All posts by Chris Boisvert

PUBLISHED: Transperitoneal Laparoscopic Right Adrenalectomy for Cortical Adenoma

Transperitoneal Laparoscopic Right Adrenalectomy for Cortical Adenoma
Sonia Cohen, MD, PhD; Richard Hodin, MD
Massachusetts General Hospital

Primary hyperaldosteronism, or Conn’s syndrome, is a disease in which one or both adrenal glands produce excess amounts of aldosterone, leading to hypertension and hypokalemia. High blood pressure may cause headaches or blurred vision. Low potassium may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis.

Primary hyperaldosteronism is diagnosed by measuring serum levels of aldosterone, renin, and potassium. Patients classically have high aldosterone levels, suppressed renin levels, and low potassium levels. Once the diagnosis is established, the localization of the source is performed using imaging studies. Adrenal vein sampling is also performed to determine more precisely and directly the side that is producing excess aldosterone.

Primary hyperaldosteronism caused by an adrenal gland tumor is treated with adrenalectomy. This is the case of a 58-year-old female with hypokalemia and long-standing hypertension refractory to medical treatment. Her blood tests showed high aldosterone levels and low renin levels, confirming the diagnosis of hyperaldosteronism. On CT scan, an adrenal nodule was noted on both sides. Adrenal vein sampling identified the right adrenal nodule as the cause. Laparoscopic access was gained, the adrenal gland was dissected and exposed, the adrenal vein ligated, and the adrenal gland was removed.

PUBLISHED: Laparoscopic Nissen Fundoplication

Laparoscopic Nissen Fundoplication
Ciro Andolfi, MD¹; Marco Fisichella, MD, MBA, FACS²
¹University of Chicago Pritzker School of Medicine
²VA Boston Healthcare System

This is the case of a 63-year-old man with a long-standing history of gastroesophageal reflux disease, refractory to medical management with high-dose proton pump inhibitors and H2-blockers. The preoperative workup consisted of: 1) an upper endoscopy, which was normal; 2) a barium swallow, which showed a normal anatomy (no hiatal hernia or diverticula); and 3) esophageal function tests, including high-resolution esophageal manometry, which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of gastroesophageal reflux disease.

Considering the amount of pathologic reflux, and the normal anatomy and esophageal peristalsis, it was decided to proceed with a laparoscopic Nissen (360°/total) fundoplication. The operation went well and lasted less than 90 minutes. The patient was discharged the following morning after resuming a light diet, and recovered quickly. With this surgical approach, complete control of reflux was achieved, and the patient was able to discontinue his treatment with proton pump inhibitors.

PUBLISHED: Arthrodesis of the Distal Interphalangeal (DIP) Joint of the Right Ring Finger for Arthritis

Arthrodesis of the Distal Interphalangeal (DIP) Joint of the Right Ring Finger for Arthritis
Lasya P. Rangavajjula, BS1Amir R. Kachooei, MD, PhD2Asif M. Ilyas, MD, MBA, FACS1,2
1Sidney Kimmel Medical College at Thomas Jefferson University
2Rothman Institute at Thomas Jefferson University

Osteoarthritis commonly impacts the finger distal interphalangeal (DIP) joints. The prevalence of DIP joint arthritis is high, with more than 60% of individuals older than 60 having DIP joint arthritis.

Operative treatment for arthritis of the DIP joint is indicated for pain, deformity, dysfunction, and instability in patients who are recalcitrant to conservative measures. Arthrodesis, or the fusion, of the DIP joint is a widely accepted surgical treatment for DIP joint arthritis.

Several surgical techniques have been historically described, with headless compression screw (HCS) fixation being a particularly common technique because of its advantages, including reliable compression, rigid fixation, lack of prominence, and no need for removal. This video demonstrates arthrodesis using HCS for arthritis in the right ring finger DIP joint.

PUBLISHED: Laser Stapedotomy for Otosclerosis

Laser Stapedotomy for Otosclerosis
C. Scott Brown, MD; Calhoun D. Cunningham III, MD
Duke University Medical Center

Otosclerosis can lead to progressive conductive hearing loss, significantly affecting quality of life. For patients who choose surgery, the tympanic membrane is elevated, and the middle ear space is explored. If the surgeon confirms that the stapes is fixed in the oval window, either a stapedotomy or stapedectomy can be performed.

