Monthly Archives: August 2026

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Femoral Hernia Repair

Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Femoral Hernia Repair
Katie A. Marrero, MD1; Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.)2
1Henderson Hospital, NV
2Penn State Health Milton S. Hershey Medical Center

Femoral hernias are an uncommon cause of groin pain but occur more frequently in women than men and are often overlooked during clinical evaluation and imaging review. Failure to recognize these “hidden” hernias may lead to persistent symptoms despite previous inguinal hernia repair.

A 43-year-old woman presented with chronic left groin pain despite prior open left inguinal hernia repair with mesh plug placement. Her medical history included cesarean section and abdominoplasty, with pain initially attributed to postoperative nerve injury. A CT scan obtained in 2023 was interpreted as negative for recurrent hernia; however, retrospective review demonstrated an obvious left femoral hernia adjacent to the previously placed mesh plug. She subsequently underwent treatment for May-Thurner syndrome with left common iliac vein stenting without improvement in symptoms. Clinical examination, office ultrasound, and re-evaluation of prior imaging confirmed the diagnosis of a symptomatic femoral hernia.

A robotic transabdominal preperitoneal (rTAPP) repair was performed. After establishing abdominal access and creating a generous preperitoneal flap, the myopectineal orifice was completely exposed. The previously placed mesh plug was identified medial to the inferior epigastric vessels and largely left undisturbed with only a small portion excised to facilitate flat placement of new mesh. The femoral hernia sac and incarcerated preperitoneal fat were reduced, the round ligament was divided, a large preperitoneal mesh was positioned to cover the femoral canal and all potential groin defects, and the peritoneal flap was closed.

This case demonstrates the importance of maintaining a high index of suspicion for occult femoral hernias in women with persistent groin pain, particularly following previous anterior inguinal hernia repair. Robotic TAPP repair provides excellent visualization of the entire myopectineal orifice and enables definitive treatment while preserving previously implanted mesh when appropriate.

Anesthesiology, Press Release

PUBLISHED: Ultrasound-Guided Rectus Sheath Block in a Pediatric Patient

Ultrasound-Guided Rectus Sheath Block in a Pediatric Patient
Jun Takeshita, MD, PhD
Osaka Women’s and Children’s Hospital

Rectus sheath block (RSB) is a regional anesthesia technique in which a local anesthetic is injected between the posterior aspect of the rectus abdominis muscle and the posterior rectus sheath to block the anterior cutaneous branches of the thoracoabdominal nerves. In pediatric patients, RSB is particularly useful for surgeries performed through umbilical or circumumbilical incisions, such as umbilical hernia repair, laparoscopic surgery with umbilical port placement, pyloromyotomy for hypertrophic pyloric stenosis, and surgery for duodenal atresia, intestinal malrotation, or ovarian cysts. Ultrasound guidance improves the precision and safety of the block by enabling direct visualization of the rectus abdominis muscle, posterior rectus sheath, and underlying peritoneum.

This video demonstrates ultrasound-guided bilateral RSB in a 27-day-old, 3.9-kg neonate undergoing circumumbilical pyloromyotomy for hypertrophic pyloric stenosis. The video highlights the key technical aspects of the procedure, including the identification of the posterior rectus sheath, continuous visualization of the needle tip, appropriate lateral placement of the local anesthetic within the posterior rectus sheath plane, and measures to avoid peritoneal puncture and vascular injury. Particular attention is also given to the conservative dosing of ropivacaine in neonates to minimize the risk of local anesthetic systemic toxicity.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures

Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures
Donald L. Fejfar, MD1; Nikhil Gattu, MD1; Ridwan M. Saeed, MD2; Hizkyas Kassaye, MD3; Bitiel Banda, MD4; Pierre M. Woolley, MD5; Kiran J. Agarwal-Harding, MD, MPH1,6
1Harvard Global Orthopaedics Collaborative, Boston, MA
2Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
3Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
4Mzuzu Central Hospital, Mzuzu, Malawi
5Hôpital Universitaire La Paix, Port au Prince, Haiti
6Beth Israel Deaconess Medical Center, Boston, MA

Open tibial shaft fractures represent a significant clinical challenge, particularly when presentation is delayed and wounds have become infected. This case demonstrates the surgical management of bilateral neglected open tibial shaft fractures in a young adult male who presented three weeks after initial injury from a motor vehicle collision in rural Malawi. He also suffered a bimalleolar fracture of the left ankle. The patient had grossly contaminated wounds with exposed bone and signs of infection bilaterally. The key procedural steps included aggressive irrigation and debridement of necrotic and infected tissue, skeletal stabilization with external fixation, local antibiotic therapy with gentamicin-impregnated collagen pellets, and soft tissue coverage with primary wound closure and a rotational subcutaneous flap on the left leg. External fixation is an essential treatment modality for open fractures with severe soft tissue injury when internal fracture fixation is not possible, especially in delayed cases with early signs of infection. This allows for staged management, repeated wound access, and preservation of blood supply while providing adequate stability for bone healing and soft tissue rest. This technique is particularly valuable in resource-limited settings where staged reconstruction and damage control orthopaedics are essential. The bilateral nature of these injuries, prolonged contamination period, immunocompromised status, and need for complex soft tissue reconstruction make this case unique and highlight the principles of managing neglected open fractures in challenging clinical circumstances.

Anesthesiology, Print Release

PUBLISHED: Neuraxial Ultrasound and Combined Spinal-Epidural (CSE) Anesthesia for Cesarean Delivery

Neuraxial Ultrasound and Combined Spinal-Epidural (CSE) Anesthesia for Cesarean Delivery
Lauren Blake, MD; Fatine Karkri, MD; Brendan Carvalho, MBBCh, FRCA, MDCH, FASA
Stanford University School of Medicine

Neuraxial anesthesia is the gold standard approach for cesarean delivery, offering surgical anesthesia while optimizing maternal and fetal outcomes. This video provides a stepwise demonstration of a combined spinal-epidural (CSE) technique for cesarean delivery. This technique covers patient positioning, identification of the appropriate interspace, sterile preparation, infiltration of local anesthetic, and spinal/epidural needle placement. For single-shot spinal (SSS), a spinal needle is advanced into the subarachnoid space, cerebrospinal fluid return is confirmed with aspiration, and intrathecal medication is administered. For CSE, an epidural needle is advanced into the epidural space using a loss-of-resistance technique, followed by spinal needle insertion through the epidural needle for intrathecal medication administration. This needle-through-needle technique concludes with epidural catheter insertion and securement. Indications and medication dosing for cesarean delivery are discussed for each technique.