All posts by Chris Boisvert

General Surgery, Print Release

PUBLISHED: Robotic Whipple Procedure for an Ampullary Intramucosal Carcinoma

Robotic Whipple Procedure for an Ampullary Intramucosal Carcinoma
Charles C. Vining, MD, FACS, FSSO; Rushin D. Brahmbhatt, MD, FACS; Lawrence M. Knab, MD, FACS, FSSO
Penn State Health Milton S. Hershey Medical Center

A 76-year-old man presented to the emergency department with fatigue and chest pain. Initial laboratory evaluation revealed significant anemia with a hemoglobin level of 7.4 g/dL. He was transfused one unit of packed red blood cells and discharged with plans for outpatient gastroenterology follow-up. Upper endoscopy performed shortly thereafter demonstrated a tubulovillous adenoma without high-grade dysplasia at the level of the ampulla. Subsequent cross-sectional imaging with CT of the abdomen and pelvis identified an area of mass-like thickening in the descending duodenum as well as two suspicious peripancreatic lymph nodes. Endoscopic ultrasound with biopsy confirmed the presence of a uT3N1 duodenal mass. Histopathologic analysis revealed at least intramucosal adenocarcinoma arising within an adenoma.

The case was reviewed at a multidisciplinary tumor board, where consensus recommendation was for surgical resection. The patient subsequently underwent diagnostic laparoscopy, laparoscopic liver biopsy, robotic pancreaticoduodenectomy (Whipple procedure), and falciform ligament flap. Pathologic examination of the resected specimen revealed an 8.2-cm, grade 2, moderately differentiated invasive adenocarcinoma of intestinal type, arising from a duodenal adenoma. The tumor demonstrated direct invasion into the pancreas, peripancreatic soft tissues, and periduodenal tissue. All surgical resection margins were negative for carcinoma. A total of 22 lymph nodes were examined, of which 6 were positive for metastatic adenocarcinoma, consistent with a final pathologic stage of pT3b pN2 duodenal adenocarcinoma.

This case highlights the diagnostic and therapeutic challenges associated with duodenal adenocarcinoma, a rare and often late-presenting malignancy. It further demonstrates the role of a multidisciplinary approach in guiding management, as well as the feasibility of a minimally invasive robotic pancreaticoduodenectomy in selected patients.

Print Release, Surgical Technology

PUBLISHED: Setup for an Exploratory Laparotomy with Possible Splenectomy (South College, Knoxville, TN)

Setup for an Exploratory Laparotomy with Possible Splenectomy (South College, Knoxville, TN)
Chris Blevins, BS, AAS-ST, CST, FAST
South College, Knoxville, TN

The combination of an exploratory laparotomy with a possible splenectomy demands a quick and efficient back table and Mayo stand setup. This video demonstrates an efficient setup that includes placement of surgical instruments, sponges, hemostatic agents, and vascular clamps. The demonstrated setup techniques shown here provide surgical technologists with useful strategies to prepare for complex trauma cases.

General Surgery, Print Release

PUBLISHED: Parathyroidectomy and Four-Gland Exploration for Hyperparathyroidism

Parathyroidectomy and Four-Gland Exploration for Hyperparathyroidism
Allison S. Letica-Kriegel, MD, MSc; Antonia E. Stephen, MD
Massachusetts General Hospital

Primary hyperparathyroidism is a common endocrinopathy. Surgery is the mainstay of treatment. Preoperative imaging is useful in localization of diseased glands and can allow for focal rather than four-gland exploration. Intraoperative adjuncts such as intraoperative parathyroid hormone (ioPTH) monitoring can be useful in select cases in determining the extent of parathyroid resection.

Print Release, Surgical Technology

PUBLISHED: Setup for a C-Section (Ivy Tech Community College, Indianapolis, IN)

Setup for a C-Section (Ivy Tech Community College, Indianapolis, IN)
Heather Seib, BA, AAS, CST
Ivy Tech Community College, Indianapolis, IN

A planned cesarean section (C-section) involves two patients, maternal and newborn, so the operating room (OR) should be prepared and arranged to provide for their safety, and to optimize efficiency for the surgical team. The three essential components for effective perioperative care include creation and maintenance of the sterile field, instrument organization, and accurate surgical counts. This video presents an example of how to set up the back table and Mayo stand for a C-section, including a demonstration of how to perform the initial surgical count.

Print Release, Urology

PUBLISHED: Ureteroscopy and Laser Lithotripsy for Ureteral and Renal Stones in a Patient with a Nephrostomy Tube

Ureteroscopy and Laser Lithotripsy for Ureteral and Renal Stones in a Patient with a Nephrostomy Tube
Zachary Tully, MD; Joseph Y. Clark, MD
Penn State Health Milton S. Hershey Medical Center

Ureteroscopy is a minimally invasive surgical procedure used for the diagnosis and treatment of ureteral and renal pathology, most often urolithiasis. The presence of a percutaneous nephrostomy tube, commonly placed for urgent decompression of an obstructed kidney, often in obstructing stone disease, introduces unique perioperative considerations. Indications for ureteroscopy in this setting involve persistent obstruction with failure of spontaneous stone passage when percutaneous nephrolithotomy is not indicated. Surgical treatment aims to remove obstructing calculi, restore antegrade urinary drainage, and prevent long-term complications such as decline of renal function. Ureteroscopy involves cystoscopic access, ureteroscopic stone fragmentation, and extraction. When coupled with antegrade access as provided by a nephrostomy tract, it enables combined antegrade and retrograde (“rendezvous”) approaches. This video presents a case of a patient with a left-sided distal ureteral stone, nonobstructing renal stones, and an indwelling nephrostomy tube who underwent definitive management with ureteroscopy and laser lithotripsy.

