Patients who undergo longitudinal sleeve gastrectomy (LSG) may develop de novo or worsening of existing gastroesophageal reflux (GERD) symptoms, which include postprandial retrosternal burning, food refluxing, or dysphagia. Often patients with GERD following LSG present with a concomitant hiatal hernia. Workup serves to characterize a patient’s GERD disease burden by way of fluoroscopic upper gastrointestinal (UGI) series, pH studies, manometry, or esophagogastroduodenoscopy (EGD). Treatment first involves medical management with lifestyle modifications followed by use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If GERD symptoms remain intractable to medical management, surgical intervention can be pursued.
Historically patients would undergo a conversion to a Roux-en-Y gastric bypass (RYGB). New data demonstrate comparable outcomes regarding GERD symptoms and improvements in anti-reflux medication use in patients status-post LSG who undergo ligamentum teres cardiopexy with hiatal hernia repair. This article describes a robotic ligamentum teres cardiopexy with hiatal hernia repair in an adult patient who previously underwent LSG and was experiencing intractable GERD symptoms despite lifestyle modification and optimization on anti-reflux medications.
Intraperitoneal Mesh Repair for Incisional Hernia William B. Hogan1; Yoko Young Sang, MD2; Shabir S. Abadin, MD, MPH3 1Warren Alpert Medical School of Brown University 2Louisiana State University Shreveport 3World Surgical Foundation
Incisional hernias remain an important postoperative complication of any procedure involving a laparotomy incision. Although most incisional hernias remain asymptomatic, incarceration and strangulation are emergent complications requiring prompt diagnosis and intervention. Mesh repair has become widely favored over simple suture repair of abdominal fascial defects in recent decades, though recurrence of incisional hernias remains high. Despite the advent of laparoscopic approaches to hernia repair, open approaches are utilized when numerous adhesions are encountered, laparoscopic access is unsafe, or when laparoscopy is not readily available. We present an open surgical repair of a large incisional hernia involving the abdominal midline and parastomal site in a woman with a history of laparotomy and colostomy with a subsequent reversal for a perforated colon.
Airway Management: Techniques and Equipment Dany Accilien, MD*, Dexter C. Graves, MD*, Nicholas Ludmer, MD†, Stephen Estime, MD†, Abdullah Hasan Pratt, MD UChicago Medicine
This video article discusses airway management techniques in trauma resuscitation. It outlines the preparation and equipment used in patients with impending airway failure that require airway protection and ventilatory support. We discuss the innovative airway towers used in the University of Chicago emergency room as well as the general approach to airway management. We also go over the different types of laryngoscopy, assist devices, and cricothyroidotomy surgical airway procedures.
Occasionally, the treatment of breast cancer requires the removal of the breast while also leaving a large chest skin deficit. Especially if radiation has been done or is planned, the best way to restore the missing skin to preserve its essential function would be by the use of a vascularized flap. Sometimes this can be achieved while simultaneously providing a reconstruction of a very aesthetic breast mound. Depending on circumstances and the extent of disease, a simpler solution might be to just close only the chest wound that has been created.
A “workhorse” flap alternative that is almost always available to achieve this is the latissimus dorsi (LD) muscle from the back, as this can be moved to almost all regions of the chest. The LD muscle usually can be swung to the chest about its blood vessels that remain attached to the armpit, and so would be called a local flap that as such avoids the complexities of a transfer requiring microsurgery to reconnect the blood supply. The long-term experience by reconstructive surgeons in using the LD muscle as a local flap, not just for the chest but also the back, head, and neck, has proven its deserved accolade to be a versatile flap unparalleled by most other donor sites.
Contact lens insertion and removal proficiency is paramount to successful resolution in several sight-threatening ocular conditions. With contact lenses so often being the culprit for corneal ulcers, it may seem counterintuitive to use them as a Band-Aid. However, in many cases of ocular trauma such as corneal abrasion and foreign body removal, a bandage contact lens along with topical antibiotics is an advisable form of treatment. Bandage contact lenses are also heavily utilized in surgical refractive procedures such as photorefractive keratectomy (PRK) and epi-off corneal cross-linking. There are many new advances in bandage contact lens technology such as contact lenses eluted with antibiotics, steroids, and amniotic tissues for managing both chronic and acute ocular conditions.
A left lower quadrant partial-thickness Spigelian-type incisional hernia resulting from wound complications after deep inferior epigastric perforator (DIEP) flap harvest is repaired in a minimally-invasive, robotic-assisted, transabdominal preperitoneal (TAPP) fashion. Utilizing robotic assistance, a large preperitoneal flap is created, fascial closure is achieved using barbed suture, and the hernia defect is reinforced widely with medium-weight polypropylene mesh. In this patient, this approach also allows for areas that had previously had mesh placed to be avoided, and for repair of a fat-containing indirect left inguinal hernia. Similar approaches can address primary or lateral incisional hernias. This patient had an uncomplicated postoperative course without early wound morbidity.
Partial laryngectomy, with its roots tracing back to the early 19th century, has evolved over time as an alternative operative approach for a select group of patients with glottic and supraglottic malignancies. The goal was to preserve speech and swallowing without committing to a permanent tracheostomy. In this video, in the context of a cadaver dissection course held at Duke University, the techniques for partial laryngectomy are demonstrated. The initial segment of this video focuses on explaining the two types of laryngeal surgeries: supraglottic laryngectomy and supracricoid laryngectomy with cricohyodopexy, or cricohyodoepiglottopexy (CHEP). Although these surgeries aim to preserve the functionality of the larynx, performing them may impact voice, swallowing, and airway protection.
Surgery has been the first line of treatment for oral cavity cancer. After appropriate workup, the decision to include an ipsilateral or bilateral neck dissection is made. The patient presented here was diagnosed with a posterior maxillary alveolar tumor. The treatment plan included wide local excision of the tumor with total alveolectomy, reconstruction with a buccal fat pad advancement, and placement of surgical obturator. Additionally, an ipsilateral supraomohyoid neck dissection was performed due to the relative risk of regional metastases.
Functional endoscopic sinus surgery (FESS) is a minimally-invasive technique involving the use of an endoscope to visualize and access the paranasal sinuses, allowing for precise and targeted removal of diseased tissue. The cadaveric video on FESS presented here offers a detailed and comprehensive guide to maxillary, ethmoid, and sphenoid sinus dissection. The step-by-step approach, coupled with the emphasis on anatomical considerations, makes this video an essential resource for healthcare professionals involved in the management of sinonasal disorders.
Aspiration of Ganglion Cyst on Right Wrist Jonathan E. Sledd1; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2 1Edward Via College of Osteopathic Medicine – Auburn Campus 2Philippine Children’s Medical Center
Ganglion cysts are sacs containing a gel-like fluid that can form over tendons and joints. They are commonly seen as visible lumps on the hand and back of the wrist. Ganglion cysts are not cancerous, and most are asymptomatic. But if a cyst puts pressure on a nerve, it can cause pain, tingling, and muscle weakness. Initial treatment of a ganglion cyst is not surgical. Observation may be recommended because half of ganglion cysts may disappear over time. Activity often causes the cyst to increase in size, and thus immobilization may be an option. If a ganglion cyst causes pain and limits activities, aspiration of the fluid may decrease pressure and relieve pain. Surgical excision may also be recommended if symptoms are not relieved or if the cyst recurs. This article presents the case of a 51-year-old female who had a ganglion cyst on her right wrist. Treatment options were presented to the patient, and she opted to undergo aspiration over excision.
