PUBLISHED: Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach

Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach
Prabh R. Pannu, MDDavid Berger, MD
Massachusetts General Hospital

Laparoscopic low anterior resection (LAR) is a complex surgical procedure used for resecting the distal sigmoid colon or rectum while preserving sphincter function. The patient is a 37-year-old, obese male with rectal cancer.

Abdominal access is gained through four laparoscopic port sites. The omentum is freed from the transverse colon to enter the lesser sac. The splenic flexure and descending colon are mobilized from the retroperitoneum. The left colic artery is identified and divided. Following proximal mobilization, the dissection is carried towards the pelvis. The sigmoid colon is mobilized, and the presacral space is entered. The inferior mesenteric artery is divided between clips. The dissection in this case could not be carried down low enough in a laparoscopic fashion, and a lower midline incision was made. A suitable area on the descending colon is identified and the marginal artery divided. The proximal bowel is then divided with a stapler. A flexible colonoscope is then used to confirm tumor location and the rectum is divided below the tumor. Finally, a Baker type side-to-end anastomosis is performed with a powered EEA stapler, and its integrity verified endoscopically under water. A diverting loop ileostomy is then created at a previously marked site and the abdomen closed.

In this video, the surgical steps of this procedure are demonstrated and insight is provided into intraoperative decisions.

PUBLISHED: Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy

Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy
Hannah A. Bougleux Gomes, MD¹; Divyansh Agarwal, MD, PhD¹; Charu Paranjape¹’²
¹Massachusetts General Hospital/Brigham and Women’s Hospital
²Newton-Wellesley Hospital

A hiatal hernia occurs when part of an intra-abdominal organ, most commonly the stomach, migrates through the diaphragmatic crura. The condition can cause a range of uncomfortable symptoms, including heartburn, chest pain, and difficulty swallowing. While several individuals with a hiatal hernia can manage their symptoms with lifestyle changes and anti-reflux medications, some with refractory symptoms or complications secondary to the hernia require surgical treatment to repair the defect.

Here we present the case of a 60-year-old female with a paraoesophageal hiatal hernia and chronic gastrointestinal reflux disease (GERD) refractory to proton-pump inhibitors (PPI), dietary changes, and lifestyle modifications. She underwent an elective robotic hiatal hernia repair, fundoplication, and esophagogastroduodenoscopy (EGD) as a two-hour procedure with routine postprocedure recovery. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

PUBLISHED: Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair
Scott D. Martin, MD
Brigham and Women’s Hospital

Hip arthroscopy with femoral neck or acetabular osteoplasty with or without labral repair can be used for treatment of femoroacetabular impingement (FAI). Patients may present with insidious onset of hip pain and mechanical symptoms and pain worse with activity and sitting.

On physical exam hip flexion and internal rotation may be reduced and anterior impingement testing will produce groin pain in the majority of patients with FAI. Imaging may demonstrate lesions responsible for cam-type or pincer-type impingement, and MRI may demonstrate labral tear or cartilaginous lesions. Arthroscopic surgical treatment is indicated for patients who have failed conservative treatment.

PUBLISHED: Anal Fistulotomy

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.

PUBLISHED: Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision

Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision
Prabh R. Pannu, MD; David Berger, MD
Massachusetts General Hospital

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.