Octav GINGHINA*, Marius ZAMFIR, Mara MARDARE, Andrei VACARASU, Irina BONDOC, Alin BURLACU, Razvan IOSIFESCU, Theodor VOIOSU, Carmen PANTIS, Bogdan TANASE. Ann Hepatobiliary Pancreat Surg 2023;27:S432. https://doi.org/10.14701/ahbps.2023S1.EP-166

Introduction: Bilateral inguinal hernia can be safely repaired simultaneously, open or minimally invasive, in an elective sce-nario. The choice of surgical approach depends on the patient's status, hernia characteristics, surgeons and patient preferences. Whether age criteria should be considered when selecting between the two approaches is still a matter of debate. Considering that there is no consensus regarding the best repair in bilateral inguinal herniorrhaphy, the aim of the study is to perform an analysis regarding elective surgical approach of patients with bilateral inguinal hernias. Material and Methods: To study the relationship between exposure to an open versus laparoscopic approach in patients with bilateral inguinal hernia, we conducted a case-control study. In our retrospective analysis, cases (23 patients) were the open-approach hernia repair, and controls (82 patients) were laparoscopic hernia repair. We analyzed two sets of variables: first, related to patient characteristics (age 65 years, BMI 30 kg/m2, smoking habit, HTA status, COPD status, DM status, use of anticoagulants, presence of neoplastic status) and second, variables related to hernia features (inguinoscrotal hernia, recurrent hernia and complicated hernia). Results: The mean age for cases was 73.26 (Ã+-12.99) years and that of controls, was 56.48 (Ã+-15.15) years. Univariate analysis demonstrated four variables with statistical significance: age 65 years, inguinoscrotal hernia, neo-plastic status, and anticoagulant use. When introduced into the multivariate analysis, we noted that only two variables, age 65 years (OR=4.183, 95% CI [1.289, 13.572], p=0.017) and use of anticoagulants (OR=38.876, 95% CI [1.305, 1158.011], p=0.035) reached statistical significance. Conclusion: This study demonstrates that when we refer to bilateral inguinal hernia repair, patients aged 65 years are at risk of having an open procedure at least fourfold more than patients aged 65 years. In addition, the use of anticoagulants increases the risk of open hernia repair 38 times more than that of minimally invasive repair for the same age group. Interestingly, in our study, hernia characteristics were not found to be associated with open hernia repair and age 65 years. In our study we found that age 65 years is associated with electing open hernia repair over minimally invasive repair, which can be linked to age-related risk factors. Further re-search is needed to investigate the impact of age and age-related risk factors on surgical outcomes of bilateral inguinal hernia repair.

Anorectal melanoma (ARM) is an extremely rare and aggressive malignancy. There is no standard therapeutic management, mainly due to scarcity of data and randomized control trials regarding the optimal surgical strategy. We present the case of a male patient aged 65 years in our hospital, presenting perineal pain and rectal bleeding. Patient’s performance status (PS) was good. Hematological analysis revealed normocytic normochromic anemia. In the rectoscopy, an anal canal tumor formation was identified. The diagnosis of ulcerated melanoma was confirmed at the histopathological examination. The pelvic MRI detected a circumferential parietal thickening, posteriorly accentuated at the level of the anal canal, about 4.4 cm long, situated 2 cm from the external anal orifice, causing a subtotal lumen stenosis. The patient underwent abdominoperineal resection (APR). Postoperative course was favorable and the patient was discharged on the 13th postoperative day, with no complications. A multidisciplinary cancer care team will prove to be of substantial value, because it may develop a personalized treatment plan for this unusual tumor. Although the therapeutic approach is still controversial, surgery is considered the mainstay therapy.

