Print Release, Vascular Surgery

PUBLISHED: Fistulogram for a Cephalic Arch Aneurysm

Fistulogram for a Cephalic Arch Aneurysm
Tiffany R. Bellomo, MD1,2; Brett J. Salomon, MD1,2; Jonah Thomas, MD2; Anahita Dua, MD, MS, MBA, FACS1
1Massachusetts General Hospital
2Mass General Brigham

More than 100,000 arteriovenous fistulas (AVFs) are created annually in the United States, but are frequently complicated by venous outflow stenosis, aneurysm formation, and aneurysms that often require angiographic evaluation and intervention. Cephalic arch stenosis is a particularly common cause of dysfunction in brachiocephalic fistulas due to high flow. This is typically managed with fistulogram-guided angioplasty, although repeated interventions are associated with restenosis and access-related complications.

This article present the case of a 63-year-old, right-hand dominant male with end-stage renal disease secondary to glomerulonephritis on dialysis through a left upper extremity brachiocephalic AVF that was complicated by recurrent cephalic arch stenosis requiring multiple angioplasties, which ultimately resulted in the development of a cephalic arch aneurysm. Subsequent fistulograms demonstrated a high-grade stenosis that could not be traversed despite multiple attempts.

Comprehensive preoperative evaluation included focused history, physical examination, duplex ultrasound, and computed tomography venography. The fistulogram described in this article demonstrated a patent, high-flow AVF with a saccular aneurysm of the proximal cephalic vein measuring up to 28 mm without thrombus and no hemodynamically significant flow-limiting stenosis. Given the absence of flow limitation and the risk of compromising future access, stent placement was deferred.

This case highlights the importance of individualized decision-making in the management of complex AVF complications. Fistulograms serve as a critical diagnostic and therapeutic tool, allowing real-time assessment of anatomy and flow to guide intervention. In select patients, conservative endovascular management with surveillance may preserve access durability and delay the need for more invasive procedures.

General Surgery, Print Release

PUBLISHED: Robotic Preperitoneal eTEP Repair for Umbilical Hernia and Diastasis

Robotic Preperitoneal eTEP Repair for Umbilical Hernia and Diastasis
Hector A. Valenzuela Alpuche, MD; Juan P. Saucedo Gonzalez, MD; Roland K. Cethorth Fonseca, MD
Hospital Angeles del Carmen, Guadalajara, Mexico

Robotic extraperitoneal approaches have expanded the possibilities of minimally invasive abdominal wall reconstruction. The suprapubic preperitoneal eTEP (PeTEP) technique offers an alternative for selected patients with small-to-medium midline hernias, with or without rectus diastasis, in whom preservation of the retrorectus plane is desirable. This article describes the application of PeTEP in a 58-year-old male with a 3-cm primary umbilical hernia and a 5-cm rectus diastasis, using a suprapubic robotic extraperitoneal approach to achieve functional midline reconstruction while maintaining the integrity of the retrorectus space. The procedure includes pretransversalis access, development of the preperitoneal and pretransversalis planes, midline restoration, and placement of a preperitoneal polypropylene mesh. This technique avoids posterior sheath division, neurovascular bundle manipulation, and retromuscular dissection, thereby reducing potential morbidity in selected patients. This case illustrates the feasibility of PeTEP in a carefully selected patient. The authors do not propose this approach as a replacement for open or transabdominal techniques, but rather as an additional option within a broader reconstructive spectrum.

Print Release, Surgical Technology

PUBLISHED: Setup for a Laparoscopic Hemicolectomy (Kingsborough Community College, Brooklyn, NY)

Setup for a Laparoscopic Hemicolectomy (Kingsborough Community College, Brooklyn, NY)
Gina Forsythe, CST
Kingsborough Community College, Brooklyn, NY

Laparoscopic hemicolectomy has become the standard of care for the surgical management of various colonic pathologies. Proper instrument setup and systematic counting protocols are essential components of surgical safety and procedural efficiency. The setup protocol for laparoscopic hemicolectomy shown in this video is based on established guidelines for sterile technique and encompasses instrument arrangement, the initial count, and discussion of fluid management on the sterile field. The setup includes organized placement of laparoscopic instruments, trocars, sponges, sharps, and essential equipment. This setup promotes surgical safety, reduces procedural delays, and minimizes the risk of retained surgical items.

Anesthesiology, Print Release

PUBLISHED: Neuraxial Ultrasound and Spinal Anesthesia for Cesarean Delivery

Neuraxial Ultrasound and Spinal Anesthesia for Cesarean Delivery
Fatine Karkri, MD; Lauren Blake, MD; Brendan Carvalho, MBBCh, FRCA, MDCH, FASA
Stanford University School of Medicine

This video provides a step-by-step demonstration of preprocedural neuraxial ultrasound for lumbar neuraxial procedures. The film shows probe selection and orientation, sonoanatomy landmarks (sagittal and transverse views), measurement of skin-to-posterior complex depth, and skin marking. Indications and evidence for improved procedural accuracy and reduced needle passes are discussed. The technique is applicable to routine obstetric neuraxial procedures and is especially useful in patients with challenging surface landmarks or a history of difficult neuraxial placement.

