Pediatric Infant Bilateral Open Inguinal Hernia Repair – Twin A
Shai I. B. Stewart, MD1; Lissa Henson, MD2; Domingo Alvear, MD3
1Howard University Hospital
2Philippine Society of Pediatric Surgeons
3World Surgical Foundation
An inguinal hernia (IH) is a protrusion of intra-abdominal contents through the inguinal canal that can arise at any time from infancy to adulthood. It is more common in males with a lifetime risk of 27% as compared to 3% in females. Most pediatric IHs are congenital and caused by failure of the peritoneum to close, resulting in a patent processus vaginalis (PPV). IH present as a bulge in the groin area that can become more prominent when crying, coughing, straining, or standing up, and disappears when lying down. Diagnosis is based on a thorough medical history and physical examination, but imaging tests such as ultrasound can be used when the diagnosis is not readily apparent. IHs are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring. In infants and children, IH are always operated on to prevent incarceration.
Surgical correction in infants and children is done by high ligation of the hernia sac only, called a herniotomy. Here, we present a female infant with bilateral IH. Upon exploration, a hernia sac was found, and ligation was performed bilaterally. In female patients, it is believed that failure of the closure of the canal of Nuck alongside the round ligament of the uterus is the etiology. Oftentimes there is a “sliding hernia” where the ovary and or the fallopian tube is attached to the sac, sometimes the uterus itself is attached.
Placing Knotless Suture Anchor Through Mid-Glenoid Portal
Travis J. Dekker, MD; Liam A. Peebles; Matthew T. Provencher, MD
Massachusetts General Hospital
Optimal portal placement for arthroscopic shoulder stabilization procedures can significantly aid a surgeon’s visualization during the repair as well as suture anchor placement. A percutaneous knotless anchor insertion kit used through a mid-glenoid portal allows the surgeon to access positions on the glenoid rim that are commonly difficult to reach. Moreover, the knotless kit has the ability to save valuable time during arthroscopic stabilization procedures and also eliminates the risk of postoperative knot impingement.
The mid-glenoid portal should be made approximately 1 cm lateral from the joint line of the humeral head and 2–3 cm inferior and 1–2 cm medial from the posterolateral acromial angle. This portal placement avoids injury to the labrum and should be determined after assessing both the thickness of the local soft tissues and the size of the relevant bony architecture. A hole for the knotless anchor should be drilled approximately 1–2 mm onto the face of the glenoid, and the labral tape is then passed a short distance through the eyelet of the knotless fixation device before the construct is inserted into the glenoid. A hemostat is used to hold the tape as it is placed into the drill hole, and a mallet is used to drive the interference portion of the plastic implant to a marked depth. Finally, once the suture anchor is securely affixed, the insertion device is unloaded and pulled out of the portal with 6 counterclockwise turns.
Cystoscopy and Transurethral Resection of Bladder Tumors with Stent and Foley Catheter Placement
Austin Bramwell, MD; Tullika Garg, MD, MPH, FACS
Penn State Health Milton S. Hershey Medical Center
Bladder cancer is the sixth most common cancer in the United States. Transurethral resection of bladder tumor (TURBT) is a common urologic surgical procedure used to diagnose, stage, and treat bladder cancer. This article presents a patient who had multiple episodes of gross hematuria and was found to have multifocal bladder tumors. In this case, TURBT was performed to confirm the diagnosis of bladder cancer, remove all visible bladder tumors, and prevent further episodes of gross hematuria.
Approach to Marginal Ulceration Following RYGB Surgery: Laparoscopic Excision of the Marginal Ulcer and Retrocolic, Retrogastric Rerouting of the Roux Limb with Truncal Vagotomy and Hiatal Hernia Repair
Deborah D. Tsao, BS1; Janey Sue Pratt, MD2
1Stanford University School of Medicine
2Massachusetts General Hospital
Gastrogastric fistula is a rare complication following a Roux-en-Y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy.
Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. This article presents a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.
Elbow Arthroscopy (Cadaver)
Patrick Vavken, MD; Femke Claessen, MD
Smith and Nephew Endoscopy Laboratory
Elbow arthroscopy is a technically demanding procedure but it is very useful to evaluate the entire elbow joint for pathology with minimal surgical exposure and faster recovery than a traditional arthrotomy. The neurovascular structures of the elbow joint are in close proximity to the joint, thus there is a risk of injury to these structures, so care must be taken to fully understand elbow anatomy and to be prepared for aberrations. Elbow arthroscopy can be used diagnostically, as in this video article, or to surgically treat a variety of conditions including ligamentous tears, loose bodies, capsular stiffness, osteochondritis dissecans of the elbow, osteophyte debridement, and lateral epicondylitis. A patient with a previous ulnar nerve transposition is a relative contraindication to elbow arthroscopy, as there is a high risk of injury to the ulnar nerve during portal placement.
