All posts by Chris Boisvert

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy

Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy
Hannah A. Bougleux Gomes, MD¹; Divyansh Agarwal, MD, PhD¹; Charu Paranjape¹’²
¹Massachusetts General Hospital/Brigham and Women’s Hospital
²Newton-Wellesley Hospital

A hiatal hernia occurs when part of an intra-abdominal organ, most commonly the stomach, migrates through the diaphragmatic crura. The condition can cause a range of uncomfortable symptoms, including heartburn, chest pain, and difficulty swallowing. While several individuals with a hiatal hernia can manage their symptoms with lifestyle changes and anti-reflux medications, some with refractory symptoms or complications secondary to the hernia require surgical treatment to repair the defect.

Here we present the case of a 60-year-old female with a paraoesophageal hiatal hernia and chronic gastrointestinal reflux disease (GERD) refractory to proton-pump inhibitors (PPI), dietary changes, and lifestyle modifications. She underwent an elective robotic hiatal hernia repair, fundoplication, and esophagogastroduodenoscopy (EGD) as a two-hour procedure with routine postprocedure recovery. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

Orthopedics, Print Release

PUBLISHED: Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair
Scott D. Martin, MD
Brigham and Women’s Hospital

Hip arthroscopy with femoral neck or acetabular osteoplasty with or without labral repair can be used for treatment of femoroacetabular impingement (FAI). Patients may present with insidious onset of hip pain and mechanical symptoms and pain worse with activity and sitting.

On physical exam hip flexion and internal rotation may be reduced and anterior impingement testing will produce groin pain in the majority of patients with FAI. Imaging may demonstrate lesions responsible for cam-type or pincer-type impingement, and MRI may demonstrate labral tear or cartilaginous lesions. Arthroscopic surgical treatment is indicated for patients who have failed conservative treatment.

General Surgery, Global Surgery, Print Release

PUBLISHED: Anal Fistulotomy

Anal Fistulotomy
M. Grant Liska, BS¹; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES²
¹University of Central Florida College of Medicine
²Philippine Children’s Medical Center

Fistula-in-ano is a chronic abnormal communication between the anal canal and, usually, the perianal skin. It can be described as a hollow tract that is lined with granulation tissue and connects a primary opening inside the anal canal to a secondary opening in the perianal skin. It usually originates from the anal glands and is frequently the result of a previous anal abscess. Anal fistulae present with pain, swelling, pruritus, skin irritation, and purulent or bloody drainage. Most anal fistulae are diagnosed based on clinical findings, but complex and deep anal fistulae usually require imaging studies such as CT scan or MRI to delineate the tract.

Currently, there is no medical treatment available and surgery is almost always necessary. A simple intersphincteric fistula can often be treated with fistulotomy or fistulectomy, while trans-sphincteric and suprasphincteric fistulae are treated by placement of a seton to maintain drainage and induce fibrosis. Extrasphincteric fistula treatment depends on the anatomy and etiology of the fistula.

This article presents the case of a 1-year-old male with a history of recurrent perianal infection, which led to the development of an anal fistula. The anal fistula was noted to be superficial, and a fistulotomy was performed.

General Surgery, Print Release

PUBLISHED: Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision

Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision
Prabh R. Pannu, MD; David Berger, MD
Massachusetts General Hospital

Anterior component separation is an abdominal wall reconstruction technique used in the repair of ventral wall defects to avoid the use of prosthetic mesh. The procedure releases the external oblique fascia to provide a tension-free midline approximation.

The patient is a 72-year-old, obese female who has multiple large incisional hernias along an upper midline incision. An anterior component separation technique is used to repair the defect.

An incision is made over the previous abdominal scar. The dissection is carried down to the hernia sac. The hernia sac is then separated from the surrounding tissue to identify the fascial edges. The hernia sacs are removed from the fascia. Surrounding adhesions are lysed. A colotomy occurred, which was repaired in two layers: the outer layer with interrupted 3-0 silk suture, and the inner layer with running 3-0 Vicryl suture. The fascial incision is extended to ensure complete removal of the hernia sacs along with completion of adhesiolysis. Bilateral subcutaneous flaps separating the subcutaneous fascia from the external oblique fascia are developed. Perforating vessels are ligated with 2-0 or 3-0 silk. The dissection is carried laterally to the anterior axillary line. The external oblique fascia is released bilaterally using electrocautery. The midline defect is then closed with running #1 Prolene. After achieving hemostasis, two drains are placed, and the skin is closed.

Hand Surgery, Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Biceps Tenodesis for Distal Biceps Tendon Repair

Biceps Tenodesis for Distal Biceps Tendon Repair
Harish S. Appiakannan, BS¹; Amir R. Kachooei, MD, PhD²; Asif M. Ilyas, MD, MBA, FACS¹’²
¹Sidney Kimmel Medical College at Thomas Jefferson University
²Rothman Institute at Thomas Jefferson University

Distal biceps tendon ruptures can result in loss of supination and elbow flexion strength, for which surgical repair is often indicated to restore preinjury level of functionality. The distal biceps tendon can be repaired via single- or double-incision techniques using several associated implants, including endobuttons, suture anchors, or interference screws.

