Laparoscopic lysis of adhesions is a minimally-invasive approach to the resolution of a closed loop small bowel obstruction (SBO) due to adhesions. A patient with an SBO can present with nausea, vomiting, abdominal pain, and obstipation. History of prior abdominal surgeries serves as a significant risk factor for development of intra-abdominal adhesions. Imaging using either plain abdominal radiography or computed tomography (CT) can be diagnostic for closed loop SBOs. Conservative management with gastrografin can be considered in some SBOs, but closed loop SBOs are considered surgical emergencies. Utilization of specific signs (two transition points, pneumoperitoneum, signs of bowel ischemia) on imaging and patient presentation can facilitate earlier intervention.
Laparoscopic lysis of adhesions can resolve symptoms through releasing the bowel from the adhesion to improve flow. Lysis of adhesions can be performed open, laparoscopically, or with robotic techniques. This case presents a laparoscopic lysis of adhesions in a patient with a closed loop small bowel obstruction.
Surgical Staplers Brandon Buckner, CST, CRCST Lamar State College Port Arthur (TX)
For nearly two centuries, surgeons have been using mechanical devices to approximate tissues and facilitate their healing process. Currently, surgical staplers are widely used and have become essential tools in surgery. Staples facilitate rapid wound closure, hence shortening the duration of the surgical procedure. In comparison to intradermal sutures, stapling is associated with better cosmetic outcomes.
Staplers are classified into five categories: circular, linear, linear cutting, ligating, and skin staplers. With distinct names, color-coded features, and variations in length and tissue thickness, each stapler serves a specific purpose in the surgical setting. The distinct characteristics of various tissue types in the human body significantly influence the selection of staples. This video aims to provide a comprehensive overview of stapling instruments and their associated use.
This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.
With the increasing use of computed tomography (CT) for screening and diagnostic workup, increasing numbers of patients are found to have pulmonary nodules. The patient in this case presented with vision changes, neck weakness, and dysphagia. Workup revealed non-thymomatous myasthenia gravis as well as an incidental right lower lobe lung nodule that was suspicious for malignancy based on imaging characteristics, interval growth, and history of breast cancer.
She required a lung resection for diagnostic and therapeutic purposes. Additionally, a thymectomy was indicated to help control her myasthenia gravis symptoms. Consequently, a combined approach was conducted.
Diaphyseal tibial fractures are common injuries that are most often treated with intramedullary nailing. However, certain patient factors may necessitate alternative treatment strategies such as open reduction internal fixation (ORIF) with plates and screws. Presence of a total knee arthroplasty (TKA) in the injured extremity is one such factor. TKA is a common operation that is only increasing in popularity, and management of tibia fractures distal to TKA may be a frequently encountered clinical scenario.
This video presents a technique for ORIF of a distal diaphyseal tibia fracture distal to a TKA that precludes intramedullary nail fixation. The fracture is fixed with lag screws and secured with an anatomically-contoured distal tibia locking-compression plate (LCP) in neutralization mode.
This case presents a patient with a pathologic subtrochanteric femur fracture secondary to an undiagnosed primary lung adenocarcinoma. The fracture, occurring in the context of persistent atraumatic thigh and knee pain, prompted swift identification of its pathological nature in the Emergency Department. The treatment plan involved open reduction and internal fixation utilizing a carbon fiber nail, considering the immediate need for stabilization and underlying oncologic factors.
This article highlights the strategic use of carbon fiber implants in managing pathologic fractures, offering advantages in postoperative imaging, disease monitoring, and precision in radiation therapy planning. The multidisciplinary approach underscores the importance of considering implant selection nuances, especially in metastatic bone disease, to optimize outcomes.
Acute ankle sprains are most frequently treated conservatively, although some surgeons may advocate acute repairs in certain situations. Surgery is indicated for chronic sprains with persistent ankle instability despite well-designed conservative management. Several anatomic and nonanatomic operative procedures are available. The Broström-Gould procedure is a widely-used operative intervention for the treatment of chronic lateral ankle sprains. It consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex (Broström procedure), followed by suturing of the inferior extensor retinaculum to the periosteum of the distal fibula (Gould modification).
This article describes the standard Broström-Gould procedure starting with the identification of the anatomic landmarks. The skin incision follows the anterior border of the distal fibula, and careful subcutaneous dissection is carried out to expose the extensor retinaculum and the torn ligaments. This is followed by bone preparation and ligament repair utilizing a box stitch technique while holding the ankle in an appropriate position. Finally, the Gould portion of the procedure is demonstrated.
Patient ocular complaints often center around discomfort, foreign body sensation, and/or recent trauma. Determining the cause of the ailment is not always straightforward, and the use of fluorescein can provide valuable information that aids in clinical diagnosis. Many corneal conditions and emergencies can be identified with the aid of fluorescein such as corneal erosion, superficial punctate keratitis, corneal abrasion, foreign bodies, and tracking patterns of foreign bodies. This article and video will demonstrate proper technique to instill fluorescein and examine ocular tissues, as well as some examples of staining defects characteristic of compromised ocular tissues.
Burn injuries are often devastating accidents that result in long-term physical and psychosocial consequences and the formation of hypertrophic scars. Laser treatment is a low risk minimally invasive approach to treating such burn scars.
This video discusses the pulsed dye laser (PDL) and fractional ablative CO2 laser, and demonstrates their use in treating the scars on a pediatric patient who suffered from burn injuries 7 years ago in Vietnam.
This is a case discussing a 21-year-old male who suffered from both non-comminuted mandibular parasymphyseal and body fractures as a result of a motor vehicle accident, requiring open reduction internal fixation (ORIF) without postoperative maxillomandibular fixation (MMF). The fracture was complicated by a broken tooth root, which required extraction.
After intraoperative MMF, ORIF was performed. The parasymphyseal fracture was plated using two locking four-hole 2-mm thick miniplates utilizing two locking screws on either side of the fracture with one plate along the alveolar surface (monocortical screw) and one along the basal surface (bicortical screw). For the right body fracture, a three-dimensional locking ladder plate was used via a transbuccal trocar approach for additional exposure needed for proper screw placement. Once the hardware was secured, the patient was taken out of MMF and restoration of premorbid occlusion was confirmed. Lastly, watertight mucosal closure was performed using absorbable sutures and Dermabond (cyanoacrylate adhesive).
