At most institutions caring for patients with early gastric cancer (EGC), tumors arising in the upper third of the stomach are usually managed with total gastrectomy and Roux-en-Y esophagojejunostomy. Given the impaired quality of life related to associated reflux and vitamin deficiencies, several high-volume centers have sought alternative gastrectomy and reconstruction strategies to total gastrectomy.
In this case, a patient with EGC in the cardia found on screening endoscopy undergoes robotic proximal gastrectomy with double-tract reconstruction. His postoperative course was unremarkable, and he was discharged on postoperative day 7. His pathology demonstrated no residual tumor after preoperative endoscopic submucosal dissection. This video demonstrates the technique of an experienced surgeon performing robotic proximal gastrectomy with double-tract reconstruction.
Vacuum-assisted closure (VAC) is a method of wound management commonly employed as an adjunct to surgery that uses negative pressure to accelerate healing. This video is a comprehensive step-by-step demonstration of VAC change for a complex right hip wound. The patient is a male in his fourth decade with a history of paralysis beginning in childhood due to a spinal tumor. He was admitted to the hospital with a right hip joint infection complicated by methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Given his immobility at baseline, the patient was deemed a suitable candidate for a Girdlestone procedure, which involved resection of the femoral head and proximal aspect of the femur, resulting in a complex wound with exposed bone.
This is the case study of a 17-year-old male Reserve Officers’ Training Corps (ROTC) cadet who suffered a superficial perforating saber wound to the medial part of the right knee during a routine practice session. This video demonstrates the step-by-step patient assessment process and subsequent saber removal.
This case illustrates a laparoscopic resection of a gastrointestinal stromal tumor (GIST): the most common mesenchymal tumor found in the gastrointestinal tract. GISTs can be found anywhere along the gastrointestinal tract; however, they are most commonly found in the stomach and small intestine. These tumors are often associated with mutations in the KIT (receptor tyrosine kinase) and PDGFRA (platelet-derived growth factor receptor alpha) genes. Because it is difficult to achieve a permanent cure using protein tyrosine kinase inhibitors, such as imatinib, surgical resection is the recommended therapy in most cases. While the surgical approach may vary on tumor characteristics, the laparoscopic approach is associated with low perioperative morbidity and mortality.
In patients with difficult gallbladders due to anatomy prohibiting a clear critical view of safety, a subtotal cholecystectomy can be considered as a safer alternative to a total cholecystectomy. Subtotal cholecystectomies can be divided into “reconstituting” or “fenestrating.” Subtotal reconstituting cholecystectomies include closing off the lower end of the gallbladder to create a remnant gallbladder, while subtotal fenestrating cholecystectomies do not occlude the gallbladder and instead may involve suturing the cystic duct. The most common indication for subtotal fenestrating cholecystectomy is inflammation in the hepatocystic triangle, and subtotal fenestrating cholecystectomy has proven to be useful specifically for patients with a history of cirrhosis.
This case report describes the performance of a subtotal fenestrating cholecystectomy for the management of acute on chronic cholecystitis in a patient with cirrhosis initially managed with transcystic stent placement endoscopically. Management of this patient’s omental adhesions to the gallbladder required alterations to typical surgical technique, which will be described in this report. Additionally, the indications for subtotal fenestrating cholecystectomy will be discussed alongside the benefit of this technique to specific patient populations presenting with acute on chronic cholecystitis.
A diaphragmatic hernia (DH) is characterized by protrusion of abdominal organs into the chest cavity through an opening in the diaphragm. A sliding or paraesophageal hernia is the most prevalent type, characterized by its occurrence near the esophageal hiatus. Typically present since birth, it can also develop later in life, occasionally arising as a result of severe trauma or iatrogenic injury. Less often, congenital DHs protrude through posterolateral or substernal diaphragmatic defects, referred to as Bochdalek and Morgagni hernias, respectively.
DH can remain asymptomatic and is commonly detected as an incidental finding during evaluation for other medical issues. Hiatal hernias differ from abdominal wall hernias in that they are influenced by the constant motion of the diaphragm, which exerts continuous friction and pressure changes on the esophagus and the stomach. As a result, hiatal hernias have a higher likelihood of recurrence following surgical correction in comparison to abdominal hernias.
This is the case of an exploratory laparotomy for bowel obstruction and primary pledgeted repair of two diaphragmatic hernias.
For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation. PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications, laparoscopic-assisted PEG (LAPEG) was introduced.
LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.
Over the past decade, laparoscopic donor nephrectomy has gradually replaced the conventional open approach and has become the standard of care in living donor kidney transplantations. Compared to open nephrectomy, laparoscopic nephrectomy reduces postoperative pain, shortens the length of hospital stay, and improves the cosmetic outcome. This article illustrates the author’s technique of pure laparoscopic donor nephrectomy.
Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.
In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․
Barbed suture is an increasingly popular type of suture used by surgeons across the world. It is an efficient suture that provides several benefits, including better distributed tensile strength, reduced surrounding inflammatory reaction and local tissue hypoxia, and less foreign body exposure. However, there have been a handful of cases of complications with barbed sutures over the past few decades.
This is the case of a patient who initially underwent an uncomplicated robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and re-presented postoperative day two with a small bowel obstruction. This video shows the operative findings from the return to the operating room with the identification of a barbed suture that had become caught in the mesentery, causing kinking of the bowel.
