships (friends, co-workers, etc.): a higher level of depression is associated with a lower level of satisfaction regarding the way clothes fit and the physical appearance of the patient with or without clothes; as far as the sex life is concerned, a higher level of depression is associated with a less frequent sexual activity and a distorted perception of femininity.
There were no relevant correlations regarding the libido, satisfaction, the state of comfort and relaxation during the sexual activity; a higher level of depression is associated with a lower selfesteem, especially in the public space, with lower levels of optimism and happiness, while self-esteem within the family space does not present a relevant correlation.
The data obtained by the pilot study support the transition of QoL-M in the psychometric validation stage in order to draft the final version of the questionnaire. As well as this we have to mention the introduction of the zero response option (0=this question does not regard me) in the final version of the questionnaire, in order to avoid, as much as possible the refuse of the patients to answer certain questions to which they were actually unable to answer (for instance "relationship with your husband" when women filling in the questionnaire were either unmarried, divorced or widows). This research shows that physical comfort-related aspects greatly influence the quality of life and the level of depression. The type of therapy after breast cancer diagnosis is associated with psychological parameters, meaning that chemotherapy is more frequently associated with depression than other forms of therapy (hormone therapy, radiation therapy or targeted therapy). No causal relationship have been identified between the time elapsed since surgery and age at the time of surgery, meaning that these two variables have no influence on the quality of life.

Introduction
Ileosigmoid knot (ISK), also known as compound volvulus, is an unusual and rare cause of intestinal obstruction. In this condition, a loop of ileum encircles the loop of sigmoid colon & then knots on itself. It generally occurs in areas with a high incidence of sigmoid volvulus [1]. ISK is an unusual entity in the West, but is comparatively common in certain African, Asian and Middle Eastern nations, known as 'volvulus belt'. The aetiology of ISK is controversial. ISK rapidly progress to gangrene of the ileum as well as of the sigmoid colon.

Case Report
A 25-year-old male was brought to the emergency department with severe pain and distension of abdomen for 12 hours duration, which he developed in the later part of the night. Patient presented with vomitings and obstipation. On examination his pulse rate was 112/ min, having low volume, BP was 90/60 mm Hg and respiratory rate was 30 cycles/min. Abdomen was distended without visible peristalsis. Abdominal examination revealed guarding and rebound tenderness without any audible bowel sounds. Patient was in hypovolemic shock, so resuscitated immediately. Investigations revealed leucocytosis (TLC-16,000), hypokalemia (Serum K + -2.8 meq/lit) and multiple air fluid levels along with dilated colonic loops in plain X-ray abdomen in erect position (Figure1).
With a provisional diagnosis of acute large bowel obstruction and peritonitis, we proceeded for emergency exploratory laparotomy. On exploration, minimal hemorrhagic peritoneal fluid was noted. A gangrenous loop of ileum encircling base of loop of gangrenous sigmoid colon was found (Figure 2). Unknotting of ileosigmoid knot was successfully achieved and on further exploration, a kink was found in the ileum distal to the knot. Entire colon along with distal ileum except 10 cm of ileum adjacent to Ileo-caecal junction was gangrenous (Figures 3 and 4). Total colectomy with distal ilectomy (50cms) followed by Hartmann's procedure with end ileostomy in the right iliac fossa was done. Patient was allowed enteral nutrition on 3 rd postoperative day and was supplemented with multivitamins (vitamin B 12 ). Postoperative period was uneventful and the patient was discharged on tenth post-operative day.
Patient was on regular follow-up and his general condition improved after 3 months when he was planned for relaparotomy and ileorectal anastomosis was done. Patient was allowed liquid diet on 5 th postoperative day and was gradually advanced to solid diet on 7 th postoperative day. Entire postoperative period was uneventful and was discharged on twelfth postoperative day. Patient is on regular followup for last 1 year and without any features suggestive of either bile salt or vitamin B 12 malabsorption.

Discussion
Parker has been credited for describing the first patient of ileosigmoid knot in 1845. It more commonly affects men who are in fourth decade of life. Aetiology of ileosigmoid knot remains controversial [1]. This condition is common in east Africa, particularly among the young males of the Baganda tribe. Three factors are responsible for ileosigmoid knot; a long small bowel mesentery and a freely mobile small bowel, a long sigmoid colon on a narrow pedicle and finally, the ingestion of a high bulk diet in presence of an empty small bowel [1][2][3]. In our case all three factors were present. Ileosigmoid knot has been categorized into four types. In type I, ileum acts as active component and wraps around the sigmoid colon. In type II, sigmoid colon is the active component wrapping itself around ileum. In both these types it is subdivided as type A, when the direction of torsion is clockwise and type B when torsion is counter-clockwise. In type III, the Ileo-caecal segment acts as the active component, while in type IV (undetermined type) [1,4]. Our case was type I, A ileosigmoid knot. The predominant symptoms and signs of presentation include abdominal pain and tenderness (100%), abdominal distension (94% to 100%), nausea and vomiting (87% to 100%), rebound tenderness (69%), and shock (0% to 60%) [1,4,5]. ISK can rapidly progress to gangrene of the ileum as well as of the sigmoid colon. Generalized peritonitis, sepsis, and dehydration are the principal complications. Radiographically, ISK is often mistaken for simple sigmoid volvulus. CT scan reveals the classical "whirl sign" of volvulus, created by the twisted mesentery and bowel, and the afferent and efferent limbs of the sigmoid colon have the appearance of a beak [2,5]. The anatomical and pathological changes dictate the operative procedure. In 73.5% to 79.4% of the cases, gangrenous bowel was encountered, whereas in 20.6% to 26.5% both small and large bowels were assessed to be viable in surgery. In 52.9% to 60.3% cases, both the small intestine and sigmoid colon were gangrenous. Paradoxically, the incidence of bowel gangrene was 90.9% in those who presented within 24 hours of their symptoms. Among those who presented after 24 hours after their initial symptoms, bowel gangrene was seen in 57% [2,4,6,]. In our case we found total colon along with distal ileum except 10 cm of ileum adjacent to Ileo-caecal junction were gangrenous. Closed loop obstruction caused distension of sigmoid loop, ileal loop & the bowel between these two loops. Both strangulation and thrombosis of the vessels due to increased intramural pressure because of the closed-loop obstruction contributed to ischemia and gangrene of long segment of bowel except 10 cm of non-gangrenous ileum. This type of presentation we did not find to be reported in English literature even after doing through search, so a rare presentation. Various surgical procedures have been conducted in these patients depending upon the bowel viability [5].