The splenic rupture is one of the major causes of hemorrhagic shock with great mortality even in the case of early diagnosis and proper treatment. We present here the case of a patient aged 84 years who came to the intensive care unit of ‘Sf. Ioan’ Clinical Emergency Hospital from Bucharest with an unspecific clinical presentation: confusion, agitation, tachycardia, hypotension and presenting Livedo reticularis. The paraclinical investigations revealed critical condition on arrival: hypochromic microcytic anemia with 7.2 g/dL hemoglobin. Thorax, abdomen and pelvis computed tomography (CT) scan revealed dense, perihepatic, perigastric, interhepatogastric and perisplenic accumulations, suggesting hemoperitoneum. Shortly after the arrival, the patient suffered a cardiopulmonary arrest responsive to resuscitation procedures. Based on these findings the patient was submitted to exploring laparotomy. Peritoneal cavity exploration revealed: hemoperitoneum through splenic rupture in 2 sites and gastric infarction with an almost-total necrosis. Taking into account the hemodynamic instability, damage control was decided as the best approach. Therefore, splenectomy, subtotal gastrectomy and feeding jejunostomy were performed, ensuring this way the control of lesions and the stabilization of the patient in the intensive care unit (ICU). Soon after admission and surgical intervention the patient was found to be positive for SARS-CoV-2. The postoperative course of the patient was unfavorable as the patient died from a heart attack unresponsive to resuscitation. Overall, it is important to bear in mind that although gastric infarction is a rare event, it is accompanied by great morbidity and mortality. Despite that only few cases of gastric infarction are reported in literature, this diagnosis must be taken into consideration, especially in SARS-COV-2 positive patients or history of recent COVID-19.

Introduction: Bilateral inguinal hernia is a distinct entity in the inguinal hernia category. Open and minimally invasive techniques for the treatment of bilateral inguinal hernia have been previously described. If resources and surgeon expertise are available, guidelines recommend laparoscopic repair for this entity. Methods:We analyzed data from 83 patients who underwent laparoscopic inguinal hernia repair (total extraperitoneal repair - TEP) of 158 hernias (146 inguinal hernias and 12 other types). Patients had bilateral symptomatic hernias. Results:Male predominance, with a mean age of 56.7 years, was noted. Lateral hernias (according to EHS classification) were prevalent (71.08%). In the majority of cases (77.11%), meshes made up of a custom polypropylene monofilament mesh were used, followed by Bard 3D Max mesh and Ultralight mesh. Regarding postoperative complications, seroma was the most frequently encountered one in our series (7.23%), followed by urinary retention and 'feeling' of mesh (2.41%). Hydrocele, wound hematoma, cord hematoma and chronic pain were seen in 1.20% of patients. No wound infections were observed. The average operative time was 97.77 minutes (SD=17.08); when associated surgery was present, it prolonged the operative time, and we found statistical significance (p=0.002). Similarly, the presence of recurrent hernia extended the operative time, which was found to be statistically significant (p=0.003). The conversion rate in our data was 2.41%. Drainage, which was performed in 13 patients (15.66%), decreased the incidence of complications, especially seroma (p=0.026). The mean length of hospital stay was 2.93 days (SD=1.81), with most of the patients having been discharged on the second postoperative day (37.35%). Only one recurrence was identified (1.20%). Conclusion:The laparoscopic approach for bilateral inguinal hernia treatment is feasible and has been proven to be advantageous. Our study emphasizes that the TEP procedure has low rates of complications, conversion and recurrence; hence, we recommend bilateral hernia repair.

Mara MARDARE*, Razvan IOSIFESCU, Marius ZAMFIR, Andrada SPANU, Andrei VACARASU, Irina BONDOC, Dana CERNOV, Diana BERZAN, Monica DUMITRASCU, Maria BARBU, Octav GINGHINA. Ann Hepatobiliary Pancreat Surg 2022;26:S288. https://doi.org/10.14701/ahbps.2022S1.EP-6