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Repair for Ventral Hernias

Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Repair for Ventral Hernias
Daphne Y. Lu, MD, MPH, MBA; Olivia Ziegler, MD; Saamia Shaikh, DO, JD; Jerome R. Lyn-Sue, MD, FACS
Penn State Health Milton S. Hershey Medical Center

This case describes a 58-year-old man who developed a symptomatic incisional ventral hernia following a trauma laparotomy and left nephrectomy after a motor vehicle collision. The patient presented with multiple midline hernia defects associated with bulging and discomfort. This video demonstrates a robotic transabdominal preperitoneal (rTAPP) repair with mesh. The case highlights practical strategies for managing intra-abdominal adhesions and a prior gastrostomy site, while outlining alternative operative approaches for cases in which preperitoneal flap development is technically challenging.

General Surgery, Print Release

PUBLISHED: Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis

Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis
Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2
1North York General Hospital, University of Toronto
2Penn State Health Milton S. Hershey Medical Center

A 55-year-old female has a history of multiple abdominal surgeries including laparoscopic cholecystectomy, appendectomy, laparoscopic hysterectomy, tubal ligations, and multiple cesarean sections through a low transverse (Pfannensteil) incision. Cross-sectional imaging demonstrated multiple midline hernias ranging from 1–3 cm, a rectus diastasis measuring 4 cm wide, and intraparietal cesarean section (C-section) hernia (Zanellato Type II). She underwent a robotic retromuscular extended totally extraperitoneal (eTEP) repair wherein her ventral midline hernias, rectus diastasis, and intraparietal hernia were all repaired and reinforced with wide mesh overlap. This case highlights the strengths of an eTEP approach, the decision making behind considering all of a patient’s abdominal wall pathology, and the considerations with intraparietal hernias post C-section.

Print Release, Surgical Technology

PUBLISHED: Setup for an Open Total Thyroidectomy (Ivy Tech Community College, Indianapolis, IN)

Setup for an Open Total Thyroidectomy (Ivy Tech Community College, Indianapolis, IN)
David Wiseman, AAS, CST
Ivy Tech Community College, Indianapolis, IN

Open total thyroidectomy is a commonly performed endocrine surgery. Using a standardized protocol for back table and Mayo stand setup can improve surgical efficiency and boost patient safety. The protocol demonstrated in this educational video covers instrument arrangement, specialized equipment preparation, and safety considerations specific to thyroid surgery. The setup includes organization of forceps, specialized bipolar energy devices, clip appliers, nerve monitoring equipment, and self-retaining retractors. Key safety measures include dual towel protection layers, separation of toothed versus smooth instruments, and sharps management. This protocol provides surgical technology students with a comprehensive framework for thyroidectomy setup and reinforces the fundamental principles of patient safety and procedural efficiency.

General Surgery, Print Release

PUBLISHED: Excision of Suspected Chronic Infected Suture Sinus

Excision of Suspected Chronic Infected Suture Sinus
Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2
1North York General Hospital, University of Toronto
2Penn State Health Milton S. Hershey Medical Center

A 65-year-old female with a history of a left deep inferior epigastric perforator (DIEP) flap for breast reconstruction presented with an incisional hernia and a draining sinus tract overlying the site for her DIEP flap harvest confirmed on physical exam and cross-section imaging. She underwent a wound exploration where the entire suture sinus was excised, and it was confirmed that there was no residual foreign material left in the area. This case highlights the importance of staged abdominal wall reconstruction and addressing chronic infection before proceeding with surgery.

General Surgery, Print Release

PUBLISHED: Excision of Infected Onlay Mesh

Excision of Infected Onlay Mesh
Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2
1North York General Hospital, University of Toronto
2Penn State Health Milton S. Hershey Medical Center

A 73-year-old female has a history of ventral hernia repair with onlay mesh complicated by mesh infection requiring multiple debridement. She later underwent additional laparotomies for other procedures that led to her previous mesh being chronically infected and exposed to air. Multiple office debridement did not successfully remove all of the mesh. She was taken to the operating room where her onlay mesh was completely excised. This case highlights the importance of complete foreign body excision when dealing with infected prostheses of the abdominal wall.

Print Release, Surgical Technology

PUBLISHED: Setup for an Exploratory Laparotomy with Possible Splenectomy (Ivy Tech Community College, Indianapolis, IN)

Setup for an Exploratory Laparotomy with Possible Splenectomy (Ivy Tech Community College, Indianapolis, IN)
David Wiseman, AAS, CST
Ivy Tech Community College, Indianapolis, IN

Proper operating room setup for an exploratory laparotomy with possible splenectomy is critical for optimal surgical outcomes and patient safety. This educational video includes discussion of the proper draping sequence, warm irrigation, instrument organization, and preparation for the initial count with a circulator.

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