In the stapedotomy, the surgeon removes the stapes superstructure, creates a fenestration in the footplate, and places a prosthesis from the incus through the fenestration into the vestibule. In this instance, the patient was able to regain nearly all of the hearing that had been lost as a result of stapes fixation.

PUBLISHED: Triceps Repair for Acute Triceps Tendon Rupture

Triceps Repair for Acute Triceps Tendon Rupture
Gregory Schneider, BS¹; Asif M. Ilyas, MD, MBA, FACS¹’²
¹Sidney Kimmel Medical College at Thomas Jefferson University
²Rothman Institute at Thomas Jefferson University

The patient in this case suffered an acute triceps tendon rupture and opted for surgical repair to restore function. His physical exam findings of tenderness at the olecranon and weakness against resistance during elbow extension, combined with plain film imaging revealing a positive fleck sign representing an avulsion the triceps tendon off of the olecranon, gave the diagnosis of acute triceps tendon rupture.

The patient underwent surgical repair under general anesthesia in lateral decubitus position with a sterile tourniquet applied for hemostasis. The treatment goal was re-approximating the distal triceps tendon to the olecranon in order to restore elbow extension strength and upper extremity function. The surgical technique demonstrated in this video is the suture bridge technique.

PUBLISHED: Primary Low Transverse C-Section

Primary Low Transverse C-Section
Taylor P. Stewart, MD; Juliana B. Taney, MD
Massachusetts General Hospital

Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals.

In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.

PUBLISHED: Vaginal Hysterectomy, Uterosacral Ligament Suspension, Anterior Repair, and Perineorrhaphy

Vaginal Hysterectomy, Uterosacral Ligament Suspension, Anterior Repair, and Perineorrhaphy
Emily C. Von Bargen, DO; Patricia L. Hudson, MD; Lori R. Berkowitz, MD
Massachusetts General Hospital

This is the case of a 74-year-old female who presented with bothersome stage III pelvic organ prolapse. She desired definitive surgical management for her prolapse and opted for total vaginal hysterectomy, uterosacral ligament suspension, and anterior/posterior vaginal repairs. She had urodynamic testing before the surgery that showed no stress urinary incontinence, no detrusor overactivity, and normal bladder capacity. The surgery was uncomplicated. She was discharged home the same day as surgery, and her postoperative recovery was unremarkable.

PUBLISHED: Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis for Crohn’s Colitis and Multifocal Dysplasia

Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis for Crohn’s Colitis and Multifocal Dysplasia
Winta T. Mehtsun, MD, MPH; Richard Hodin, MD
Massachusetts General Hospital

Crohn’s disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract, with a propensity for the distal ileum. It causes transmural inflammation of the intestines, where it can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition.

There is no cure for Crohn’s disease; the goal of treatment is to palliate symptoms, accomplished with both medical and surgical options. Surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications.

Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn’s colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing; therefore, a total abdominal colectomy with ileorectal anastomosis was performed.

PUBLISHED: Endolymphatic Sac Decompression

Endolymphatic Sac Decompression
C. Scott Brown, MD; Calhoun D. Cunningham III, MD
Duke University Medical Center

Endolymphatic sac (ELS) decompression can be performed for patients with Meniere’s disease who have failed conservative treatment such as dietary changes and medical therapy. The full pathophysiological mechanisms that result in Meniere’s disease are not entirely understood. The variation in techniques for performing ELS decompression support this; there is no concrete data to justify one approach over another. Regardless, in the correct patient, ELS decompression can significantly alleviate the patient’s symptoms. To do so, a mastoidectomy is performed to expose the bony labyrinth as well as the bone overlying the sigmoid sinus. Decompression of the sac can be accomplished by removing overlying bone, incising the dura, or stenting the dura open.

PUBLISHED: Transmastoid Repair of Superior Semicircular Canal Dehiscence

Transmastoid Repair of Superior Semicircular Canal Dehiscence
C. Scott Brown, MD; David M. Kaylie, MD, MS
Duke University Medical Center

Superior semicircular canal dehiscence (SSCD) is associated with conductive hearing loss, autophony, and pressure/sound induced vertigo. Patients who are symptomatic may elect to undergo surgical intervention.

Here, Dr. Kaylie demonstrates the transmastoid approach to repairing SSCD. This approach affords the opportunity for an outpatient procedure to expose and plug the canal around the defect.