Conclusion
Ileosigmoid knot as such is a very rare cause of intestinal obstruction and a high degree of suspicion is needed in cases mimicking sigmoid volvulus. Timely intervention is needed as it is a closed loop obstruction and that rapidly progresses to peritonitis and gangrene. It is uncommon to see cases presenting with total gangrenous colon and distal ileum which is an atypical presentation in our case and till now not reported in literature.

Introduction
Gastric metastases from primary renal cell carcinoma (RCC) are considered rare. However, there are nearly 50 cases described in the literature. We present two cases of patients presenting with clinically significant bleeding from gastric RCC metastasis; utilising lessons learnt from these cases, and from a literature review, we propose a model of treatment for gastrointestinal (GI) bleeding secondary to metastases from RCC.

Case 1
A 68-year-old Caucasian lady (Ms DA) was referred to the emergency department (ED) by her general practitioner following a collapse. She complained of fatigue, anorexia and weight loss of around 1.5 stone over 6 months. Blood tests revealed a microcytic anaemia (haemoglobin = 51 grams/litre, mean corpuscular volume (MCV) = 71 femtolitres).
Past medical history was significant for left-sided clear cell renal cell carcinoma 21 years prior to this presentation, for which she underwent a nephrectomy. Her drug history included levothyroxine, aspirin and prochlorperazine. Ms DA lived with her partner, was a non-smoker and consumed no alcohol. Physical examination at the time of presentation did not reveal anything of note.
Initial treatment involved resuscitation and transfusion of 3 units of packed red cells and an infusion of vitamin B complex. Her haemoglobin levels returned to normal parameters following this.
A computerised tomography (CT) scan showed an elevated soft tissue lesion arising from the posterior wall of the central stomach with no evidence of metastatic disease.
Ms DA subsequently underwent a gastroscopy which showed 2 ulcerated, sessile polyps, the largest measuring 20 millimetres, and a submucosal polyp on the greater curvature of the stomach. All lesions were biopsied. A colonoscopy was attempted but was limited by melaena.
A positron emission tomography CT scan and a nuclear medicine bone scan were performed, neither of which showed metastatic disease.
Histological examination of the biopsies showed clear cell RCC metastasis. Her case was discussed at a multi-disciplinary meeting (MDM), where it was decided that a laparoscopic gastric wedge resection would be most appropriate for her. This procedure was performed successfully without post-operative complications.
Histology of the resected specimen showed a well circumscribed 15 millimetre nodule in the submucosa with ulceration into the mucosa, no spread into stomach muscle and clear surgical margins.
Since this, Ms DA has annual surveillance gastroscopies which have not shown any evidence of recurrence (Figure 1).
Of those patients who did not receive surgery, 10 had endoscopic therapy, either in the form of polypectomy, ablation or mucosal resection. Palliative embolization was the treatment of choice in 2 cases, both requiring multiple embolizations in order to achieve haemostasis. Lamb et al. (2005) report a case of a patient who required 6 embolizations following 10 upper GI bleeds. Eight patients received chemotherapy and 7 did not receive any treatment. There were no case reports in the literature which described the use of palliative radiotherapy.
Cessation of bleeding was achieved in all patients who underwent surgical or endoscopic treatment for bleeding lesions (Figure 3).

Survival
Survival rates are generally poor with metastatic RCC, with most patients dying a few months after diagnosis [1,2]. In those with metastases to other organs in addition to the stomach, outcomes were worse (range 4 weeks to 36 months survival) than in those with isolated gastric metastases (range 4 weeks survival to alive after 6 years). Nearly half of the cases with widespread metastatic disease did not survive beyond 6 months, although several papers did not report survival data.
Of the 10 patients who received surgical intervention for isolated gastric metastases, 5 were cancer-free after 2-18 months. As only 7 cases in this category had published survival statistics, it is evident that surgical intervention carries symptomatic benefit in these patients, as well as the potential for curative treatment.
Overall survival for patients with RCC metastases to the stomach ranged from 4 weeks to alive after 6 years.

Discussion
Gastric metastases from RCC are rare and usually present with significant upper gastrointestinal haemorrhage.

Case 2
A 73-year-old Asian lady (Mrs HB) presented to the ED with a one day history of per rectal bleeding, including both fresh blood and melaena. There were no associated symptoms and examination was unremarkable.
Serological investigations confirmed a microcytic anaemia, with haemoglobin = 82 grams/litre, and MCV = 77.3 femtolitres. She had already been receiving iron supplementation for this.
In 2005, she underwent left-sided nephrectomy for clear cell RCC. Surveillance CT scan that year had shown nodules in the nephrectomy bed as well as pulmonary spread. She received Sunitinib for this.
During her admission she required repeated transfusions of packed red cells for continuous per rectal bleeding and persistent anaemia.
A gastroscopy showed a distal gastric lesion in the greater curvature of the stomach with ulcerated overlying mucosa and clot. Biopsies of the lesion were taken which confirmed clear cell RCC metastasis.
Mrs HB's case was discussed in a MDM, where it was felt surgical intervention would not be appropriate given the presence of multiple metastases. Palliative radiotherapy was thought to be the best course of treatment in view of her ongoing bleeding. Thus, she underwent a repeat gastroscopy to reassess the lesion and endoscopically place marking clips for focused palliative radiotherapy. Cessation of bleeding was successfully achieved (Figure 2).

Literature Review
Renal cell carcinomas account for nearly 2% of cancers worldwide and are associated with high rates of metastases, with these often occurring several months after curative treatment [1,2]. Metastases originating from RCCs are most commonly found in the lungs, brain, breast and bones and are of clear cell histology [3][4][5][6][7][8].

Method
A review of the current literature on metastatic renal cell carcinoma to the stomach was performed using PubMed. The search terms were: "renal cell carcinoma stomach" + "renal cell carcinoma metastasis stomach". A total of 48 cases were identified (Table I).

Demographics and clinical characteristics
The majority of patients were male (67%) with a mean age of 67 years (range 45-83 years). The mean interval post-nephrectomy was 6.9 years. This implies a significant delay in the development of gastric metastases following curative treatment. Melaena was the most frequently reported presenting complaint (46%).

