Monthly Archives: December 2024

Print Release, Vascular Surgery

PUBLISHED: Thoracoabdominal Aortic Aneurysm Repair

Thoracoabdominal Aortic Aneurysm Repair
Andrew Del Re, MD1; Jahan Mohebali, MD, MPH2; Virendra I. Patel, MD, MPH2
1The Warren Alpert Medical School of Brown University
2Massachusetts General Hospital

Thoracoabdominal aortic aneurysms (TAAAs) are generally asymptomatic and are discovered incidentally on thoracic or abdominal imaging. When they are identified, management is often expectant, depending on the size of the aneurysm and its rate of growth. Surgery is indicated for larger aneurysms and those that expand rapidly so as to avoid the catastrophic rupture of the aneurysm.

This article presents the case of a 70-year-old female with a TAAA, whom had been followed with serial computed tomographic angiography scans. The decision to operate was made when the aneurysm began revealing growth in diameter. Her anatomy was not conducive to endovascular treatment; therefore, her aneurysm was repaired using a traditional open approach.

Basic Skills for the OR, General Surgery, Print Release

PUBLISHED: Nasogastric (NG) Tube Insertion

Nasogastric (NG) Tube Insertion
Deanna Rothman, MD
Massachusetts General Hospital

Nasogastric (NG) tube insertion is a crucial skill in medical practice that involves the placement of a flexible tube through the nasal passage into the stomach, serving multiple purposes in patient care. This video article aims to provide a detailed overview of NG tube insertion, including its indications, contraindications, necessary materials, and the step-by-step process of placement.

General Surgery, Pediatrics, Print Release, Urology

PUBLISHED: Cloacal Exstrophy Repair

Cloacal Exstrophy Repair
William Remley1; Howard Jen, MD2; Carl-Christian A. Jackson, MD2; Jeremy Wiygul, MD2
1Lake Erie College of Osteopathic Medicine
2Tufts Medical Center

Cloacal exstrophy is congenital malformation marked by an abdominal wall defect with open and exposed hindgut and bladder. It is the most severe birth defect within the exstrophy-epispadias complex, and when spinal defects are also present, it is called the OEIS (omphalocele, exstrophy, imperforate anus, and spinal defect) complex. Cloacal exstrophy is rare, occurring in 1/200,000–400,000 births, but it can be diagnosed on prenatal ultrasound. The defect results in two exstrophied hemibladders separated by an exposed cecal plate, with the distal hindgut being foreshortened and blind-ending, resulting in an imperforate anus. There is diastasis of the pubic symphysis, and the genitalia are separated. In males, the phallus is usually split in half, flattened and shortened, with the inner surface of the urethra exposed. In females, the clitoris is split, the labia are widely separated, and there may be two vaginal openings. Cloacal exstrophy is also highly associated with other birth defects, especially spina bifida, which coexist in up to 75% of cases. Multidisciplinary care followed by surgical management should begin immediately following the baby’s delivery.

Surgical goals in the neonatal period include closure of the meningocele and repair of the exstrophy and omphalocele, resulting in approximation of the bladder halves and repair of the hindgut defect with colostomy creation. Closure of the bladder, with positioning within the pelvis, can either occur at the initial operation or be staged to occur after a period of monitored growth, and is best performed with pelvic osteotomies to protect the closure from tension. Subsequent surgeries over several years will address genital reconstruction and colonic pull-through for fecal continence, if the patient is a candidate. Here, we present a patient diagnosed with OEIS complex by prenatal ultrasound, with a postnatal exam confirming the diagnosis and demonstrating a closed (covered) myelomeningocele. The cloacal exstrophy and omphalocele were repaired in one stage, with primary closure of the involved bowel and the bladder, facilitated by pelvic osteotomies.

General Surgery, Global Surgery, Pediatrics, Print Release

PUBLISHED: Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus

Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus
Jacob Blank1; Paulo Castillo, MD2; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2World Surgical Foundation
3Philippine Children’s Medical Center

Imperforate anus is a birth defect in which the anal opening is absent. This condition develops during the fifth to seventh weeks of pregnancy and the cause is unknown. It affects about one in every 5,000 newborns and is noted to be more common among boys than girls. Imperforate anus is usually present with other birth defects such as vertebral defects, cardiac problems, tracheoesophageal fistula, renal anomalies, and limb abnormalities, collectively known as the VACTERL association. The diagnosis is made by performing a physical exam after birth. An x-ray of the abdomen and abdominal ultrasound can help reveal the extent of the abnormalities.

Treatment is surgical creation of an opening or new anus to allow stool to pass. The type of surgery differs and depends on whether the anus ends high or low in the pelvis. In the case of a low type, an anal opening is made in a single operation, and the rectum is pulled down to the anus. For high type, surgical correction is performed in three stages. The first procedure is bringing the intestine out of the abdomen creating a stoma; the second procedure is pulling the rectum down to the anus where a new anal opening is created; and the third procedure is closure of the intestinal stoma. Here, we present a case of a 9-month-old male who was born with a high-type imperforate anus. A posterior sagittal anorectoplasty (PSARP) was done as the second of three stages of treatment. The first was an emergency sigmoid colostomy, and the third will be to close the colostomy in about 6 to 8 weeks following the PSARP.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Intramedullary Nail for Open Tibial Fracture

Intramedullary Nail for Open Tibial Fracture
Caleb P. Gottlich, MD, MS1; Michael J. Weaver, MD2
1Department of Orthopedic Surgery, Texas Tech University Health Science Center
2Brigham and Women’s Hospital

This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.

