Opening Sterile Surgical Packs
Lamar State College Port Arthur (TX)
Surgical site infection (SSI) poses a significant risk to patients undergoing surgery. The prevalence of SSI is influenced by various factors. Within an ideal perioperative environment, exclusively sterile surgical instruments are employed. Care should be taken to thoroughly explore all methods of maintaining a contamination-free operating room (OR) environment.
The proper opening of sterile surgical instrument packs has critical importance in maintaining aseptic conditions in the OR. This video demonstrates all the nuances of this process, emphasizing the importance of package integrity checks and adherence to strict protocols for sterile surgical attire.
Local Tissue Advancement: Reconstructing Superior Helical Rim Defect and Exposed Ear Cartilage After Mohs Surgery
1; 2; 1; 1; 1; 3; 1
1Virginia Commonwealth University Medical Center
2University of Texas Southwestern Medical Center
3Mass Eye and Ear/Harvard Medical School
Reconstruction of external ear defects often poses various challenges due to the complex anatomy of the ear and its significant role in overall facial aesthetics. The location of the defect independently impacts the repair as various locations present distinct, additional factors to consider during planning. Specifically, defects of the superior auricle complicate the reconstructive process, due to the role of the helical root and superior rim in providing mechanical support for facial accessories such as glasses or hearing aids. The approach to reconstruction must be systematic while also being individually tailored in order to appropriately restore both optimal cosmesis and function.
The featured case involves the reconstruction of a full-thickness superior helix and auricular defect in a patient who wears eyeglasses with a cochlear implant on the same side. The discussion highlights the complexity of superior auricular reconstruction as well as the various surgical options used and challenges encountered.
Cystoscopy and Placement of Ureteral Stents: Preoperative for HIPEC Surgery
Massachusetts General Hospital
This video provides a comprehensive overview of the prophylactic ureteral stenting and cystoscopy performed on a patient with advanced metastases of appendiceal cancer who is scheduled for cytoreduction and hyperthermic intraperitoneal chemotherapy. The video focuses on urethral instrumentation, identification of ureteral orifices, stent placement, and subsequent bladder inspection. The patient’s preoperative evaluation had revealed no evidence of ureteral involvement with the tumor.
The cystoscopic technique employed in this case allowed the surgeons to visualize the bulbar urethra, sphincter, and prostatic urethra, illustrating the step-by-step process of advancing into the bladder. Next, the vesical trigone is identified, aiding in the visualization of the ureteral orifices. The careful placement of stents into both ureters is demonstrated. No resistance was encountered in the process of stent placement, suggesting no involvement of the ureters with the tumor. A thorough bladder inspection revealed no unusual findings such as abnormal lesions, masses, or other pathology. The stents were secured with silk sutures to prevent inadvertent dislodgement.
Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement
Katherine H. Albutt, MD
Massachusetts General Hospital
For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation. PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications, laparoscopic-assisted PEG (LAPEG) was introduced.
LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.
Pulmonary AVM Embolization
1; 1; 1; 2; 2
1Frank H. Netter, MD School of Medicine at Quinnipiac University
2Yale School of Medicine
Pulmonary arteriovenous malformations (PAVMs) are rare fistulous connections between pulmonary arteries and veins that, as in this case, are commonly associated with hereditary hemorrhagic telangiectasia (HHT). Embolotherapy, the mainstay of treatment for PAVMs, is a procedure in which the feeding arteries of a malformation are endovascularly occluded under fluoroscopic guidance. Effective and well-tolerated, embolotherapy has been shown to decrease right-to-left shunting following treatment and decrease risks of paradoxical embolization and lung hemorrhage and to improve pulmonary gas exchange and lung function. Patients are selected for treatment according to clinical suspicion for the presence of a PAVM and feeding artery diameter. The occlusion of PAVMs with arteries that exceed 2–3 mm in diameter is recommended.
Diagnostic contrast-enhanced pulmonary angiography is performed via injection of contrast through a percutaneous catheter to characterize and confirm PAVMs suitable for embolization. Lesions are then treated by catheter-directed placement of embolic material— vascular plugs in this case—into the feeding artery, terminating blood flow to the area of the lesion. Although multiple PAVMs may be embolized during a single session, in patients with HHT, who may present with large numbers of PAVMs, treatment is limited by maximum contrast dosage, and additional sessions may be performed if PAVMs remain perfused.
Epidural at T9-T10: Preoperative for HIPEC Surgery
Massachusetts General Hospital
Heated Intraperitoneal Chemotherapy (HIPEC) coupled with cytoreduction is increasingly being used to treat isolated peritoneal dissemination of intra-abdominal malignancies. Cytoreductive surgery (CRS) is initially performed using either a conventional open or laparoscopic approach. CRS includes removal of the main tumor, excision of any other visible tumors, peritonectomy, omentectomy, and intestinal resections, if necessary. Following CRS, a chemotherapeutic solution is administered at a temperature of 40 to 41.5 °C. Infusing chemotherapy immediately following CRS facilitates a uniform distribution of the solution throughout the entire peritoneal cavity. This strategy prevents localized spread that may arise from postoperative adhesion formation, ensuring that peritoneal surfaces are exposed to a concentrated chemotherapy dose while minimizing systemic toxicity.
Epidural analgesia provides effective pain management and is generally well tolerated by patients undergoing CRS in conjunction with HIPEC. This video provides a comprehensive step-by-step demonstration of the entire procedure. The epidural injection involves the delivery of anesthetic solution to the epidural space surrounding the spinal cord within the vertebral column, inducing anesthesia in the spinal segments below the site of catheter placement.