Tumour characteristics
Clear cell histology was evident in all cases which reported a histopathological diagnosis. Over two thirds of patients had single lesions with the appearance of polyps, ulcers or tumours. The majority of lesions were located in the body of the stomach (63%).
Concurrent metastatic disease was found in 28 patients, the majority of which was present in the lung (86%), followed by metastases to the brain (25%), and bone (21%).

Management and outcomes
Surgical intervention was used in 20 of the 48 cases identified, half of which had no other concurrent metastatic disease. Four patients underwent total gastrectomy. The remainder had partial gastrectomies including 5 subtotal gastrectomies, 4 wedge resections and 1 antrectomy. Six cases did not specify the type of surgery. Three of the cases reporting use of wedge resections were performed for treatment of lesions <7 centimetres located in the gastric body.    Establishing the histopathological differentiation between metastatic disease and other tumours such as primary gastrointestinal stromal tumours (GIST) is essential in determining the appropriate treatment [9].
Laparoscopic wedge resection is the treatment of choice for isolated small/medium gastric tumours (<7 centimetres) near the greater curvature of the stomach as it is associated with quicker recovery in comparison to open procedures [10]. Saidi et al. (2007) report one case where this resection technique was used in a patient with an isolated gastric metastasis of RCC origin, after which they remained diseasefree 18 months following surgery. Our patient is one of the longest surviving patients after laparoscopic wedge resection for isolated gastric RCC metastasis and remains disease-free 8 years post-surgery.
Subtotal and total gastrectomies are more frequently reported and are used to treat larger tumours or those which are localised within the antral or fundal regions of the stomach [2,11]. In the cases reviewed, all patients who underwent wedge resection in the absence of metastases to other organs were disease-free after 2-18 months with no evidence of further bleeding.
Endoscopic clipping is used to achieve haemostasis in upper GI bleeding, although it is also a technique used to localize gastric or oesophageal tumours to aid external beam radiotherapy [12]. Radiotherapy to gastric tumours is primarily utilised to palliatively treat symptoms of bleeding, pain and dysphagia [13,14]. To the best of our knowledge, there are no case reports on gastric metastases from renal carcinoma in which radiotherapy has been used as a treatment modality for cessation of bleeding.
Given the relatively small number of patients who develop gastric metastases from RCC, it would not be feasible to conduct trials to determine which interventions have the best outcomes. Hence, based on our experience and our literature review, we propose the following paradigm for treating gastric metastases from RCC primary (Figure 4) Sugasawa     Discussion of such cases in a multi-disciplinary setting is critical. It is thought that oncology patients who are discussed at such meetings often have better outcomes [15,16].

Conclusion
Gastric metastases in RCC are uncommon, but not as rare as once thought. They can cause significant haemorrhage and are generally associated with poor prognosis. Treatment should be patient-tailored depending on general condition at time of presentation, presence of extra-gastric metastases and the available resources and expertise. However, based on both our experience and the literature, we suggest that surgical intervention has good therapeutic and prognostic benefit in patients with isolated metastatic disease to the stomach. On the other hand, for those with widespread metastatic disease, other management options, if available, including embolization therapy, endoscopic submucosal resection and chemotherapy, should be considered. Furthermore, we advise that radiotherapy should also be considered as a viable option in the management of patients with bleeding lesions and concurrent metastases.

Introduction
Foreign bodies are often encountered by oral and maxillofacial surgeons and may present a diagnostic challenge to the trauma surgeon due to many factors such as the size of the object, the difficult access, and a close anatomic relationship of the foreign body to vital structures. They are usually a result of injuries or operations [1][2][3]. Fragments of broken instruments can be left behind and entire teeth or their fragments can be displaced during extraction. In particular, penetrating injuries represent a rare but a complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echo tomography [1,4,5]. Removal of the foreign body can be delayed in approximately one third of all foreign bodies because they are initially radiologically missed or misdiagnosed [6]. The approach to this kind of injury should be sequential and multidisciplinary, beginning with the trauma unit that will provide maintenance of the airways, hemodynamic stabilization, and, but only if necessary, neurologic, ophthalmologic, and vascular evaluation [7]. The case of an infratemporal region impacted foreign body, caused by a stabbing weapon is presented.

Case Report
A 33-year-old male patient was admitted to ENT and Maxillofacial Surgery department with a complaint of painful swelling over his left cheek and evident limitation of mouth opening for three days. He gave a history of drunken brawl in which he got a stab on the left cheek area. On examination the patient was conscious and well oriented. His vital signs were normal. There was a small laceration measuring approximately 1.0 cm in the left parotidea-masseterical region ( Figure  1). The lacerated area was swollen with a little bruise and there was no neurosensory dysfunction. The mouth opening was limited up to 1.5 cm and painful. The oral cavity clinical examination did not reveal any pathology: there was no open communication into the oral cavity. The CT scan examination showed 2.7 × 0.38 cm cylindrical XRnegative gaseous zone, which was at the depth of 3 cm from the skin in the infratemporal region with the distal end between condylar and coronoid processes (Figure 2a-c). As an additional finding left side maxillary sinusitis and hypertrophic rhinitis were revealed.
The patient was taken up for surgery under local anesthesia for wound revision. The 2 cm long incision was done from the upper point of wound laterally and parallel to facial nerve buccal branch. The skin and SMAS were excised and the deeper tissues were opened by blunt dissection. Finger was used as a tactile sensor in the surgical pocket to probe the object (Figure 3). His distal end was at the depth of 3-3.5 cm from skin. The tissue tunnel was performed, when the finger was kept approximately 1 minute in touch with foreign body edge. Once the finger was located precisely the embedded foreign body was grasped with a haemostat and was retrieved out successfully. The retrieved object was a plastic pen cap (Figure 4). It was estimated, that the stab was done by the pen with cap, and after pen removing the cap was stuck in the surrounding soft tissues, may be because of mandible movement at that moment. The wound was inspected for hemostasis, a rubber ribbon drain was inserted, and the wound was closed in layers. The patient was prescribed routine antibiotics. The drain was removed on the second postoperative day ( Figure 5). Sutures were removed on the seventh postoperative day ( Figure 6). No facial nerve branch injures or salivary fistulas were observed in postoperative period.

