Anal Fistulotomy
M. Grant Liska, BS¹; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES² ¹University of Central Florida College of Medicine ²Philippine Children’s Medical Center
Fistula-in-ano is a chronic abnormal communication between the anal canal and, usually, the perianal skin. It can be described as a hollow tract that is lined with granulation tissue and connects a primary opening inside the anal canal to a secondary opening in the perianal skin. It usually originates from the anal glands and is frequently the result of a previous anal abscess. Anal fistulae present with pain, swelling, pruritus, skin irritation, and purulent or bloody drainage. Most anal fistulae are diagnosed based on clinical findings, but complex and deep anal fistulae usually require imaging studies such as CT scan or MRI to delineate the tract.
Currently, there is no medical treatment available and surgery is almost always necessary. A simple intersphincteric fistula can often be treated with fistulotomy or fistulectomy, while trans-sphincteric and suprasphincteric fistulae are treated by placement of a seton to maintain drainage and induce fibrosis. Extrasphincteric fistula treatment depends on the anatomy and etiology of the fistula.
This article presents the case of a 1-year-old male with a history of recurrent perianal infection, which led to the development of an anal fistula. The anal fistula was noted to be superficial, and a fistulotomy was performed.
Anterior component separation is an abdominal wall reconstruction technique used in the repair of ventral wall defects to avoid the use of prosthetic mesh. The procedure releases the external oblique fascia to provide a tension-free midline approximation.
The patient is a 72-year-old, obese female who has multiple large incisional hernias along an upper midline incision. An anterior component separation technique is used to repair the defect.
An incision is made over the previous abdominal scar. The dissection is carried down to the hernia sac. The hernia sac is then separated from the surrounding tissue to identify the fascial edges. The hernia sacs are removed from the fascia. Surrounding adhesions are lysed. A colotomy occurred, which was repaired in two layers: the outer layer with interrupted 3-0 silk suture, and the inner layer with running 3-0 Vicryl suture. The fascial incision is extended to ensure complete removal of the hernia sacs along with completion of adhesiolysis. Bilateral subcutaneous flaps separating the subcutaneous fascia from the external oblique fascia are developed. Perforating vessels are ligated with 2-0 or 3-0 silk. The dissection is carried laterally to the anterior axillary line. The external oblique fascia is released bilaterally using electrocautery. The midline defect is then closed with running #1 Prolene. After achieving hemostasis, two drains are placed, and the skin is closed.
Unilateral aldosteronoma is best managed by adrenalectomy, with the laparoscopic approach being the preferred method. This is the case of a 48-year-old woman who had long-standing hypertension and hypokalemia and was found to have hyperaldosteronism and low renin levels. A CT scan showed a small mass in the left adrenal gland, and adrenal vein sampling showed higher levels of aldosterone on the left side than on the right, confirming a unilateral aldosteronoma.
Laparoscopic access was gained, the adrenal gland was exposed and dissected by controlling the periadrenal tissues with the harmonic scalpel, the adrenal vein was then ligated, and the adrenal gland was removed.
Wide local excision (WLE) with sentinel lymph node biopsy (SLNB) remains the cornerstone for treatment of patients with intermediate-thickness and thick melanoma lesions with clinically negative nodes. This procedure involves resection of the melanoma with circumferential margins including all the subcutaneous tissue to the level of the deep fascia. WLE is accompanied by lymphatic mapping in order to localize, resect, and analyze the sentinel node(s) for the presence of lymph node metastases. In this paper with accompanying animation and video, a 40-year-old otherwise healthy patient presents with a new melanoma on his back diagnosed via biopsy. The surgical management of intermediate-thickness melanoma and rationale for treatment are reviewed, and recent advances in postoperative treatment of those with clinically occult regional disease are highlighted.
This video demonstrates an algorithm for evaluating suspected vascular injury secondary to penetrating extremity trauma on a 42-year-old man who sustained a gunshot wound to his left lower extremity. Descriptions of how to perform an arterial-brachial index (ABI) and arterial-pulse index (API) are reviewed, along with criteria to determine if a CT angiography is indicated. Relevant imaging is reviewed with a radiology resident with descriptions of how to systematically assess the scans for injury. Lastly, a tibial traction pin is placed as a temporizing measure for long bone fractures to prevent shortening and to help with pain management.
Primary hyperaldosteronism, or Conn’s syndrome, is a disease in which one or both adrenal glands produce excess amounts of aldosterone, leading to hypertension and hypokalemia. High blood pressure may cause headaches or blurred vision. Low potassium may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis.
Primary hyperaldosteronism is diagnosed by measuring serum levels of aldosterone, renin, and potassium. Patients classically have high aldosterone levels, suppressed renin levels, and low potassium levels. Once the diagnosis is established, the localization of the source is performed using imaging studies. Adrenal vein sampling is also performed to determine more precisely and directly the side that is producing excess aldosterone.
Primary hyperaldosteronism caused by an adrenal gland tumor is treated with adrenalectomy. This is the case of a 58-year-old female with hypokalemia and long-standing hypertension refractory to medical treatment. Her blood tests showed high aldosterone levels and low renin levels, confirming the diagnosis of hyperaldosteronism. On CT scan, an adrenal nodule was noted on both sides. Adrenal vein sampling identified the right adrenal nodule as the cause. Laparoscopic access was gained, the adrenal gland was dissected and exposed, the adrenal vein ligated, and the adrenal gland was removed.
Laparoscopic Nissen Fundoplication
Ciro Andolfi, MD¹; Marco Fisichella, MD, MBA, FACS² ¹University of Chicago Pritzker School of Medicine ²VA Boston Healthcare System
This is the case of a 63-year-old man with a long-standing history of gastroesophageal reflux disease, refractory to medical management with high-dose proton pump inhibitors and H2-blockers. The preoperative workup consisted of: 1) an upper endoscopy, which was normal; 2) a barium swallow, which showed a normal anatomy (no hiatal hernia or diverticula); and 3) esophageal function tests, including high-resolution esophageal manometry, which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of gastroesophageal reflux disease.
Considering the amount of pathologic reflux, and the normal anatomy and esophageal peristalsis, it was decided to proceed with a laparoscopic Nissen (360°/total) fundoplication. The operation went well and lasted less than 90 minutes. The patient was discharged the following morning after resuming a light diet, and recovered quickly. With this surgical approach, complete control of reflux was achieved, and the patient was able to discontinue his treatment with proton pump inhibitors.
Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals.
In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.
This is the case of a 74-year-old female who presented with bothersome stage III pelvic organ prolapse. She desired definitive surgical management for her prolapse and opted for total vaginal hysterectomy, uterosacral ligament suspension, and anterior/posterior vaginal repairs. She had urodynamic testing before the surgery that showed no stress urinary incontinence, no detrusor overactivity, and normal bladder capacity. The surgery was uncomplicated. She was discharged home the same day as surgery, and her postoperative recovery was unremarkable.
Crohn’s disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract, with a propensity for the distal ileum. It causes transmural inflammation of the intestines, where it can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition.
There is no cure for Crohn’s disease; the goal of treatment is to palliate symptoms, accomplished with both medical and surgical options. Surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications.
Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn’s colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing; therefore, a total abdominal colectomy with ileorectal anastomosis was performed.
