All posts by Chris Boisvert

PUBLISHED: Blepharoplasty for Bilateral Upper Eyelids

Blepharoplasty for Bilateral Upper Eyelids
Lilit Arzumanian, MD1Alexander Martin, OD2John Lee, MD2
1Vardanants Center for Innovative Medicine
2Boston Vision

Upper blepharoplasty is one of the most commonly performed oculoplastic procedures. It is aimed at correcting the involutional changes of the upper eyelids, characterized by loose, excess eyelid skin (dermatochalasis) and preaponeurotic fat herniation (steatoblepharon) as well as some cases of ptosis. These conditions could result in functional symptoms, such as reduced visual fields, as well as cosmetic concerns and perceived body dysmorphia.

In this case, the patient underwent upper blepharoplasty for cosmetic improvement and to remove xanthomatous lesions. This article discusses and demonstrates the preoperative assessment of the patient, the preparation, the surgical technique, and possible complications.

PUBLISHED: Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy
Ozanan R. Meireles, MD1Julia Saraidaridis, MD1Amir Guindi2
1Massachusetts General Hospital
2Ross University School of Medicine

The goal of obesity treatment is to reach and maintain a healthy weight. The primary treatment consists of diet and physical exercise; however, maintaining weight loss is difficult and requires discipline. Medications such as orlistat, lorcaserin, and liraglutide may be considered as adjuncts to lifestyle modification.

One of the most effective treatments for obesity is bariatric surgery. There are several bariatric surgery procedures, including laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Sleeve gastrectomy is the most commonly performed bariatric surgery worldwide. It is performed by removing 75% of the stomach, leaving a tube-shaped stomach with limited capacity to accommodate food. This is the case of an obese patient who undergoes laparoscopic sleeve gastrectomy.

PUBLISHED: Robotic-Assisted Laparoscopic (rTAPP) Umbilical Hernia Repair with Intra-abdominal Preperitoneal Underlay Mesh (IPUM)

Robotic-Assisted Laparoscopic (rTAPP) Umbilical Hernia Repair with Intra-abdominal Preperitoneal Underlay Mesh (IPUM)
Chloe A. Warehall, MD1Divyansh Agarwal, MD, PhD1Charu Paranjape, MD, FACS1,2
1Massachusetts General Hospital
2Newton-Wellesley Hospital

An umbilical hernia occurs due to weakened umbilical fascia or at the site where the involuted umbilical vessels exited. Depending on the hernia contents—preperitoneal fat, omentum, or small intestine—symptoms may include a new bulge at the umbilical site, abdominal pain, tenderness to palpation, color changes to the surrounding skin, as well as obstructive symptoms such as nausea, emesis, and constipation. Given that umbilical hernias tend to have narrow necks compared to size of the sac, incarceration and strangulation are relatively common. Elective repair of symptomatic umbilical hernias is done to minimize these risks.

Here we present the case of an 81-year-old male with a recurrent umbilical hernia who first presented secondary to obstructive symptoms caused by an incarcerated umbilical hernia. After reduction was successful, he underwent an elective robotic transabdominal (rTAPP) umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (IPUM). This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

PUBLISHED: Foley Catheter Placement: Indications, Maintenance, Complications, and Demonstration on a Preoperative Male Patient

Foley Catheter Placement: Indications, Maintenance, Complications, and Demonstration on a Preoperative Male Patient
Danielle Shibley, BSN, RN
VCU Medical Center

Foley catheterization is a frequently-employed medical procedure to treat urinary retention, aid in bladder drainage/decompression, and facilitate measurement of urine output. This article provides an overview of the indications for Foley catheterization, the steps involved in its insertion, proper care guidelines, and potential complications associated with its use. It is of utmost importance for healthcare practitioners to be comfortable with catheterization procedures to guarantee the comfort, safety, and general welfare of their patients.

PUBLISHED: Exploratory Laparotomy and Splenectomy for Ruptured Spleen Following Blunt Force Trauma

Exploratory Laparotomy and Splenectomy for Ruptured Spleen Following Blunt Force Trauma
Sebastian K. Chung, MD1Ashley Suah, MD2Daven Patel, MD, MPH2Nadim Michael Hafez, MD2Brian Williams, MD2
1University of Massachusetts Medical School
2UChicago Medicine

The spleen is highly vascular, is the largest secondary lymphoid organ, and is the most commonly injured organ in the setting of blunt abdominal trauma. Patients may present asymptomatically or with abdominal pain, nausea and vomiting, or signs of hemodynamic instability. Although many splenic injuries caused by blunt abdominal trauma may be managed conservatively, free intra-abdominal fluid with hemodynamic instability warrant surgical management in the form of exploratory laparotomy and splenectomy.

This video report demonstrates the management of a patient who was assaulted, sustaining blunt abdominal trauma and a hemodynamically significant grade IV splenic laceration. An exploratory laparotomy and splenectomy were performed.