Discussion
The incidence of retained foreign body deep in the maxillofacial region has increased greatly in recent years [1]. Retained foreign bodies following a penetrating trauma may pose a diagnostic difficulty for an Oral and Maxillofacial surgeons [2]. The foreign body can often modify the regional anatomy [8]. Inflammatory response in the tissues around a foreign body can add difficulties [9]. Patient history, physical examination, and radiographic examinations may not confirm the presence of a foreign body [5,10]. The clinical examination of the patient who presented an impacted object injury in the face should be carried out in a systematic manner [11]. The paranasal region is the most affected by this kind of injury, and it is important to observe the *Corresponding author: Anna Yu Poghosyan, MD, PhD, Head of ENT and Maxillofacial Surgery Department, "Heratsy" №1 University Hospital, 60 Abovyan Str., Yerevan, Armenia, Tel: +374-91-474 169; E-mail: anna.yu.poghosyan@gmail.com pen cap has shown the gas cylinder that was observed deep in the infratemporal region, horizontally, close to the nasopharynx.
Foreign bodies may migrate within the tissues and become symptomatic after a certain time lapse. In these cases, it is very difficult to correlate the direct relation between the suspected foreign body and the present clinical symptoms. One should therefore suspect a foreign body when presented with a laceration due to a blow [16]. In our case, the patient gave a history of drunken brawl in which he got a stab on the left cheek area, which gave us an idea for knife injury and, as a result, mandible fracture or any remaining foreign body. Removal      major anatomic structures, such as the facial nerve and the parotid gland and duct [12].
Metallic objects are radiopaque and mostly are clearly visible on plain radiographs itself [13]. Though a surgeon might still desire a CT scan for precise location and accurate diagnosis of these metallic objects [9]. Wood or bamboo foreign bodies are difficult to diagnose if they are placed very deeply [14]. Radiological examination including three dimensional CT enables the surgeon to choose the optimal surgical approach to remove the foreign body, thereby avoiding purulent inflammatory complications [15]. Wooden or bamboo foreign bodies in both fat and soft tissues may present in CT patterns simulating as different as a gas bubble or a bone fragment [13,14]. In our case plastic of the foreign bodies can be delayed because of a misdiagnosis or because of their asymptomatic behavior [6]. In the reported case the patient complained of painful swelling over his left cheek and evident limitation of mouth opening for 3 days. The first thing we thought was the mandible condyle fracture, as a result of knife injury, and CT scan examination was organized.
Treatment of penetrating lesions located in the maxillofacial region can vary according to the lesion´s etiology, the nature of the retained foreign body, the site of the lesion, as well as extension of damage to soft and hard tissues of the region and neighboring structures [2]. It should initially prioritize the patient's stabilization with evaluation and maintenance of the upper airways, followed by hemodynamic control and neurologic evaluation [17]. Only after this treatment the foreign body should be carefully removed, preferably under general anesthesia [5,18]. When the impacted object is superficially confirmed by imaging examinations and it is not near any major vessel, the removal under local anesthesia can be performed. In presented case we have carried out operation under local anesthesia in spite of the fact, that impacted foreign body was located deep in the infratemporal region. The finger is the most sensitive probe and will readily palpate the buried foreign body [19]. If a long curved hemostat is passed along the line of finger, the foreign body can be grasped and removed by an experienced surgeon through a relatively small wound. In such manner we have done the reported operation.
The wound should be explored, followed by hemostasis, copious irrigation with saline solution and suture for planes [20]. It is advisable to prescribe antibiotics before and after surgery, as well as tetanus prophylaxis [7,16,18].

Conclusion
Timely removal of impacted foreign bodies in the maxillofacial region may avoid functional, allergic and infective complications. This case demonstrated foreign body retrieval which was impacted in the infratemporal region. Preoperative CT imaging is a prerequisite for the diagnosis and accurate localization of the foreign body. The case describes, that intralesional finger palpation could be a sensitive and helpful probe for foreign bodies finding and removal.