Background:The SARS-CoV-2 pandemic has put pressure on the entire medical system and has made it difficult to provide healthcare and optimal treatment to patients with hepato-pancreato-biliary pathology.Surgeons had to adapt to these changes and hospitals underwent a systematic reorganization of their activity.Methods: The cases with HPB onco-surgical pathology treated between March 2020-December 2021 in the General Surgery Clinic within the Saint John Emergency Clinical Hospital Bucharest and Monza Oncology Hospital Bucharest have been analyzed.Results: At the beginning of the SARS-CoV2 pandemic, there was a sudden decrease in HPB treated by the team due to the decrease in general addressability to health services, most likely generated by the fear of hospitalization in pandemic conditions.In the following months, the activity was gradually resumed, but did not reach the average number of cases treated before the onset of the pandemic.There has been an increase in the severity of cases compared to the current period.As of November 2020, Saint John Hospital has been transformed into a COVID-19 support unit and the entire work has focused on treating patients with SARS-CoV2 infection.A solution for treating the patients was to perform surgeries in the private medical network.Conclusions: Discontinuation of surgical and oncological activity during the pandemic has led to an increase in the number of terminal cases from a surgical point of view with patients presenting with more advanced stages of the disease, treatment being limited and the postoperative evolution has been longer.

Matrix Metalloproteinases (MMPs), these calcium-dependent zinc-containing endopeptidases play an important role in adipogenesis and angiogenesis by modifying tissues and degrading the extracellular matrix (ECM). Matrix glycoproteins, gelatin, collagens, proteoglycans and elastin are all found in the ECM. Current meta-analysis confirmed the lower levels of IL-6 and CRP was found following bariatric surgery. Several studies have shown correlations between E-selectin levels, BMI, and MMP-9 levels. There was also a strong link between the metalloproteinases MMP-2 and MMP-9. MMP-2 and adiponectin levels are related. MMP-9 levels, on the other hand, were modestly linked with E-selectin and HDL cholesterol levels, as previously stated. Also current observations imply that alterations in the ECM caused by MMP-mediated degradation may be crucial for the differentiation of adipocytes. The most crucial component of this is that MMPs are involved in the remodeling of tissue after gastric bypass surgery, as revealed by these markers (especially MMP-2 and MMP-9). Thus, it is tempting to assume that adipocyte derived MMPs may constitute a novel pharmaceutical target for limiting adipose tissue development through the reduction of adipocyte differentiation and angiogenesis. MMP-2 exhibits far more accurate oscillations than MMP-9 during pre- and post-surgical weight fluctuations, and hence may be used as a predictor for gastric bypass success. The purpose of this paper is to conduct a comprehensive review of the literature with an emphasis on the critical functions that MMPs have in the pathophysiology of obesity and the related diseases.

Objective: There was a critical inconsistency in making therapeutic choices regarding anticoagulation in patients with COVID-19. This study aims to evaluate and determine the causes that led to the formation of hematomas, spontaneous bleeding or what is involved in this hypothesis and the elements related to this aspect. Patients and methods: The present study is a case series analysis that aims to identify and verify the cause of spontaneous hematomas in COVID positive patients for whom surgery was required. Thus, we analysed patients who presented various spontaneous hematomas during the covid pandemic (March 2020 - May 2021) for which surgery was performed, having as a control group (CG) a homogeneous group in terms of age, covid infection severity, and comorbidities with the study group (SG). Results: Regarding the preoperative and postoperative days, SG had average values of 4.76±5.36 (Mean±SD) for preoperative days and 9.5±9.327 for postoperative days. Given that one of the most suspected causes of hematomas was considered an anticoagulant overdose, we compared the anticoagulant doses and the type of anticoagulant, so the anticoagulant doses did not show statistically significant differences (0.836±0.294ml in SG versus 0.866±0.343ml in CG with p=0.588). As expected, hemoglobin (Hb) was significantly lower for SG with mean values of 7.266±1.431mg/dl compared to CG that had mean values of 12.9±2.092mg/dl (p=0.001). The correlation between the value of Hb (average value was 12.9 mg/dl, a minimum of 8.7 mg/dl and a maximum of 16.6 mg/dl) and the value of procalcitonin (average value was 0.13, a minimum of 0.02 and a maximum of 0.7) is statistically significant having p=0.012. In SG, hemoglobin can be correlated with ESR (erythrocyte sedimentation rate), p=0.008 and with procalcitonin, p=0.05. Both have a negative correlation explained by a proinflammatory status that can aggravate low hemoglobin levels, but without a direct link to high ESR and procalcitonin values. Conclusions: The hypothesis of anticoagulant overdose is not supported or verified by the present study, we consider that additional thromboelastography tests are necessary to be able to completely refute it. Mortality did not increase statistically significantly

