PUBLISHED: Split-Thickness Skin Graft for Scar Release, Permanent Pigment Transfer, and Fractional CO2 Laser Therapy

Split-Thickness Skin Graft for Scar Release, Permanent Pigment Transfer, and Fractional CO2 Laser Therapy
Aleia M. Boccardi, DO1Robert J. Dabek, MD2Lisa Gfrerer, MD, PhD3Daniel N. Driscoll, MD, FACS4
1St. John’s Episcopal Hospital
2Massachusetts General Hospital
3Harvard Plastic Surgery Combined Residency Program
4Shriners Hospitals for Children – Boston

Pediatric burns are one of the most common forms of injury affecting children worldwide. Of these, hand involvement occurs in 80–90% of such incidents. With the skin in children already diffusely thinner throughout the body than adults, this provides a particular challenge for areas naturally possessing thinner skin, such as the dorsal hand. There, the cutaneous tissue is the only protection for vital structures in the hand that allow full function, such as extensor tendons, nerves, and vessels. Injury to this area early in life can have a detrimental impact on how the survivor interacts with the physical world, affecting their functional capacity and quality of life.

Here presents a case of burn contractures on the right hand of an 8-year-old boy that will be released using a split-thickness graft, along with a pigment transfer graft for his left knee and fractional CO2 laser therapy over areas of hypertrophic scar tissue on his bilateral upper extremities. The split-thickness graft will greatly decrease the tension built up from the burn contracture, while the fractional CO2 laser procedure can soften the surrounding scar, allowing mild remodeling and increased range of motion.

PUBLISHED: Back Table Setup for an Open Umbilical Hernia Repair

Back Table Setup for an Open Umbilical Hernia Repair
Devon Massey, CSTShirin Towfigh, MD
Beverly Hills Hernia Center

Surgical instrument tables are considered as basic furniture for the operating room (OR). The largest table, typically rectangular or “L”-shaped, serves as a central hub for arranging and storing sterile supplies until needed during surgical procedures. The Mayo stand is an extension of the large table. It is small, height-adjustable, and intended to hang over the operating table and hold instruments and other sterile items for immediate use and within easy reach for the scrub nurse. Both the large table and the smaller Mayo stand are often referred to as back tables.

The specific equipment and arrangement of the back table may vary depending on the type of surgery and the surgeon’s preferences. This video provides a detailed, step-by-step guide to the back table setup for an open umbilical hernia repair surgery. It covers the preparation of the surgical field, the handling of sterile supplies, and the organization of the surgical tray. Additionally, it discusses the importance of adhering to sterile technique and the surgeon’s preferences during the procedure.

PUBLISHED: Laparoscopic Lysis of Adhesions for Closed Loop Small Bowel Obstruction

Laparoscopic Lysis of Adhesions for Closed Loop Small Bowel Obstruction
Jade Refuerzo, BSNicole B. Cherng, MD
UMass Memorial Medical Center

Laparoscopic lysis of adhesions is a minimally-invasive approach to the resolution of a closed loop small bowel obstruction (SBO) due to adhesions. A patient with an SBO can present with nausea, vomiting, abdominal pain, and obstipation. History of prior abdominal surgeries serves as a significant risk factor for development of intra-abdominal adhesions. Imaging using either plain abdominal radiography or computed tomography (CT) can be diagnostic for closed loop SBOs. Conservative management with gastrografin can be considered in some SBOs, but closed loop SBOs are considered surgical emergencies. Utilization of specific signs (two transition points, pneumoperitoneum, signs of bowel ischemia) on imaging and patient presentation can facilitate earlier intervention.

Laparoscopic lysis of adhesions can resolve symptoms through releasing the bowel from the adhesion to improve flow. Lysis of adhesions can be performed open, laparoscopically, or with robotic techniques. This case presents a laparoscopic lysis of adhesions in a patient with a closed loop small bowel obstruction.

PUBLISHED: Surgical Staplers

Surgical Staplers
Brandon Buckner, CST, CRCST
Lamar State College Port Arthur (TX)

For nearly two centuries, surgeons have been using mechanical devices to approximate tissues and facilitate their healing process. Currently, surgical staplers are widely used and have become essential tools in surgery. Staples facilitate rapid wound closure, hence shortening the duration of the surgical procedure. In comparison to intradermal sutures, stapling is associated with better cosmetic outcomes.

Staplers are classified into five categories: circular, linear, linear cutting, ligating, and skin staplers. With distinct names, color-coded features, and variations in length and tissue thickness, each stapler serves a specific purpose in the surgical setting. The distinct characteristics of various tissue types in the human body significantly influence the selection of staples. This video aims to provide a comprehensive overview of stapling instruments and their associated use.