Introduction
Cancer associated with pregnancy is rare. The incidence of cancer during pregnancy accounts for approximately 0.1% [1]. As women defer childbearing to the third or fourth decade of life, this rare coexistence is likely to become more common. The common malignancies associated with pregnancy include malignant melanoma, breast cancer, cervical cancer, lymphoma, ovarian cancer, gastrointestinal cancer and genitourinary cancer [2]. Gastric cancer in pregnancy is often diagnosed late due to misinterpretation of clinic presentations as pregnancy-related digestive symptoms. The difficulties in the early diagnosis of gastric cancer in pregnant women deter timely surgical treatment of the disease.
In an analysis by Sakamoto et al. that includes 137 cases of pregnancy-associated gastric cancer from Japan, most cancer were at advanced or late stages at the time of diagnosis, which to a large extent would cause dilemma for surgeons [3]. Here we reported our cases and reviewed literatures from China in order to analyze the clinicopathological characters of pregnancy-associated gastric cancer and shed light on the early diagnostic strategies.
Volume 11 • Issue 4 • 9 associated with pregnancy is uncommon. For this reason, gastric cancer might not be the first differential diagnosis for pregnant women with digestive symptoms in most of the cases. Secondly, gastric cancer symptoms can easily be concealed by pregnancy-related digestive symptoms. Pregnancy can decrease the secretion of acid in the stomach and increase mucus production at the same time. On the other hand, histaminase produced by the placenta deactivates histamine function. These factors will decrease the body sensitivity to cancerous ulcer injury. Jaspers et al. pointed out that the incidence of gastric cancer was not obviously different between pregnant women and other young people, but there was often a delay in diagnosis in pregnant women due to the lack of attention to upper abdominal discomfort during pregnancy [13]. Finally, the diagnostic measures are especially restricted for pregnant women. For instance, radiological examinations are not suitable for pregnant women and the safety of endoscopy is also questioned. All our 3 cases were delayed in diagnosis. One was considered to be hyperemesis gravidarum, and the other two were mistaken for digestive symptoms associated with pregnancy.
In our opinion, the causes of the poor prognosis of gastric cancer in pregnancy could be coming from many aspects. Firstly, most patients were found to have advanced cancer on diagnosis. Our data revealed that in all reported cases the tumors were diagnosed at an advanced stage. 83.6% of patients underwent surgery but only 14.3% of them had curative resection. In the Japanese data, 26 out of 29 patients had advanced gastric cancer at diagnosis. Secondly, a majority of patients had highly malignant tumor. In China, the percentage of infiltrative type (Borrman III and IV) is 76.9%, and the percentage of diffuse type (poorly differentiated adenocarcinoma, mucus adenocarcinoma, signet ring cell cancer) is 92.3%, of which signet ring cell cancer accounts for 30.8%. Sakamoto et al. analyzed the pathology of the tumors in the 61 patients whose data were available [3]. The results showed that the percentage of infiltrative type and diffuse type were 83.6% and 86.9% respectively in gastric cancer associated with pregnancy.; Thirdly, the change of local biology in the stomach promotes the development of neoplasms during pregnancy. According to a report by Lanciers et al, H. pylori infection rate is significantly higher for pregnant women than non-pregnant women [15]. Given that circulatory blood flow increases and immunity attenuates during pregnancy, pregnant women are particularly susceptible to the rapid growth and spread of cancer [14]; besides, treatment is comparably restricted due to pregnancy. Ueo et al. have recommended that surgical treatment for gastric cancer should be immediately performed without regard for the pregnancy when gastric cancer is diagnosed prior to week 24 of gestation; At weeks 25 to 29 of gestation, the decision should depend on the stage of the gastric cancer as well as the resectability of the tumor; For week 30 of gestation and beyond, obstetric treatment followed by surgical intervention is recommended to guarantee the infant to be viable by cesarean section or vaginal delivery [12]. As the definition of abortion in Japan was revised in 1993, the above three categories correspond to prior to 22 weeks, 22 to 27 weeks as well as 28 weeks and beyond, respectively [3]. In our cases, two patients at week 23 to 27 underwent pregnancy termination because of their late tumor stage or poor nutritional condition, and then were delayed for the time of surgery or adjuvant therapy.
According to the record of Japanese cases in the last two decades, a majority of patients (7/9) prior to week 24 of gestation selected surgical intervention after termination of pregnancy. All the patients (13/13) at week 28 of gestation and beyond implemented cesarean section or vaginal delivery, as well as two patients at week 24 to 27 of gestation carried out cesarean section. The survival rate of gastric cancer for the patients with pregnancy is far lower than those without pregnancy at the corresponding time period (Table III).

Discussion
As far is known, there is no clear definition of gastric cancer associated with pregnancy. In current literature, patients who are diagnosed with gastric cancer during pregnancy or within one year of childbirth are included [1,3,12,13]. Although the incidence of gastric cancer is in the second place among all malignancies around the world, the rate of gastric cancer during pregnancy is reported to be only 0.016% in Japan, a gastric cancer prevailing area [14]. In South Korea, among 14,563 patients with primary gastric cancer admitted at Seoul National University Hospital, only 15 patients (0.103%) were identified as pregnancy-associated [1]. There were only 3 patients (0.36%) with gastric cancer associated with pregnancy admitted at Department of General Surgery in the Third Hospital of Peking University, among 838 patients with primary gastric cancer during the period of 2001 to 2014.
Many factors may lead to the delayed diagnosis of gastric cancer associated with pregnancy. First of all, the incidence of gastric cancer   The impact of gastric cancer associated with pregnancy on fetus should be taken into account when deciding treatment. The perinatal mortality of the fetus is greatly influenced by the treatment methods. According to the statistical data from Jaspers's data, the prognosis for the fetus is favorable with 72% surviving. For pregnancies ≥ 30 weeks, only two babies died out of 29 cases [13]. With the development of perinatal medicine, fetal survival rate has gradually increased. The other factor impacting fetal survival is the potential occurrence of fetal tumor metastasis. Neonates delivered with concomitant placental or villous cancer involvement should be considered a high-risk population. Alexander et al. found that fetal risk of melanoma metastasis is approximately 22% with placental involvement [16]. There were less than 10 case reports of gastric carcinoma metastatic to the placenta, none of which found villous invasion or fetal metastasis.
On the basis of the clinical and pathological features of gastric cancer associated with pregnancy, early diagnosis is the only possibility for the better outcome. Eliakim et al. indicated that digestive symptoms would gradually remit after 16 weeks of gestation in 90% of patients with hyperemesis gravidarum and completely remit by 20 weeks in 99% of patients [17]. Most researchers emphasized that active examinations should be taken into account for pregnant women with persisting digestive symptoms. At present, the ultrasonography and gastroscopy are the main methods for gastric cancer patients in pregnancy.
Compared with endoscopy, ultrasonography could display both the intragastric and perigastric lesions and also the depth of invasion, with the advantage of noninvasion, economy and repeatability. Seevaratnamet al. made a meta-analysis about preoperative imaging for TNM staging of gastric cancer. The results showed the primary tumor detection rates ranged from 90.7 to 100 and the overall accuracy was 67.8% ± 10.8% for ultrasonography [18]. Ultrasonography has guiding significance for further investigation. One of our cases showed a lesion of gastric wall by ultrasound, and then underwent endoscopy. But it is debatable to diagnose the lesion of gastric fundus, tiny gastric cancer and small gastric cancer by ultrasonography.
Magnetic resonance imaging may be used to diagnose pregnancyrelated gastric cancer. M. Anzidei et al. found that MRI and 64-MDCT accuracy levels did not differ in advanced stages of disease, whereas MRI was superior in identifying early gastric cancer [19]. K. M. Jang et al. analyzed a series of data of the patients who underwent gadoxetic acid-enhanced MRI with diffusion-weighted imaging and multidetector constrast-enhanced abdominal computed tomography imaging [20]. They pointed out that the diagnostic accuracy and sensitivity of combined conventional and DW MRI set for detection of gastric cancer was significantly higher than that of the CT imaging set or the conventional MRI set. But it is still not clear whether MRI or gadoxetic acid is safe for pregnant women or fetuses. MRI might be a valid alternative in clinical practice after finding a safer contrast agent instead of gadoxetic acid.
Endoscopy can diagnose gastric cancer definitively and provide pathological biopsy. The safety of gastroscopy in pregnancy might hesitate pregnant patients. The potential risks of endoscopy include arrhythmia, hypertension, hypotension, hyoxemia, malformation, premature and so on. The research by Cappell et al. including 83 patients showed that gastroscopy didn't induce labor or result in congenital malformation [21]. No significant endoscopic complications occurred and none of the infants had a congenital malformation in the neonatal nursery. And compared with normal control group, neonatal Apgar scores were no significantly different. Another retrospective evaluation of 60 pregnant women also showed that endoscopy could be safely performed in pregnancy with no maternal and fetal complications [22]. American Society for Gastrointestinal Endoscopy outlined the main indications for endoscopy in pregnancy and general principles that apply to endoscopy in the Guidelines for Endoscopy in Pregnant and lactating Women. The safety of endoscopy could be greatly improved by following these indications and general principles [23].