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

Introduction: What does hepato-biliary-pancreatic (HBP) surgery mean and how does the life of the resident in a young team practicing such surgery in a developing country look like?Methods: Surgical residents interested in acquiring advanced training in HBP surgery should take a fellowship in this kind of surgery, spending at least four years in a specialized center.Results: The pre and postoperative management of patients is a core function of a junior doctor, but they have to be involved in every step of the journey represented by complex HBP surgery: from establishing anesthesia routine to training team and taking part in tumor board meetings.Mentorship is also a key factor in promoting and maintaining fulfillment in surgical practice.Conclusions: In a young HBP team, bidirectional growth -both mentors and residents is crucial to developing this king of surgery.Working hard, studying and training every day are very important steps in order to build a career as a HBP surgeon.

Introduction: Obesity is currently an endemic problem worldwide largely caused by an environment that promotes excessive food consumption and discourages physical activity. The sources of obesity are directly related to two areas: genetic and environmental factors, which constantly interact in the regulation of body weight. Aim: Through this research, it was aimed to evaluate the typical profile of the individual who uses metabolic surgery and the degree of physical and psychological satisfaction after such an intervention. Materials and methods: The patients introduced in the study are from personal cases, in number of about 1130, operated during 9 years. Of these, 122 represented the basis for the analysis and had to answer 37 questions in a preoperative questionnaire and 34 questions in a postoperative one and we extracted 15 questions from each of the questionnaire. Results: Statistics show that there was an improvement in quality of life as reported by 77.78% of interviewers, libido and sexual quality were improved in 44% of the included patients and a level of stress considered responsible for food hyperapetitis in only about 43% of respondents. Conclusions: Improving the quality of life is directly related to weight loss. In addition, there is a correlation between improving the quality of life and improving sex life or increasing the frequency of exercise. Metabolic surgery must be understood with all the benefits it generates.

Objective: Obesity is an exceedingly current pathology with many clinical, molecular, and psychological implications. The number of obese people has doubled in the past ten years, and we can observe an early onset of obesity. Bariatric surgery is an effective treatment for severe obesity and type 2 diabetes mellitus (T2DM); Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most prevalent types of this procedure . Nevertheless, no single mechanism has emerged that thoroughly explains the metabolic benefit and subsequent long-term effects after surgery. Webster's new collegiate dictionary defines the noun model as: 'a descriptive or analogy used to help visualize something that cannot be directly observed.' Sustained by this definition, the animal models in nutritional research are fundamental to improve human conditions. Due to the recent boost in experimental surgery, our aim in this study is to set the main technical characteristics of the gastric bypass operation and specific animal care in the metabolic surgery field we have been undertaking in our center. Materials and methods: We chose Wistar rats fed with a high caloric diet (HCD) 82g / 100 g fat, 53/100 g saturated fat, 64/100 g carbohydrates. After 7-15 weeks of this diet, depending on the protocol understudy, a consistent three-fold greater weight gain is achieved than the usual range of the free eating chow. After approximately three months on an HCD, the obese rats manifest biochemical features of the metabolic syndrome. Results: The weight loss for group B (By-pass) was 125 ± 16.16 g, and for group BS (By-pass + Sulodexid), it was 133.10 ± 14.38 g. Although the weight loss was higher in group BS, it is not statistically significantly higher than in group B (p = 0.345), despite administering a pharmacologically active substance in group BS. Although small (approximately 40-50 g), the difference between the control group and groups B and BS is statistically significant with p = 0.016 and 0.026 and Pearson index of 0.674 and 0.628, respectively. Statistical significance also kept the difference between group C and group S (p = 0.028, Pearson Coefficient = 0.621). Conclusions: First of all, Metabolic surgery is the most effective weight-loss method and improvement or even remission of some diseases associated with obesity. Like today's high-calorie diet, the diet administered, mostly of adolescents, generates both obesity and its associated diseases: diabetes, hypertriglyceridemia, hypercholesterolism, thus increasing mortality and overall morbidity. Second, metabolic surgery radically improves the parameters targeting obesity (weight,% EBWL) and its associated conditions: diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, strongly associated with decreasing life expectancy of the general population. Parameters targeted by gastric bypass: glycemia, TGL, CHO, hepatic steatosis, testicular atrophy registering significant improvements.