Here is the case of a middle-aged male presenting with an acute distal biceps tendon rupture. The tendon was repaired via a single-incision technique using an endobutton and an interference screw.

Fundamentals, Global Surgery, Print Release

PUBLISHED: Sebaceous Cyst Excision

Sebaceous Cyst Excision
Casey L. Meier, RN¹; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES²
¹Lincoln Memorial University, DeBusk College of Osteopathic Medicine
²Philippine Children’s Medical Center

Sebaceous cysts are closed sacs filled with foul-smelling, cheese-like material found underneath the skin. They form when a gland or hair follicle becomes blocked and are commonly found on the scalp, face, neck, or torso. Sebaceous cysts are non-cancerous and usually present as painless lumps, but can become tender when infected.

In most cases, smaller sebaceous cysts may be ignored as they do not cause any symptoms; however, larger cysts may need to be removed with complete excision recommended to prevent recurrence. Oral antibiotics may be required when a sebaceous cyst becomes infected. Here is the case of a 33-year-old male patient who underwent complete resection of a 2-year-old cyst.

General Surgery, Print Release

PUBLISHED: Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma

Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma
Richard Hodin, MD
Massachusetts General Hospital

Unilateral aldosteronoma is best managed by adrenalectomy, with the laparoscopic approach being the preferred method. This is the case of a 48-year-old woman who had long-standing hypertension and hypokalemia and was found to have hyperaldosteronism and low renin levels. A CT scan showed a small mass in the left adrenal gland, and adrenal vein sampling showed higher levels of aldosterone on the left side than on the right, confirming a unilateral aldosteronoma.

Laparoscopic access was gained, the adrenal gland was exposed and dissected by controlling the periadrenal tissues with the harmonic scalpel, the adrenal vein was then ligated, and the adrenal gland was removed.

General Surgery, Print Release

PUBLISHED: Wide Local Excision of an Intermediate-Thickness Back Melanoma with a Sentinel Lymph Node Biopsy of Left Axillary Lymph Nodes

Wide Local Excision of an Intermediate-Thickness Back Melanoma with a Sentinel Lymph Node Biopsy of Left Axillary Lymph Nodes
Kailan Sierra-Davidson, MD, DPhil1; Ogonna N. Nnamani Silva, MD2; Sonia Cohen, MD, PhD1
1Massachusetts General Hospital
2Brigham and Women’s Hospital

Wide local excision (WLE) with sentinel lymph node biopsy (SLNB) remains the cornerstone for treatment of patients with intermediate-thickness and thick melanoma lesions with clinically negative nodes. This procedure involves resection of the melanoma with circumferential margins including all the subcutaneous tissue to the level of the deep fascia. WLE is accompanied by lymphatic mapping in order to localize, resect, and analyze the sentinel node(s) for the presence of lymph node metastases. In this paper with accompanying animation and video, a 40-year-old otherwise healthy patient presents with a new melanoma on his back diagnosed via biopsy. The surgical management of intermediate-thickness melanoma and rationale for treatment are reviewed, and recent advances in postoperative treatment of those with clinically occult regional disease are highlighted.

General Surgery, Orthopedic Trauma, Orthopedics, Print Release, Trauma

PUBLISHED: Ankle-Brachial Index, CT Angiography, and Proximal Tibial Traction for Gunshot Femoral Fracture

Ankle-Brachial Index, CT Angiography, and Proximal Tibial Traction for Gunshot Femoral Fracture
Johnathan R. Kent, MD; James Jeffries, MD; Andrew Straszewski, MD; Kenneth L. Wilson, MD
University of Chicago Medicine

This video demonstrates an algorithm for evaluating suspected vascular injury secondary to penetrating extremity trauma on a 42-year-old man who sustained a gunshot wound to his left lower extremity. Descriptions of how to perform an arterial-brachial index (ABI) and arterial-pulse index (API) are reviewed, along with criteria to determine if a CT angiography is indicated. Relevant imaging is reviewed with a radiology resident with descriptions of how to systematically assess the scans for injury. Lastly, a tibial traction pin is placed as a temporizing measure for long bone fractures to prevent shortening and to help with pain management.

Print Release, Vascular Surgery

PUBLISHED: Femoral Endarterectomy for Severe Peripheral Arterial Disease

Femoral Endarterectomy for Severe Peripheral Arterial Disease
Katherine L. Morrow, MD; Anahita Dua, MD, MS, MBA, FACS
Massachusetts General Hospital

This case describes an 85-year-old gentleman with significant peripheral arterial disease and lifestyle-limiting claudication who had previously undergone an unsuccessful attempt at endovascular treatment of his significant right common femoral artery stenosis.

A right common femoral endarterectomy was performed to remove this patient’s significant plaque burden. Postoperatively, the patient noted significant improvement in his right lower extremity claudication, and his postoperative pulse volume recordings showed improved arterial inflow.