Conclusion
In conclusion, the features of gastric cancer associated with pregnancy are the delayed diagnosis, high degree of malignancy and poor prognosis. Further examinations should be conducted timely in pregnant patients with persistent gastrointestinal symptoms for the differential diagnosis of hyperemesis gravidarum. When gastric cancer was diagnosed, a therapeutic plan should be promptly made by obstetrics and gastric cancer specialists.

Introduction
Incisional hernias represent a relatively frequent iatrogenic complication of abdominal surgery, with an incidence between 3.8 to 11.5% [1]. The underlying causes vary. Risk factors mainly include older age, obesity, bowel surgery, wound infection, immunosuppression, smoking and chronic obstructive pulmonary disease. Treatment of large incisional hernias is associated with a number of risks and complications. These primarily include acute respiratory failure, acute renal failure associated with an abdominal compartment syndrome, disorders of intestinal motility and circulation. Late complications may include recurrence of hernia-in up to 30-50% of cases involving defects larger than 6 cm [2,3]. Incisional hernias with significant loss of domain are hernias where >15-20% of the abdominal contents reside permanently outside their natural compartment, and returning these contents will require significant physiological adaptation (mainly respiratory) [4]. Emergency surgery is indicated especially in the case of ileus and intestinal obstruction or if signs of intestinal ischaemia within the hernial sac appear. The basic principle of treating abdominal incisional hernia entails restoring the anatomical and physiological integrity of the wall. Ideally, this involves the use of local musculoaponeurotic tissue with a good blood supply and innervations [5]. In the case of large defects, it is necessary to use alloplastic materials in order to reduce the tension load on the suture itself. Such materials include classical inorganic materials [6], which are however associated with a higher risk of complications such as infection and intestinal fistula [7]. Thus, biodegradable materials containing porcine small intestinal submucosa (SIS) are more advantageous. These materials promote healing, scar remodelling, angiogenesis at the site of the scar and represent an effective barrier against bacterial invasion [8].

Presentation of Case
A 77 year old man was admitted to our institution suffering from abdominal pain, nausea, repeated vomiting of stagnant gastric content and elevation of inflammatory parameters. The underlying cause was bowel obstruction within a gigantic irreducible hernia. The patient had undergone cholecystectomy via a classical midline laparotomy 17 years previously with subsequent incisional hernia repair 5 years later. No further surgery was indicated given the patient´s comorbidities-CAD, COPD, hypertension and diabetes. A conservative approach consisting of a hernia truss was recommended. The patient´s risk factors for developing an incisional hernia included: obesity (height 170 cm, weight 117kg, BMI 40), COPD, diabetes, increased tension of the abdominal wall in a former professional trumpet player. The CT scan (Figures 1a,1b) revealed bowel obstruction in an otherwise well-vascularised small intestine loop and the right large intestine, which were pulled into the hernial sac. The X-ray series (Figures 2a,2b) described dilation of the small intestine loops and the contrast dye failed to progress at the level of the ileum. Acute surgical intervention for progressive ileus was indicated and commenced following necessary preparations including the insertion of a nasogastric tube and correction of the present mineral imbalance.
A central venous catheter and a Foley catheter were inserted once the patient was under general anaesthesia. Amoxicillin/clavulanic acid Ventilation parameters were tested before surgery and then on the 6 th day after surgery and no fundamental changes were recorded (Table  II). The drains were removed on the 5 th day after surgery, once minimal secretion had been noted.
Bowel movement resumed on the third day after surgery. Hospitalisation was complicated by worsening of cardiac functions with right-sided heart failure that necessitated a change in the patient´s medication, which led to improvement of the patient´s condition. The patient was discharged on the twelfth day. No further complications occurred. Six-months and one year after surgery, the patient is symptom-free, the abdominal wall is firm and there are no signs of hernia recurrence.