Matrix metalloproteinases (MMPs) are enzymes involved in the modulation of extracellular matrix (ECM) and adipocytes and preadipocyte differentiation. The pathophysiology of obesity has characterized by many cellular and molecular processes such as inflammatory processes, macrophage infiltration of adipose tissue, and remodeling of ECM via MMP. The purpose of the study was to determine if we can consider MMPs as a marker of effectiveness in bariatric surgery and if sulodexide administration pre- and postoperative has a benefit in terms of tissue remodeling of weight loss. An experimental study has performed using 40 obese Wistar rats (10 rats in the control group and 30 obese rats in study groups). Those in the study group were divided into three groups and underwent gastric bypass (B group), sulodexide administration (S group), gastric bypass, and sulodexide administration (BS group). Sulodexide was administered because of its antithrombotic effect in the procoagulant status of obese subjects. The pre- and postoperative weight, glucose level, cholesterol, triglycerides, MMP-2, and MMP-9 were analyzed. We compared the results to see if bariatric surgery modifies the MMPs status and if there is a correlation between the weight loss and the other parameters and also if sulodexide has any contribution to the results. The MMP-2 and MMP-9 activities were detectable, but MMP-2 was significantly higher than MMP-9. MMP-2 correlates with body weight parameters before surgery and after surgery, after significant bodyweight reduction as a result of bariatric surgery (r = 0.478,p = 0.017). There is a strong correlation between the weight loss, glucose level, and cholesterol and the values of MMP-2 (r = 0.92,p = 0.022, respectively,r = 0.759,p = 0.033). MMP-9 is correlated with weight loss and triglycerides level. But it was not as sensitive as MMP-2. Sulodexide administration in group S had a positive influence on the MMP-2 and MMP-9 compared with the values of groups B and C but without statistical significance. MMP-2 and MMP-9 are the two most important ECM enzymes involved in adipose tissue remodeling after bariatric surgery. The correlations between cholesterol, triglycerides, glucose, weight loss, excess weight, and body mass index (BMI) parameters and MMPs level demonstrate the direct relationship of these enzymes in obesity. Although we believe that more in-depth studies are required, MMPs may be considered a marker of the effectiveness of bariatric surgery.

Introduction: In September 2013 a new Surgical Oncology departament was started in our Surgery Ward. From the begining there was a focus on liver surgery, which was at the time new to our hospital. Method: From september 2013 till april 2019, 107 hepatectomies were performed in our hospital for primary and secondary liver tumors. The first and most common indication was colorectal liver metastases, but hepatocarcinoma and complex procedurea in cholangiocarcinoma surgery followed along. Result: Having no tradition in liver surrgery, the learning curve was long and difficult. We started with minor hepatectomies, but added majr hepatectomies from the first year. The operation time shortened with 30 to 50% in the last two years compared to the first two ones. Also, while gaining experience hospital stay was reduced and laparoscopic liver resections were also performed. Conclusion: Building brick by brick a new liver surgery departament was challenging, but rewarding as we can treat complex cases from colorectal malignacies to primary hepatic tumors. Telling the story further, we hope to enrich the lifes of our collegues starting liver surgery in new places, sometimes with a lot of adversities ahead.

Obesity involves the growth of adipose tissue cells (adipocytes and preadipocytes), as well as microvascular endothelial cells. Matrix metalloproteinases (MMPs) are relevant ezymes for the modulation of extracellular matrix (ECM) and adipocyte and preadipocytes differentiation. They are elevated in obese patients, generating abnormal ECM metabolism.[1]. This article proposes a thorough study of literature with focus on the important roles of matrix metalloproteinases in the pathophysiology of obesity. The article represents a narrative review based on an English-language PubMed research of the medical literature regardind important aspects of the proposed aim. MMP-2 activity was signiucantly higher than MMP-9, both activities were detectable. MMP-9 was strongly correlated with body weight parameters before surgery, as well as after significant body weight reduction as a result of bariatric surgery. Concerning MMP-2 and MMP-9 they are also involved in the turnover of basement membranes both those of adipose tissue and endothelial. MMP-9 levels were moderately correlated with HDL cholesterol levels. Taken together, the present data suggest that changes in ECM through MMP-mediated degradation might play a critical role in the adipocyte differentiation process. These findings are detected both in clinical trials and in laboratory animal experiments. It is then tempting to speculate that the adipocyte-derived MMPs might represent a new pharmacological target for the inhibition of adipose tissue growth by inhibiting adipose differentiation as well as angiogenic process.