PUBLISHED: Basal Cell Carcinoma Excision from the Lower Lip with Versatile Keystone Flap for Vascularized Skin Replacement

Basal Cell Carcinoma Excision from the Lower Lip with Versatile Keystone Flap for Vascularized Skin Replacement
Geoffrey G. Hallock, MD
Sacred Heart Campus, St. Luke’s Hospital

Maintenance of intact skin throughout the body is essential to prevent dehydration, to act as a barrier to infection, to allow unrestricted movement, and to provide a normal appearance. A flap is a piece of body tissue, usually skin and fat, that always has its own blood supply. Therefore, a flap can be moved anywhere it can reach without worrying about the circulation present at the place that needs it, which is called the recipient site. When compared with all other possible choices, a flap best meets all the requirements for any area needing skin replacement.

The keystone type flap as one such option is so named because its design has the shape of the keystone of a Roman arch. If taken from loose tissues adjacent to a defect, it can be simply cut and advanced for any necessary skin coverage. Direct closure of the donor site where this flap comes from is possible so that usually a quite good overall cosmetic result is also obtained. These virtues are shown as an overview in this video where a keystone flap is transferred after removal of a common basal cell skin cancer from the lower lip.

PUBLISHED: Open Reduction and Internal Fixation of a Diaphyseal Periprosthetic Humeral Fracture

Open Reduction and Internal Fixation of a Diaphyseal Periprosthetic Humeral Fracture
Ikechukwu C. Amakiri1Michael J. Weaver, MD2
1Geisel School of Medicine, Dartmouth College
2Brigham and Women’s Hospital

Periprosthetic humeral shaft fractures are increasing in incidence as shoulder replacements become more common. Surgical management of humeral shaft fractures can only be deemed appropriate when the degree of pain, the extent of disability, and the number of comorbid conditions are taken into consideration.

Among trauma surgeons there exists no preferred surgical approach to fractures of different segments of the humerus; however, the anterolateral approach to midshaft fractures is the most common although viable alternative approaches exist. In this case, we perform an open reduction and internal fixation of a diaphyseal periprosthetic humeral fracture with a posterior triceps sparing approach.

PUBLISHED: Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture

Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture
Sudhir B. Rao, MD1Mark N. Perlmutter, MS, MD, FICS, FAANOS2Arya S. Rao3Grant Darner4
1Big Rapids Orthopaedics
2Carolina Regional Orthopaedics
3Columbia University
4Duke University School of Medicine

In this video, the authors describe and demonstrate a surgical technique for the treatment of an unstable nonunion of a proximal phalangeal fracture of the thumb.

The video describes the surgical exposure, preparation of the nonunion site, harvesting of autogenous iliac corticocancellous bone graft, bone grafting of the defect, and stabilization with K-wire fixation.

PUBLISHED: Cochlear Implant

Cochlear Implant
C. Scott Brown, MDCalhoun D. Cunningham III, MD
Duke University Medical Center

For patients who present with bilateral severe-to-profound sensorineural hearing loss who have little-to-no benefit from conventional hearing aids, cochlear implants can restore hearing by directly stimulating the cochlear nerve.

This video demonstrates the placement of a cochlear implant. A standard mastoidectomy and facial recess approach is performed to visualize the round window niche and membrane. The round window membrane is opened, and the cochlear implant electrode is carefully inserted into the scala tympani. After several weeks, the patient returns for implant activation with a dedicated team of audiologists.

PUBLISHED: Open Cholecystectomy for Gallbladder Disease

Open Cholecystectomy for Gallbladder Disease
Jacob C. Mesiti1Yoko Young Sang, MD2Peter F. Rovito, MD2;
1Lake Erie College of Osteopathic Medicine
2World Surgical Foundation

Gallbladder diseases are a subset of a spectrum of pathologies of the biliary system and are a particularly common etiology of abdominal pain encountered in modern medicine. These pathologies most often share a similar underlying mechanism of disease: obstruction of a portion of the biliary tree by cholelithiasis, or gallstones.

Gallstones, for the most part, form initially in the gallbladder with the exception of primary common bile duct (CBD) stones that form primarily in the CBD. Risk factors include a wide variety of conditions both pathologic and physiologic, including hyperlipidemia, hemolysis, and pregnancy. The resulting obstruction creates a state of biliary stasis, eventually leading to inflammation, pain, and an increased risk of infection. The anatomical location of the obstruction contributes greatly to both the clinical presentation and the ultimate treatment of the disease.

A hallmark of the treatment of gallbladder disease, ranging from simple biliary colic to life-threatening emphysematous cholecystitis, is the cholecystectomy. In modernized countries, this procedure is almost invariably performed laparoscopically. However, in certain clinical scenarios, such as when a patient cannot tolerate the pneumoperitoneum associated with laparoscopic surgery or when the procedure takes place in a developing country with limited access to laparoscopic capabilities, an open approach is preferred.