PUBLISHED: Laparoscopic Totally Extraperitoneal (TEP) Left Indirect Inguinal Hernia Repair with Mesh

Laparoscopic Totally Extraperitoneal (TEP) Left Indirect Inguinal Hernia Repair with Mesh
Victoria J. Grille, MDRandy S. Haluck, MD
Penn State Health Milton S. Hershey Medical Center

This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.

PUBLISHED: Combined Thymectomy and Right Lower Lobe Pulmonary Wedge Resection by Thoracoscopy

Combined Thymectomy and Right Lower Lobe Pulmonary Wedge Resection by Thoracoscopy
M. Lucia Madariaga, MDHenning A. Gaissert, MD
Massachusetts General Hospital

With the increasing use of computed tomography (CT) for screening and diagnostic workup, increasing numbers of patients are found to have pulmonary nodules. The patient in this case presented with vision changes, neck weakness, and dysphagia. Workup revealed non-thymomatous myasthenia gravis as well as an incidental right lower lobe lung nodule that was suspicious for malignancy based on imaging characteristics, interval growth, and history of breast cancer.

She required a lung resection for diagnostic and therapeutic purposes. Additionally, a thymectomy was indicated to help control her myasthenia gravis symptoms. Consequently, a combined approach was conducted.

Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate

Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate
Andrew M. Hresko, MDEdward Kenneth Rodriguez, MD, PhD
Beth Israel Deaconess Medical Center

Diaphyseal tibial fractures are common injuries that are most often treated with intramedullary nailing. However, certain patient factors may necessitate alternative treatment strategies such as open reduction internal fixation (ORIF) with plates and screws. Presence of a total knee arthroplasty (TKA) in the injured extremity is one such factor. TKA is a common operation that is only increasing in popularity, and management of tibia fractures distal to TKA may be a frequently encountered clinical scenario.

This video presents a technique for ORIF of a distal diaphyseal tibia fracture distal to a TKA that precludes intramedullary nail fixation. The fracture is fixed with lag screws and secured with an anatomically-contoured distal tibia locking-compression plate (LCP) in neutralization mode.

PUBLISHED: Carbon Fiber Implant for Fixation of a Pathologic Subtrochanteric Fracture

Carbon Fiber Implant for Fixation of a Pathologic Subtrochanteric Fracture
Paul A. Rizk, MD; Joseph O. Werenski; Santiago A. Lozano-Calderon, MD, PhD
Massachusetts General Hospital

This case presents a patient with a pathologic subtrochanteric femur fracture secondary to an undiagnosed primary lung adenocarcinoma. The fracture, occurring in the context of persistent atraumatic thigh and knee pain, prompted swift identification of its pathological nature in the Emergency Department. The treatment plan involved open reduction and internal fixation utilizing a carbon fiber nail, considering the immediate need for stabilization and underlying oncologic factors.

This article highlights the strategic use of carbon fiber implants in managing pathologic fractures, offering advantages in postoperative imaging, disease monitoring, and precision in radiation therapy planning. The multidisciplinary approach underscores the importance of considering implant selection nuances, especially in metastatic bone disease, to optimize outcomes.

PUBLISHED: Brostrom-Gould Procedure for Lateral Ankle Instability

Brostrom-Gould Procedure for Lateral Ankle Instability
William B. Hogan1Eric M. Bluman, MD, PhD2
1Warren Alpert Medical School of Brown University
2Brigham and Women’s Hospital

Acute ankle sprains are most frequently treated conservatively, although some surgeons may advocate acute repairs in certain situations. Surgery is indicated for chronic sprains with persistent ankle instability despite well-designed conservative management. Several anatomic and nonanatomic operative procedures are available. The Broström-Gould procedure is a widely-used operative intervention for the treatment of chronic lateral ankle sprains. It consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex (Broström procedure), followed by suturing of the inferior extensor retinaculum to the periosteum of the distal fibula (Gould modification).

This article describes the standard Broström-Gould procedure starting with the identification of the anatomic landmarks. The skin incision follows the anterior border of the distal fibula, and careful subcutaneous dissection is carried out to expose the extensor retinaculum and the torn ligaments. This is followed by bone preparation and ligament repair utilizing a box stitch technique while holding the ankle in an appropriate position. Finally, the Gould portion of the procedure is demonstrated.

PUBLISHED: Corneal Staining with Fluorescein

Corneal Staining with Fluorescein
Alexander Martin, OD
Boston Vision

Patient ocular complaints often center around discomfort, foreign body sensation, and/or recent trauma. Determining the cause of the ailment is not always straightforward, and the use of fluorescein can provide valuable information that aids in clinical diagnosis. Many corneal conditions and emergencies can be identified with the aid of fluorescein such as corneal erosion, superficial punctate keratitis, corneal abrasion, foreign bodies, and tracking patterns of foreign bodies. This article and video will demonstrate proper technique to instill fluorescein and examine ocular tissues, as well as some examples of staining defects characteristic of compromised ocular tissues.

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