PUBLISHED: Hypoglossal Nerve Stimulator

Hypoglossal Nerve Stimulator
Russel Kahmke, MD1Adam Honeybrook, MBBS1Clayton Wyland2C. Scott Brown, MD1
1 Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center
2 Lake Erie College of Osteopathic Medicine

Obstructive sleep apnea (OSA) is a common condition with several effective treatment strategies centered around relieving airway obstruction. The gold standard for OSA treatment remains continuous positive airway pressure (CPAP), but other options exist.

A recent therapy developed within the past decade utilizes hypoglossal nerve stimulation (HGNS) through a surgically implanted device. As the patient inspires, the device sends an electrical impulse similar to a cardiac pacemaker. The impulse activates targeted branches of the hypoglossal nerve, leading to stimulation of muscles that protrude the tongue and open the airway posteriorly. This mechanism has been shown to reduce airway obstruction by activating these muscles during inspiration.

Along with detailing the chronological order of events, this case outlines various complex anatomical structures that are identified in order to safely and effectively implant the hypoglossal nerve stimulator.

PUBLISHED: Open Cholecystectomy for Gallstone Disease

Open Cholecystectomy for Gallstone Disease
Liborio “Jun” Soledad, MDEnrico Jayma, MDTed Carpio, MD
World Surgical Foundation

Gallstone disease is one of the most common disorders affecting the digestive tract. Most individuals with gallstones are asymptomatic and do not require treatment. For symptomatic patients, however, cholecystectomy is recommended.

Cholecystectomy is one of the most common abdominal surgeries performed worldwide. Indications include moderate-to-severe symptoms, stones obstructing the bile duct, gallbladder inflammation, large gallbladder polyps, and pancreatic inflammation due to gallstones.

Here, we report the case of a 53-year-old male with stones in his biliary duct. Despite having uncomplicated disease, the patient was treated with a primary open cholecystectomy because laparoscopy was not available.

PUBLISHED: Thumb Extensor Tendon Laceration Repair

Thumb Extensor Tendon Laceration Repair
Evan Bloom1Amir R. Kachooei, MD, PhD2Asif M. Ilyas, MD, MBA, FACS1,2
1 Sidney Kimmel Medical College at Thomas Jefferson University
2 Rothman Institute at Thomas Jefferson University

This case consists of repairing an extensor tendon laceration of a thumb. Extensor tendon lacerations are one of the most common soft tissue injuries of the hand. Surgical repair of the tendon was offered, and the operation was performed using wide-awake local anesthesia no tourniquet (WALANT) technique.

Intraoperatively, a complete laceration of the extensor tendon was confirmed repaired using a modified Kessler technique and reinforced with an epitendinous repair. Before closure, the patient tested competency of the repair with confirmation of restoration with the active extension to ensure proper function. The patient was placed in a reverse thumb spica splint following wound closure.

Postoperatively, the patient was immobilized in full thumb extension for approximately two weeks and then converted to a removable splint and prescribed supervised hand therapy for a total recovery of 8–12 weeks.

PUBLISHED: Lipoma Excision

Lipoma Excision
John Grove1Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2
1Lincoln Memorial University – DeBusk College of Osteopathic Medicine
2Philippine Children’s Medical Center

Lipomas are slow-growing lumps that occur as a result of overgrowth of fat cells. They present as doughy, moveable, and non-tender lumps usually found underneath the skin; however, they may occasionally be deeper. Lipomas occur in 1 in every 1,000 people and commonly grow on the upper back, shoulders, and abdomen. In most cases, lipomas are painless unless they affect joints, nerves, or blood vessels. A physical examination is the easiest way to diagnose a lipoma; however, imaging studies and biopsy may aid in the diagnosis when they are large, have unusual features, or appear deep.

No treatment is usually necessary for a lipoma; however, if a lipoma is painful or growing, removal may be recommended by excision or liposuction. Here, we present a 35-year-old male who has a large and deep 8-year-old lipoma on his upper back. The lipoma was excised and sent for biopsy.

PUBLISHED: Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula

Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula
Jennifer Shearer, MDBrooke Gurland, MD, FACS
Stanford University School of Medicine

Anorectal abscesses most commonly result from obstruction of glandular crypts in the anorectal canal. Abscesses are commonly diagnosed by clinical exam with fluctuance, induration, and tenderness around the perianal tissue.

Abscesses are managed with incision and drainage. For superficial perianal abscesses, bedside lancing can be performed, but for more complex or ischiorectal or postanal abscess, examination under anesthesia in the operating room is preferred. Complete evacuation of the abscess with breakdown of loculated abscess pockets is critical to fully control the infection. Drains may also be left in a deep abscess pocket to prevent the skin prematurely closing before the cavity has healed.

Imaging is selectively performed with CT or MRI to identify occult infections or further identify proximal extent of abscess cavity or associated fistula. For recurrent abscesses, associated fistula tracts should also be identified and, if possible, treated intraoperatively. Antibiotics are utilized for patients with cellulitis or those who are immunosuppressed. This video article presents an adult male with recurrent anorectal abscesses with a new anterior abscess collection, which was managed with anal exam under anesthesia with incision and drainage of abscess collection and drain placement.

PUBLISHED: Anal Examination Under Anesthesia and Botox Injection for Chronic Anal Fissures

Anal Examination Under Anesthesia and Botox Injection for Chronic Anal Fissures
Jennifer Shearer, MDBrooke Gurland, MD, FACS
Stanford University School of Medicine

Most individuals associate anal pain with hemorrhoids. However, there are many conditions that can cause anal pain and bleeding, and physical examination helps to differentiate between these diagnoses: anal fissures, hemorrhoids, or infections.

An anal fissure is a superficial tear in the anoderm. Fissures are diagnosed clinically by history and physical exam with careful spreading of the anus and direct visualization of a break in the mucosa and exposed sphincter fibers. Increased tone of the internal anal sphincter can inhibit fissure healing by decreasing blood flow to the mucosa.

Conservative management includes stool softeners and warm sitz baths to avoid traumatizing the fissure with hard stools and relaxing the sphincters with warm water. Topical nitrates or calcium channel blockers applied at the anal verge dilate and relax the internal sphincter muscle to promote healing.

Alternatively, injection of Onobotulinumtoxin A into the fissure and intersphincteric groove paralyzes sphincter muscle, decreasing muscle spasm and supporting healing of the fissure. For individuals who fail these conservative therapies, lateral internal sphincterotomy is considered. This procedure involves dividing the internal sphincter muscles but carries a small risk of fecal incontinence.

This video article presents the case of a young adult male with a history of a chronic anal fissure, who failed medical management. Anal fissure was appreciated on exam and treated with Onobotulinumtoxin A injection for relaxation of anal sphincter.