General Surgery, Print Release

PUBLISHED: Robotic Roux-en-Y Gastric Bypass (RYGB) for Treatment of Morbid Obesity

Robotic Roux-en-Y Gastric Bypass (RYGB) for Treatment of Morbid Obesity
Hany M. Takla, MD, FACS, FASMBS, DABS-FPMBS
Wentworth-Douglass Hospital

Robotic surgery as an approach for Bariatric surgery has been a subject of debate for at least two decades since the platform passed FDA approval. One could argue that the exponential growth of robotics in surgery could end such a debate. The robotic platform offers several advantages that are always advertised, but in the morbidly obese population it offers an added advantage. It is arguable that with the advanced ergonomics, superior visual tools, and wristed instruments the robotic platform is superior in its offerings to the surgeon and enables a wider variety of surgeons with variable skill set to adopt minimally-invasive surgery (MIS), especially in bariatrics. The gastric bypass is a technically demanding operation with a variety of steps that require superior technical skills and can be challenging for trainees and young surgeons.

General Surgery, Print Release

PUBLISHED: Minimally Invasive Ivor Lewis Esophagectomy

Minimally Invasive Ivor Lewis Esophagectomy
Christopher Morse, MD
Massachusetts General Hospital

Esophageal cancer is a growing problem in the United States. Surgical resection, often in combination with chemoradiotherapy, provides the only approach to offer a cure for these patients. Traditional open approaches are burdened by high levels of morbidity and mortality. Minimally invasive esophagectomy (MIE) has been proposed as an alternative approach. Although MIE is complex and perhaps more time-consuming, perioperative results are encouraging and generally trend toward fewer pulmonary complications, lower blood loss, shorter ICU stays, and shorter overall hospitalization durations.

General Surgery, Print Release

PUBLISHED: Laparoscopic Gastric Wedge Resection for a GIST

Laparoscopic Gastric Wedge Resection for a GIST
Vahagn G. Hambardzumyan, MD1; Martin Goodman, MD2
1Yerevan State Medical University, Heratsi Hospital Complex
2Tufts University School of Medicine

The stomach is involved in multiple common ailments, including gastroesophageal reflux disease, gastric ulcers, and cancer, the latter of which can take many forms. Originally, GISTs arise from the connective tissue, or stroma, of the stomach, rather than the lining, from which the more common and more deadly gastric adenocarcinoma finds its origin. However, over time, study revealed that GIST arises from a very specific cell, called the interstitial cells of Cajal, that are responsible for the timing of contraction in the stomach and small intestine. GIST masses generally behave more indolently than gastric adenocarcinoma, with distant or lymph node metastases a rare feature, although involvement of the liver and peritoneum has been described. Due to this indolent nature, certain masses, once they have been identified as GIST through endoscopic biopsy, are candidates for surveillance. However, larger masses (as identified through evidence of necrosis on imaging) and rapidly growing masses are treated primarily with surgical resection. While in the past surgical resection would have involved a large abdominal incision and a lengthy postoperative recovery, laparoscopic techniques have allowed gastric resection to become a short procedure necessitating only an overnight stay.

General Surgery, Otolaryngology, Print Release

PUBLISHED: Thyroid Biopsy: Fine-Needle Aspiration for Multinodular Goiter

Thyroid Biopsy: Fine-Needle Aspiration for Multinodular Goiter
Ayse N. Sahin-Efe, MD; Michael Misialek, MD
Mass General Brigham, Newton-Wellesley Hospital

Thyroid nodules are common with a higher prevalence in women and the older population. They can be found in more than 50% of the older population. Malignancy risk is reported to be 7–15% depending on age, sex, radiation exposure history, and family history. Thyroid nodules can be detected either by palpation or incidentally by imaging done for irrelevant purposes. About 16% of chest CT scans show an incidental thyroid nodule. Subsequent ultrasound scans would evaluate the nodule size and characteristics. If the nodules meet the biopsy criteria based on TIRADS (Thyroid Imaging Reporting and Data Systems) criteria, referral for fine-needle aspiration biopsy (FNA) is necessary. This video delivers a thorough demonstration of the correct technique for ultrasound-guided thyroid FNA with rapid on-site cytology evaluation (ROSE).

Orthopedics, Pediatrics, Print Release

PUBLISHED: Pelvic Osteotomies for Cloacal Exstrophy

Pelvic Osteotomies for Cloacal Exstrophy
Jeffrey Gray1; Purushottam Gholve, MD, MBMS, MRCS2
1Sidney Kimmel Medical College, Thomas Jefferson University
2Tufts Medical Center

Cloacal exstrophy is part of a wide-ranging spectrum of rare congenital abnormalities resulting from the same embryological defect. Conditions include bladder exstrophy, epispadias, cloacal exstrophy, omphalocele, and more. Mortality due to complications with cloacal exstrophy was historically significant as it is among the most severe of these abnormalities. However, advancements in reconstructive surgery have improved the survival of patients. Pelvic osteotomy is typically indicated in cloacal exstrophy as it normally presents with widely separated pubic bones that require approximation as part of abdominal wall closure.