Discussion
The systemic review of the literature targeting to the treatment and complications of incisional hernias with significant loss of domain and postoperative complication after this surgical techniques in Cochrane database and PubMed was created. Incisional hernias represent one of the most frequent iatrogenic complications of abdominal surgery. Several risk factors promote the development of these hernias. The ideal means of repairing abdominal incisional hernias involves midline reconstruction using native musculo-aponeurotic tissues [9]. Treatment of complex abdominal incisional hernias should be conversant with the different methods of placement of prosthetic materials and be able to deploy the techniques of abdominal components separation, was administered prophylactically. Then was the skin prepared and disinfected using a solution containing povidone-iodine. The incision was made through the initial site of the midline laparotomy dislocated to the right. The bulky hernial sac was identified and separated from the skin and subcutaneous structures. The hernial sac contained loops of the jejunum and ileum, the caecum, ascending colon and hypertrophied omentum. The intestinal loops were viable and only slightly distended. The hernia defect with a diameter of 20 cm was viable and firm musculo-aponeurotic structures were exposed. The omentum was resected and subsequently the loop of the small intestine and the colon were repositioned back into the abdominal cavity. Also the hernial sac was partially resected as well and its remains were used to cover the defect using interrupted absorbable sutures. The abdominal wall was closed using interrupted non-absorbable sutures and an onlay SIS mesh was placed on this suture. This was fixed using two continuous nonabsorbable sutures. Further interrupted sutures were placed and fixed at the positions of 1,3,5,7,9,11 o'clock. Two Redon drains were placed subcutaneously between the onlay and the skin. The skin was closed using interrupted sutures and was not reduced. It was not possible to extubate the patient immediately after surgery as he developed acute respiratory distress. Thus, the patient was extubated at the ICU 6 hours after surgery, when his spontaneous ventilation was sufficient. Subsequently, we closely monitored his ventilation parameters, the onset of bowel movement and possible signs of intestinal ischaemia. The following parameters were also monitored. (Table I)   tissue expansion, local and distant muscle flaps, free tissue transfer and vacuum-assisted closure [10]. If such natural structures cannot be used for reconstruction, prosthetic materials such as onlays or inlays are used to reduce tension [2,4,6]. However, the use of these inorganic materials is associated with the risk of infection, extrusion, protrusion and intestinal fistula [7]. New biodegradable materials containing SIS allow midline reconstruction with minimal or no tension, especially given that they act as a mechanical binder that protects the sutured midline when intra-abdominal pressure increases [11,12]. These materials also stimulate the re-growth of the fascia and collagen growth and production, thus accelerating wound healing. They also reduce the risk of foreign material associated infection [7]. Incisional hernias with a hernia defect less than 6 cm in diameter are ideal candidates for reconstruction with minimum risk of recurrence. These small hernias can be repaired successfully by a laparoscopic approach [1]. Larger hernias are associated with a higher risk of recurrence, which is described in up to 50% of cases. By using alloplastic materials, the incidence of recurrence decreases to 10% and less [2,3]. Large hernias with loss of domain can be repaired only by an open method and the onlay method is the simplest and most versatile technique in this case [1].
Large incisional hernias with significant loss of domain represent a significant problem [4]. These hernias are usually encountered in patients in whom planned surgery had been contraindicated mainly because of patient comorbidities and anaesthesiological or surgical risk at the time or in patients who had been avoiding medical care. The most serious complication of these hernias is intestinal obstruction or strangulation. Resolution of acute conditions associated with gigantic hernias represents one of the most complicated cases in emergency surgery. Apart from the objective findings, diagnosis is based on a CT examination that determines the extent of herniation, the contents of the hernial sac and the perfusion of the intestinal wall. Laboratory parameters that we monitor include the leukocytes, CRP, lactate and pH, whereby pathological values usually indicate a disorder of intestinal perfusion. Monitoring of intraabdominal pressure as an indicator of intra-abdominal hypertension and the abdominal compartment syndrome in postoperative care is very necessary [13]. Abdominal compartment syndrome refers to organ dysfunction caused by intraabdominal hypertension. Intraabdominal pressure (IAP) is the steady state pressure concealed within the abdominal cavity [14]. For most critically ill patients, an IAP of 5 to 7 mmHg is considered normal. In a prospective cohort study of 77 supine hospitalized patients, the IAP averaged 6.5 mmHg and was directly related to body mass index [12]. Intraabdominal hypertension (IAH) is defined as a sustained intraabdominal pressure ≥12 mmHg [14]. Intraabdominal pressure can be further graded as follows: Grade I = IAP 12 to 15 mmHg; Grade II = IAP 16 to 20 mmHg; Grade III = IAP 21 to 25 mmHg; Grade IV = IAP >25 mmHg [15]. Abdominal compartment syndrome (ACS) is defined as a sustained intraabdominal pressure >20 mmHg (with or without APP <60 mmHg) that is associated with new organ dysfunction. IAH can impair the function of nearly every organ system (cardiovascular -IAH decreases cardiac output by impairing cardiac function and reducing venous return, pulmonary -mechanically ventilated patients with IAH have increased peak inspiratory and mean airway pressures, which can cause alveolar barotrauma, they also have reduced chest wall compliance and spontaneous tidal volumes, which combine to cause arterial hypoxemia and hypercarbia, and gastrointestinal with reduced mesenteric blood flow and intestinal mucosal perfusion). The goals of supportive care in patients with intraabdominal hypertension include reduction of intraabdominal volume through evacuation of intraluminal contents, evacuation of intraabdominal space-occupying lesions (eg, ascites, hematoma) when possible, and measures to improve abdominal wall compliance with ventilatory and hemodynamic support. Surgical decompression is indicated for all patients whose intraabdominal pressure is greater than 25 mmHg [16]. Most surgeons perform decompression and then maintain an open abdomen using temporary abdominal wall closure. Several techniques for temporary abdominal closure are available, including patch closure, negative pressure systems (towel and spongebased), and silo closure. Each of these techniques has advantages and disadvantages with respect to their ability to control fluid loss, frequency of dressing changes, minimizing loss of domain, ease of use, and cost. The patch or silo technique can be used alone or in combination with a negative pressure system. Skin-only closures are an option but are rarely used in contemporary practice [17].
We present here the case report of a man with a gigantic incisional hernia and signs of small bowel strangulation as an example of the extreme symptomatology of such a hernia in a patient with a number of comorbidities. Nonetheless, despite the monstrous size of the hernial sac, emergency surgery enabled the reposition of the organs back into the abdominal cavity as well as the repair of the abdominal wall with no negative consequences during the post-operative course [4].
In these types of emergency procedures, it is mandatory in the days following surgery to monitor the patient´s ventilation parameters as well as to prevent the development of the intra-abdominal compartment syndrome or the progression of bowel obstruction and development of intestinal ischemia.

Conclusions
Incisional abdominal hernias develop up to 11.5% of laparotomy incisions. The basic principle of treating abdominal incisional hernia entails restoring the anatomical and physiological integrity of the wall. Large hernias with loss of domain can be repaired only by an open method and the onlay method is the simplest and most versatile technique in this case. Emergency surgery is indicated in case of intestinal obstruction and strangulation and is acquired with increasing

Background
Hydatidosis is a zoonosis produced by the larval stage of Echinococcus granulosus, with an endemic distribution, mainly in the rural areas [1]. Frequently it is localized in the liver (60%) or in the lungs (30%), with most of the patients being asymptomatic [2]. The positive diagnosis is based on ultrasonography, CT or MRI scans, as well as immunological studies (ELISA) [2,3].
The management of hydatidosis includes medical treatment with Albendazole in association with surgical treatment. Surgical procedures vary from puncture-aspiration-injection-reaspiration (PAIR) to partial resection and they can be divided into conservative or radical surgeries [2]. When talking about the conservative procedure (Lagrot pericystectomy) the hepatic parenchyma is not damaged and the pericystic cavity is saved or partially removed, whereas in the radical procedure the pericystic membrane is removed along with a portion of the hepatic tissue. Surgical treatment may be achieved by open surgery or laparoscopic approach [4,5].
We present the case of a 5 year-old patient, diagnosed with hepatic and pulmonary hydatidosis, in which we decided to perform a laparoscopic Lagrot pericystectomy.