Print Release, Surgical Technology

PUBLISHED: Setup for an Open Incisional Hernia Repair (Ivy Tech Community College, Indianapolis, IN)

Setup for an Open Incisional Hernia Repair (Ivy Tech Community College, Indianapolis, IN)
Heather Seib, BA, AAS, CST
Ivy Tech Community College, Indianapolis, IN

Operating room preparation for an open incisional hernia repair requires careful planning to provide surgical efficiency and patient safety. This video serves as a learning resource for those, such as surgical technologists, who are responsible for setting up the OR before the start of a case. Topics covered include the arrangement of instrumentation, how to prepare for and complete an initial count before the surgery, and optimal placement of essential equipment and supplies. These back table setup methods enhance surgical workflow efficiency while maintaining sterility.

General Surgery, Print Release

PUBLISHED: Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube

Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube
Charles C. Vining, MD, FACS, FSSO; Mark Knab, MD, FACS, FSSO; Rushin D. Brahmbhatt, MD
Penn State Health Milton S. Hershey Medical Center

A 66-year-old man with chronic pancreatitis and prior exploratory laparotomy and appendectomy for perforated appendicitis presented with persistent right upper quadrant pain, nausea, and weight loss after placement of a percutaneous cholecystostomy (PC) tube for gallstone pancreatitis and chronic cholecystitis. Imaging confirmed gallbladder distension with equivocal wall thickening. He underwent robotic cholecystectomy with removal of the PC tube. The procedure was notable for extensive intra-abdominal adhesions requiring prolonged adhesiolysis. A critical view of safety was achieved, and the gallbladder was removed without complication. This case illustrates the technical considerations and challenges of delayed cholecystectomy following PC tube drainage.

Print Release, Surgical Technology

PUBLISHED: OR Setup for an Open Incisional Hernia Repair with Mesh (South College, Knoxville, TN)

OR Setup for an Open Incisional Hernia Repair with Mesh (South College, Knoxville, TN)
Shannon Morris, AS-ST, CST
South College, Knoxville, TN

Successful surgical treatment of incisional hernias after abdominal surgery depends in part on the creation and maintenance of the sterile field. Optimal arrangement of surgical instrumentation and organization of the sterile field are important elements that can impact surgical outcomes and patient safety. This educational video covers sterile field preparation, including back table and Mayo stand arrangement, preparation for the initial surgical count with a circulator, and mesh management. This setup shown here presents how to arrange forceps by type/usages, and establish specific zones for sharps. The initial surgical count includes all sponges, sharps, and instruments according to current surgical safety guidelines. The goal of this educational video is to demonstrate how surgical technologists create and maintain the sterile field and prepare for the initial surgical count to support efficient surgical operations and patient safety.

Print Release, Urology

PUBLISHED: Percutaneous Nephrostolithotomy for Treatment of Impacted Ureteropelvic Junction Calculus

Percutaneous Nephrostolithotomy for Treatment of Impacted Ureteropelvic Junction Calculus
Max S. Yudovich, MD; Joseph Y. Clark, MD
Penn State Health Milton S. Hershey Medical Center

Percutaneous nephrostolithotomy (PCNL) is a minimally invasive urologic procedure used to treat large kidney stones or stones which are not accessible from a retrograde approach. When untreated, these stones can cause chronic pain, infections, and over time, decreased renal function. The indications for PCNL include total renal stone burden greater than 20 mm, lower pole stone burden greater than 10 mm, or any stone burden which cannot be treated with ureteroscopy or extracorporeal shockwave lithotripsy, such as in the setting of a ureteral stricture or ureteropelvic junction obstruction.

During the procedure, the patient is typically positioned prone, and a needle is used to puncture the kidney through the flank. As in the case of our procedure, a pre-existing nephrostomy tube can also be used. After wire access to the kidney is obtained, the tract is dilated and an access sheath is placed to facilitate irrigation and insertion of instruments. Large stones can be removed through ultrasonic lithotripsy, pneumatic (ballistic) lithotripsy, laser lithotripsy (typically holmium:YAG or thulium lasers), and combination devices that integrate ultrasonic and pneumatic mechanisms. Smaller stones, such as in our case, can be extracted using graspers. In this video, we present a left-sided PCNL in which we remove a total of 2.1 cm of renal stone burden. Following stone removal, a ureteral stent and nephrostomy tube were placed to enable maximal drainage of the kidney. Postoperative CT showed complete clearance of stone burden.

Print Release, Surgical Technology

PUBLISHED: OR Setup for a Laparoscopic Cholecystectomy (South College, Knoxville, TN)

OR Setup for a Laparoscopic Cholecystectomy (South College, Knoxville, TN)
Madison Campbell, AS-Ed, AS-ST, CST
South College, Knoxville, TN

The laparoscopic approach is widely regarded as the preferred surgical method for gallbladder removal procedures. The operating room setup for laparoscopic cholecystectomy follows established protocols that provide patient safety through the use of aseptic technique and AORN guidelines for surgical counts. These procedures form the foundation for successful surgery and are covered in this article.