All posts by Chris Boisvert

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.

Anesthesiology, Print Release

PUBLISHED: Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache

Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache
Fatine Karkri, MD; Lauren Blake, MD; Brendan Carvalho, MBBCh, FRCA, MDCH, FASA
Stanford University School of Medicine

This video demonstrates a stepwise technique for performing an autologous epidural blood patch (EBP) to treat post-dural puncture headache (PDPH). The video covers identification of the target interspace, skin cleaning, local anesthesia infiltration, epidural needle placement using loss-of-resistance technique, aseptic collection of autologous blood, controlled injection into the epidural space, and immediate assessment of EBP effect. Indications, contraindications, expected immediate responses, and troubleshooting (including repeat EBP and alternative interventions) are discussed. The technique shown aims to maximize efficacy and enhance safety, and is applicable to PDPH after dural puncture from spinal anesthesia or inadvertent dural puncture during epidural placement.

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration

Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration
Marc Mankarious, MD1; Benjamin S. C. Fung, MD, FRCSC2; Joshua S. Winder, MD1
1Penn State Health Milton S. Hershey Medical Center
2North York General Hospital, University of Toronto

Choledocholithiasis complicates cholecystectomy in 10–15% of patients. In individuals with prior Roux-en-Y gastric bypass (RYGB), altered foregut anatomy renders traditional endoscopic retrograde cholangiopancreatography (ERCP) technically challenging or unsuccessful. This report details the use of robotic-assisted transcystic endoscopic common bile duct exploration (TCBDE) in a patient with RYGB and choledocholithiasis. For patients with surgically altered anatomy and urgent need for stone clearance, robotic TCBDE represents a safe, cost-effective, single-stage alternative to two-stage approaches, effectively bypassing the anatomical limitations imposed by RYGB.

Print Release, Surgical Technology

PUBLISHED: How to Drape a C-Arm

How to Drape a C-Arm
Cindy Fletcher, M.Ed., CST
North Shore Community College, Danvers, MA

When intraoperative imaging is needed, a mobile x-ray machine must be used by a radiologic technologist (RT) to take the image. A C-arm portable imaging machine, so called because its shape resembles the letter “C”, is widely used in contemporary surgical and interventional procedures for this purpose, and its proper draping is essential for maintaining sterile field integrity. This educational video demonstrates how to receive a C-arm drape onto the sterile field, how to prepare it for use, and how to place and secure it around the C-arm using sterile technique to protect patient safety. This video was filmed in an academic setting and is intended for perioperative trainees and staff.

Pediatrics, Print Release, Vascular Surgery

PUBLISHED: Pediatric Ultrasound-Guided Internal Jugular Central Venous Catheter (CVC) Insertion for Chemotherapy Delivery

Pediatric Ultrasound-Guided Internal Jugular Central Venous Catheter (CVC) Insertion for Chemotherapy Delivery
Yuki Noguchi, MD, PhD; Kohga Masuda, MD, PhD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

Central venous catheterization is a commonly performed procedure in pediatric surgery, requiring both appropriate device selection and meticulous technique to ensure long-term function and minimal complications. This article reports the technical considerations of tunneled central venous catheter placement in a pediatric patient with neuroblastoma.

A two-year and four-month-old boy with neuroblastoma required central venous access for chemotherapy. Preoperative evaluation confirmed patency of the right internal jugular vein and other central veins. A cuffed tunneled external catheter was selected, as it allows continuous access without repeated needle puncture and is suitable for multi-lumen use, including drug administration and blood sampling. Although routine blood sampling via central venous catheters is not generally recommended, our experience suggests that the associated risks are infrequent and clinically acceptable.

The catheter was inserted via the right internal jugular vein. The anterior chest wall exit site was determined using anatomical landmarks, specifically the triangle formed by the sternal notch, right acromion, and right nipple, with the entry point positioned near its center. Key technical considerations included creation of a broad, curved subcutaneous tunnel to prevent catheter kinking, secure fixation using a cuff with additional circumferential suturing to reduce early dislodgement, and accurate tip positioning at the junction of the superior vena cava and right atrium. In practice, the optimal tip location was estimated as approximately 1–2 vertebral body units below the carina. Careful hemostasis and postoperative compression were performed to minimize hematoma formation.

General Surgery, Pediatrics, Print Release

PUBLISHED: Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male
Yuki Noguchi, MD, PhD; Kohga Masuda, MD, PhD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

This report describes the surgical management of a one-year eight-month-old boy with concurrent right inguinal and umbilical hernias, highlighting both clinical rationale and operative technique. Pediatric inguinal hernias are typically indirect and rarely resolve spontaneously, carrying a persistent risk of incarceration that necessitates surgical repair once diagnosed.

Ultrasonography confirmed a right indirect inguinal hernia with reducible protrusion of the small intestine through a patent processus vaginalis. Although the umbilical hernia showed partial improvement with external compression, the inguinal hernia was unlikely to resolve spontaneously. Therefore, laparoscopic percutaneous extraperitoneal closure (LPEC) was planned, with simultaneous umbilical hernia repair.

LPEC enables high ligation of the hernia sac with minimal dissection and excellent visualization. In male patients, careful technique is required to avoid injury to the spermatic vessels and vas deferens. Tip rotation should be avoided; instead, the needle tip is advanced perpendicularly across these structures at the shortest possible distance to minimize dissection. Gentle manipulation facilitates safe passage, and confirmation that critical structures are not entrapped within the suture loop is essential before ligation. Caudal traction of the testis may further reduce the risk of iatrogenic cryptorchidism.

Print Release, Surgical Technology

PUBLISHED: Incorrect Number of Sponges in the Initial Count

Incorrect Number of Sponges in the Initial Count
Cindy Fletcher, M.Ed., CST
North Shore Community College, Danvers, MA

An incorrect surgical sponge count must be managed immediately in order to minimize the risk of harm to the patient. This educational video explains the appropriate actions to take when an incorrect sponge count is identified during the initial sponge count.

Announcement, JoMI in Surgical Education

OpenEvidence and Journal of Medical Insight (JOMI) Partner to Bring Peer-Reviewed Surgical Videos to Clinicians

JOMI is proud to announce a new partnership with OpenEvidence to bring peer-reviewed surgical videos to clinicians. Learn more and be sure to visit OpenEvidence to see clinical surgical questions answered with both written evidence and peer-reviewed JOMI videos from real surgeries.