PUBLISHED: Lateral Tarsal Strip Procedure for Left Lower Eyelid Entropion

Lateral Tarsal Strip Procedure for Left Lower Eyelid Entropion
Lilit Arzumanian, MD1Alexander Martin, OD2John Lee, MD2
1Vardanants Center for Innovative Medicine
2Boston Vision

Lower lid entropion or inversion is a common involutional inward rotation of the tarsus and eyelid margin. It is caused by a combination of horizontal laxity of the eyelid, attenuation or disinsertion of eyelid retractors, and overriding of preseptal over pretarsal orbicularis muscle fibers. These changes result in the instability of the eyelid with age. The inverted eyelid leads to constant rubbing of eyelashes against the cornea and the globe, causing irritation, foreign body sensation, and in severe cases, corneal erosion, pannus formation, and ulceration. The lateral tarsal strip procedure is aimed at addressing the causes of entropion, thus correcting the eyelid position and improving its function. Upon successful surgical intervention, normal eyelid position and function are restored. Cosmesis of the eyelid also improves. This article will discuss the preoperative assessment of the patient, the preparation, the surgical procedure, and possible complications.

PUBLISHED: Small Bowel Obstruction Following Robotic Transabdominal Preperitoneal Ventral Hernia Repair (rTAPP) Due to Barbed Suture

Small Bowel Obstruction Following Robotic Transabdominal Preperitoneal Ventral Hernia Repair (rTAPP) Due to Barbed Suture
Kathleen C. Clement, MDKeaton L. Altom, MD
Tripler Army Medical Center

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.


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

Surgical instruments have a long history, but their modern versions have only been around for a relatively short period of time. Available in different shapes and sizes for diverse surgeries, contemporary scalpel blades and handles are typically crafted from hardened and tempered steel, stainless steel, and high carbon steel, with blade shapes designed according to their intended use. Recognized as indispensable surgical tools, scalpel blades contribute to precise incisions and minimal scarring, which is particularly crucial in minimally invasive, ophthalmic, cardiovascular, and endoscopic surgeries. Cutting in a firm and controlled way, usually at angles of 30–90 degrees from the tissues, necessitates holding the instrument in various ways, often placing a steadying forefinger along the back of the instrument. The tissue through which the scalpel is incising should also be steadied and put under a slight degree of tension.

The demonstration of surgical scalpels in this video provides valuable insights into their usage. The handles are available in different designs, serving two functions: fitting the appropriate size of surgical blades and ensuring a firm hold to reduce the chance of slipping.

Surgical blades come in sterile packaging, and the number on a surgical blade communicates both its size and shape. This video demonstration aids in understanding how each blade is tailored to meet certain demands in surgery.

PUBLISHED: Integra Scalp Reconstruction: Addressing a Full-Thickness Scalp Defect with Exposed Calvarium Along Vertex in an Elderly Immunocompromised Patient

Integra Scalp Reconstruction: Addressing a Full-Thickness Scalp Defect with Exposed Calvarium Along Vertex in an Elderly Immunocompromised Patient
Cheryl Yu, MD1Derek Sheen, MD2Katherine M. Yu, MD1Alyssa N. Calder, MD1Christopher J. Kandl, MD1Thomas Lee, MD, FACS1
1Virginia Commonwealth University Medical Center
2University of Texas Southwestern Medical Center

Reconstruction of full-thickness scalp defects often poses various challenges depending on the complexity and characteristics of the wound as well as independent patient health factors. Despite a range of reconstructive options ranging from primary closure, adjacent tissue transfer, and autografts to free flap reconstruction, there is no universally adopted decision algorithm.

Integra, an acellular matrix composed of crosslinked bovine collagen and glycosaminoglycan covered by a silicone membrane, is widely used for scalp reconstruction and has been shown to produce excellent functional and cosmetic results.

The featured case involves staged scalp reconstruction utilizing the Integra bilayer matrix wound dressing for an elderly immunocompromised patient presenting with two adjacent full-thickness scalp defects resulting in exposed calvarial bone over the vertex. The discussion centers on determining the most optimal scalp reconstructive option and exploring the treatment algorithm used at our institution. Furthermore, application of Integra for calvarial bone coverage will be discussed.

PUBLISHED: Mastoidectomy

David M. Kaylie, MD, MS1Adam A. Karkoutli2C. Scott Brown, MD1
1Duke University Medical Center
2Louisiana State University Health Sciences Center – New Orleans

Mastoidectomy involves the removal of bone and air cells contained within the mastoid portion of the temporal bone. Common indications for this procedure include acute mastoiditis, chronic mastoiditis, cholesteatoma, and the presence of tympanic retraction pockets. Mastoidectomy may also be performed as part of other otologic procedures (e.g. cochlear implantation, lateral skull base tumors, labyrinthectomy, etc.) in order to gain access to the middle ear cavity, petrous apex, and cerebellopontine angle.