Case Report
We report the case of a 5 year-old patient, who was admitted to hospital for recurrent episodes of epistaxis, shortness of breath and abdominal fullness. The chest X-ray showed a round opacity over the left diaphragm, with congestion of the parenchyma around the hilum. The thoracic CT revealed an 18mm image in the left inferior pulmonary lobe and it accidentally revealed a hypodense image in the left hepatic lobe (Figure 1). Laboratory exams show moderate leukocytosis with eosinophilia, and normal inflammatory markers.
The patient was then referred to our clinic. The preoperative abdominal ultrasonography showed a liver with compact structure, echogenic and normal size, right lobe of 11 cm, caudate lobe of 2 cm and left lobe of 6.5cm. In the left lobe, under the diaphragm, the ultrasound revealed a round image, with well-defined borders, transonic, with laminated membranes on the inside, measuring 4.5×2.4×2.7cm, localized between segment 2 and 3 of the liver, avascular on Doppler exam. Chest X-ray revealed a cystic mass in the left inferior pulmonary lobe (Figure 2). Treatment with Albendazole and antibiotic (Ceftriaxone) was initiated before surgery.
We decided to proceed with a laparoscopic approach, inserting the optic trocar at the umbilicus (5 mm) and 3 work trocars: one in the right upper quadrant (5 mm), one in the epigastrium (5 mm) and one in the left upper quadrant (10 mm). Intraoperative, a cystic mass measuring 6×4 cm could be observed between segment 2 and segment 3 of the left hepatic lobe. Hypertonic sodium chloride was injected in the cyst 3 times and then the content was aspirated. Afterwards the cyst was incised and the laminated membrane was extracted with the help of an Endobag. The need for a partial cystectomy with sub hepatic drainage was due to the proximity between the posterior wall of the cyst and segment 2 of the left lobe of the liver. On postoperative day 4 the peritoneal drainage was removed.
Due to the small size of the pulmonary hydatic cyst, we decided not to remove it and to continue medical treatment with Albendazole. Postoperative evolution was favorable; the patient being discharged on day 5 after surgery. Follow-up ultrasonography studies showed right and left liver lobes with normal structure, no lesions, and the chest X-ray revealed the decrease of the left pulmonary opacity (Figure 3).

Discussions
Hydatidosis is a zoonosis produced by the larval stage of Echinococcus granulosus, its symptoms depending on the affected organ: liver (60%), lung (30%), bones or brain [2]. Most patients are asymptomatic; symptoms usually appear when the cyst ruptures. However, some may present abdominal pain in the right upper quadrant or epigastrium, nausea, vomiting, fever [6]. Hepatic hydatidosis may lead, after the rupture of the cyst, to peritoneal or biliary dissemination and anaphylactic shock [5]. Bacterial infection of the cyst can lead to hepatic abscess, cholestasis, portal hypertension or Budd-Chiari syndrome. and the management of the remaining cavity. Surgical treatment possibilities vary from puncture-aspiration-injection-reaspiration (PAIR) to surgical radical procedures consisting in complete removal of the cyst and hepatectomy [2,4,5].
The purpose of conservative surgery is to sterilize and evacuate the content of the cyst, including the hydatic membrane, by puncture of the cyst, followed by aspiration of the entire content and partial resection of the cyst. After the partial resection, bacterial infection may appear. The purpose of radical surgery is to ablate the entire cyst, with or without hepatectomy. However, in this case the intraoperative risks and postoperative complications are higher.
Laparoscopy was not accepted immediately or used in the treatment of hepatic hydatidosis, due to the concerns of some authors who considered that the rate of recurrence and risk of intraoperative dissemination is much higher than in open surgery [7]. However, many studies have proved that the short term recurrence rate for laparoscopic intervention is low (1-9%), compared to that of open surgery (0-30%) [8,9].
Rapid development of laparoscopic techniques encouraged adapting the procedures used during open surgery to minimally invasive approach. Minimally invasive surgery has become an advantage in the case of hydatic hepatic pathology, due to the good view over the cystic cavity, the possibility to observe and resolve a biliary fistula with the help of clips, bipolar clamp or harmonic device, allows identifying and removing the rests of the germinal membrane, therefore reducing the recurrence risk and the infectious complications [10]. Numerous laparoscopic techniques were described: complete pericystectomy (used in the case of small cysts with a superficial localization), puncture aspiration followed by marsupialization and omentoplasty, cystectomy and hepatectomy (used in case of large cysts, deep localization) [1,8].
Contraindications for laparoscopic treatment of the hydatic cyst are: rupture of the cyst in the biliary duct, cyst localized in segments 7 and 1 of the liver, cysts measuring more than 15cm, a large number of cysts or cysts with thick or calcified walls [11,12].
Postoperative morbidity associated to laparoscopy varies in the literature from 8 to 25% and includes biliary fistula, infection, fluid buildup around the liver [9], and the recurrence rate after open surgery is between 0-30%, whilst in the case of laparoscopy is 1-9% [8].
The difficulty of laparoscopic approach consists in extracting the cyst without rupturing the membranes and disseminating the cystic content, especially under the increased intraabdominal pressure induced by gas insufflation [9]. Even if the laparoscopic procedure takes longer than open surgery, postoperative recovery and hospital stay proved to be shorter in the first case [6].

Conclusions
Hydatidosis is a complex pathology, in which the treatment is chosen depending on the patient. Medical treatment is used as an adjuvant of the surgical treatment, whose purpose is to excise all the components of the cyst, preventing peritoneal dissemination. Laparoscopic approach allows a better perspective regarding the treatment of hepatic cystic pathology, permitting a good view over the cystic cavity, with the possibility of resolving an eventual biliary fistula, reducing the rate of complications and recurrence.
Choosing the type of treatment depends on each case. Using only medical treatment is controversial, this option being reserved for disseminated hydatidosis or when the patient has a surgical contraindication; otherwise, treatment consists of Albendazole associated with the surgical removal of the cyst. The purpose of the surgical treatment is to excise the components of the cyst, prevent peritoneal dissemination of scolices during the intervention, and resolve the communication between the cyst and adjacent structures