Obesity is a current pathology with many clinical, molecular, and psychological implications. The number of obese people has doubled in the past 10 years and we can observe an early onset of obesity. We have used a modified BAROS and SF36TM questionnaire to conduct a descriptive study on 34 obese patients undergoing surgery for obesity—laparoscopic sleeve gastrectomy (LSG). The inclusion criteria were the embodiment of surgery for obesity: BMI (body mass index) >40 kg/m2 or BMI > 35 kg/m2 and associated comorbidities. The postoperative BMI was 25.7670 ± 3.74759 kg/m2 (mean ± SD). The average number of lost kilograms was 38.74 ± 12.526 (mean ± SD), and the average percentage of excess body weight loss (% EBWL) was 85.9952 ± 22.69028% (mean ± SD). Patients lost an average of 36.88–38.56 kg at 6–12 months after surgery, and they reach a % EBWL of 94.69 ± 30.02% and a normal BMI of 23.96 kg/m2 at 18 months postoperatively. All patients significantly reduced the amount of food eaten after surgery. More than 2 years after the surgery, patients increased their food intake by about 30%, but maintained their weight loss and a normal BMI. Related to quality of life, 77.78% of patients declared a vast improvement, 11% a good quality of life, and only 3.7% said that the quality of life is worse than before the surgery. Also, a relationship between quality of life and the improvement of sexual life, or with the increased frequency of physical exercise has been observed. Improving quality of life is directly related with the weight loss, with %EBWL, and with the postoperative BMI. Bariatric surgery should be understood in all the positive changes that it generates in everyday life.

INTRODUCTION:Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia, which can derive from either parasympathetic or sympathetic paraganglia and are closely related to pheochromocytomas.CASE REPORT:We present the case of a young male patient of 37 years old, who was admitted for hypertensive crisis and palpitations. His medical history included medically controlled type 2 diabetes mellitus, (diagnosed 10 months ago), Hepatitis A. Hormonal evaluation revealed elevated urinary metanephrines and normetanephrines, with mainly increased normetanephrines (2330 ug/24 h). Plasmatic metanephrins were in normal range, but levels of plasmatic normetanephrins were elevated (952 pg/ml). The assessment of pituitary and aldosterone-renin axis values were within normal limits. Abdominal computed tomography showed left adrenal nodular lesion on the external arm, bilobulated, size 32/33 mm with maximum axial and cranio-caudal diameter of approx. 45 cm, suggestive of a benign lesion, keeping the cleavage plane to vecinatate structures. Left adrenalectomy was performed by laparoscopic approach. We mention that immediately after induction of anesthesia were recorded blood pressures of 298/143 mmHg. Histopathologic and immunohistochemical examination diagnose paraganglioma, without invasion of adjacent tissues. The patient evolution was favorable, with the remission of the symptoms and normalization of hormonal markers. It is imperative to note the remission of diabetes in the postoperative period.DISCUSSION:This is the case of a young patient with functional retroperitoneal paraganglioma, who presented with symptoms of pheochromocytoma. Compared to pheochromocytomas, paragangliomas are rarely symptomatic and functional. Association with diabetes is even more rare. Specialized investigations allowed the proper diagnosis and the therapeutic approach above was the result of a multidisciplinary cooperation.

The main challenges of benign uterine surgery are fertility preservation, choosing the optimal approach (open or minimally invasive) and the management of complications. Conventional laparoscopy is the main technique used for laparoscopic hysterectomy for benign indications. We present three cases of complex patients with uterine fibromatosis, along with a literature review over the continually regressing limits of the laparoscopic approach of uterine pathology.