Thyroidectomy (Cadaver)
Kristen L. Zayan, BS1; Adam Honeybrook, MBBS2; C. Scott Brown, MD2; Daniel J. Rocke MD, JD2
1University of Miami Miller School of Medicine
2Duke University Medical Center
Thyroidectomy may be performed for various pathologies, consisting of either thyroid lobectomy or total gland removal. Both benign and malignant disease processes necessitate surgical intervention. Thyroid nodules, compressive thyroid goiter, or persistent thyrotoxicosis represent some of the benign indications. Malignant conditions affecting the thyroid include papillary, follicular, medullary, and anaplastic carcinomas. In the present case, a thyroidectomy via standard cervical incision is performed on a cadaver with overlying animations to emphasize the key anatomy. The discussion is in relation to a patient with obstructive goiter presenting with worsening wheezing, cough, and dysphagia, with the ultimate goal of relieving the compressive symptoms through the removal of the gland.
Bilateral Indwelling Pleural Catheter Placement for Advanced Non-small Cell Lung Cancer with Recurrent Pleural Effusion
Kathleen M. Twomey, MD; Yu Maw Htwe, MD
Penn State Health Milton S. Hershey Medical Center
Pleural effusions are frequently observed in a variety of conditions. Reasons for intervention include obtaining an underlying diagnosis as to the cause and providing symptom relief. One of the most frequent causes of a recurrent pleural effusion is malignancy, which will typically continue to accumulate for as long as the cancer is progressing. When patients have a rapidly recurring effusion, requiring frequent intervention by way of thoracentesis or chest tube, other options for management are considered. An indwelling pleural catheter (IPC) can be offered to a patient to help drain the effusion on a regular basis, without requiring repeat thoracentesis. The goal of the drain placement is to provide symptom relief, and it is often in place for as long as the patient has an appreciable effusion that can be drained intermittently by vacuum canisters.
Tying Arthroscopic Knot for Glenoid Suture Anchor
Zachary S. Aman; Liam A. Peebles; Matthew T. Provencher, MD
Massachusetts General Hospital
As arthroscopic and minimally-invasive procedures have become increasingly more common over the past decade, a versatile understanding of several arthroscopic knot tying techniques is essential for reproducible and reliable repairs. While there are numerous descriptions of unique arthroscopic knots, selection and correct implementation is critical for adequate soft tissue fixation and successful patient outcomes. Specifically, the Roeder knot, a type of locking sliding knot, with 3 alternating half hitches, has been described to provide the loop and knot security among other sliding knot techniques. Therefore, the Roeder knot has emerged as a preferred knot tying technique amongst orthopedic surgeons, especially in the setting of arthroscopic shoulder stabilization procedures. In this case, we describe the basic fundamentals of performing a Roeder knot with 3 alternating half hitches to anchor the labrum to the glenoid in the setting of an arthroscopic Bankart repair.
Lumpectomy and Sentinel Lymph Node Biopsy Using Lumicell System for Intraoperative Detection of Residual Cancer
Barbara Smith, MD, PhD
Massachusetts General Hospital
This case presentation involved a female patient with breast cancer who underwent a lumpectomy and sentinel lymph node biopsy using the Lumicell system for intraoperative detection of residual cancer. The aim was to detect residual tumor cells during the initial operation and avoid subsequent surgeries. This video provides a thorough presentation of lumpectomy and sentinel lymph node biopsy utilizing the Lumicell system to detect any remaining cancer during surgery. The video covers the entire process, from preoperative preparation to the final step of skin closure.
Open Left Upper Lobectomy in an Adult Cystic Fibrosis Patient
Douglas O’Connell, MSc1; Christopher R. Morse, MD2
1Touro University College of Osteopathic Medicine
2Massachusetts General Hospital
Cystic Fibrosis (CF) is an autosomal recessive genetic disorder characterized by mutations in the cystic fibrosis transmembrane regulator gene. The pathophysiology is based on abnormal chloride secretion from columnar epithelial cells. As a result, patients with CF have symptoms related to their inability to hydrate secretions in the respiratory tract, pancreas, and intestine, among other organs. In the lung, thick, inspissated secretions give rise to chronic obstructive pulmonary disease characterized by severe pulmonary infections, culminating in respiratory failure. Subacute exacerbations of CF lung disease are treated with antibiotics and various forms of chest physiotherapy. When large areas of the lung develop abscesses or necrosis, surgical treatment is often indicated. Options include lobectomy as a temporizing measure and lung transplantation for end-stage CF lung disease.
This article presents an unusual case of a man with CF whose lung function had remained relatively good until adulthood. His left upper lobe became chronically infected and progressively non-functional. Because the patient’s overall lung function was moderately preserved, an open left upper lobectomy was performed to prevent recurrences of subacute infections and subsequent damage to the left lung.
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