The procedure involves dissecting within the confines of the mastoid cavity, which include the tegmen superiorly, the sigmoid sinus posteriorly, the bony ear canal anteriorly, and the labyrinth medially. Mastoidectomy is traditionally classified as: simple (cortical/Schwartze), radical, and modified radical/Bondy’s mastoidectomy. The procedure can also be classified based on the preservation of the posterior canal wall: canal wall up (CWU) or canal wall down (CWD).

PUBLISHED: Surgical Technologist Prepares the OR for a Case

Surgical Technologist Prepares the OR for a Case
Lauren Beausoleil, CST
Massachusetts General Hospital

Establishing a sterile field, opening and organizing equipment and supplies, and preparing the operating room (OR) for a case are the foundations for ensuring an environment conducive to a safe and efficient operation. Surgical donning of gown and gloves is an integral component of infection control in the OR. Healthcare professionals must adhere to strict protocols to protect both patient and healthcare worker safety. Proper training, vigilance, and attention to detail are crucial in maintaining a sterile environment before and during surgical procedures. This article explores key considerations for healthcare professionals as they open up surgical equipment, establish and maintain a sterile field, doff and don gowns and gloves, and prepare the OR for a surgical procedure.

PUBLISHED: Robotic-Assisted Laparoscopic Interval Cholecystectomy

Robotic-Assisted Laparoscopic Interval Cholecystectomy
Chloe A. Warehall, MD1Divyansh Agarwal, MD, PhD1Charu Paranjape, MD, FACS1,2
1Massachusetts General Hospital
2Newton-Wellesley Hospital

Acute cholecystitis occurs when gallstones become impacted in the neck of the gallbladder or cystic duct in approximately 90–95% of cases. Symptoms may include acute right upper quadrant pain, fever, nausea, and emesis often associated with eating. Acute cholecystitis generally has imaging findings of gallbladder wall thickening, edema, gallbladder distension, pericholecystic fluid, and positive sonographic Murphy sign. However, acute cholecystitis is largely a clinical diagnosis of persistent right upper quadrant (RUQ) pain and associated tenderness on palpation of the RUQ in the setting of gallstones.

The standard treatment is a cholecystectomy to prevent recurrent cholecystitis or sequelae of gallstones. Timing of the cholecystectomy is dependent on length of symptoms, which reflect the degree of inflammation.  This is the case of a 74-year-old male who presented with six days of acute cholecystitis symptoms who was initially managed with antibiotics. After improvement of his pain and no systemic symptoms of infection, he underwent an interval robotic cholecystectomy. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

PUBLISHED: Drainage of Cystic Mass on First Left Toe

Drainage of Cystic Mass on First Left Toe
Jasmine Beloy1Jaymie Ang Henry, MD, MPH2Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2Florida Atlantic University
2Philippine Children’s Medical Center

Cutaneous cysts are closed, sac-like, or encapsulated structures that may be filled with air, liquid, or semi-solid material, and are generally benign. Many types of cysts can occur in almost any place throughout the body and can form in all ages. They are seen as slow-growing and painless lumps underneath the skin. However, some cysts may be painful if they are particularly large. Treatment depends on several factors including the type of cyst, location, size, and the degree of discomfort caused. Large, symptomatic cysts can be removed surgically, while smaller, asymptomatic cysts can be drained or aspirated. Here, we present the case of a 12-year-old male with a pus-filled cystic mass on his first left toe and discuss surgical management and follow-up.

PUBLISHED: Blepharoplasty for Bilateral Upper Eyelids

Blepharoplasty for Bilateral Upper Eyelids
Lilit Arzumanian, MD1Alexander Martin, OD2John Lee, MD2
1Vardanants Center for Innovative Medicine
2Boston Vision

Upper blepharoplasty is one of the most commonly performed oculoplastic procedures. It is aimed at correcting the involutional changes of the upper eyelids, characterized by loose, excess eyelid skin (dermatochalasis) and preaponeurotic fat herniation (steatoblepharon) as well as some cases of ptosis. These conditions could result in functional symptoms, such as reduced visual fields, as well as cosmetic concerns and perceived body dysmorphia.

In this case, the patient underwent upper blepharoplasty for cosmetic improvement and to remove xanthomatous lesions. This article discusses and demonstrates the preoperative assessment of the patient, the preparation, the surgical technique, and possible complications.