Internal Mammary Perforator Preserving Nipple-Sparing Mastectomy (IMP-NSM) to Reduce Ischemic Complications
Stanford University School of Medicine
Nipple-Sparing Mastectomies (NSMs) with breast reconstruction are commonly performed for both breast cancer treatment or risk-reducing prophylactic mastectomies and have superior aesthetic results compared to total mastectomy or skin-sparing mastectomy. Preservation of the Nipple Areolar Complex (NAC) results in a more natural aesthetic appearance of the reconstructed breast, as well as greater patient satisfaction, as indicated by improved psychosocial and sexual well-being compared to total mastectomy. Preservation of vascular supply is of utmost importance for NAC and mastectomy skin flap viability after surgery, since postoperative ischemic complications can significantly undermine the aesthetic outcomes.
This report describes a contemporary NSM surgical technique developed by the senior author (MK), to preserve the dominant NAC vascular supply, and decrease postoperative ischemic complications. A total of 114 NSM were performed from 2018 to 2020 by the senior author. Based on preoperative breast MRI with contrast visualization of the vascular supply to the NAC, the Internal Mammary Perforator (IMP) vessels exiting the pectoralis major muscle at the sternal border were found to provide the dominant blood supply to the NAC in 92% and could be preserved in 89% of cases.
The Internal Mammary Perforator Preserving Nipple-Sparing Mastectomy (IMP-NSM) surgical technique was developed to preserve this important IMP blood supply to the NAC, resulting in decreased postoperative ischemic complications. Following implementation of this surgical technique, NAC necrosis requiring NAC removal occurred in 0.9%, and mastectomy skin necrosis requiring reoperation in 1.8% of cases, resulting in successful NAC preservation in the majority of patients. Furthermore, due to the consistent anatomical location of the IMP vascular supply to the NAC, this critical vascular supply can routinely be preserved even without preoperative MRI, thereby improving clinical outcomes. The IMP-NSM surgical technique is described in detail in this report with a case example.
Laparoscopic Sigmoid Resection for Diverticulitis
Massachusetts General Hospital
Laparoscopic sigmoid resection is indicated for disease of the distal sigmoid or rectum that requires resection, most notably diverticulitis and colorectal cancer. Here, we perform a sigmoid resection for diverticular disease. In this procedure, we used four laparoscopic port sites.
In the first step, we mobilized the splenic flexure and left colon to allow for a tension-free colorectal anastomosis low in the pelvis. Second, the mesorectum was dissected to mobilize the rectum down to the level of the pelvic floor. Third, the left colic and inferior mesenteric arteries were ligated, the colonic mesentery was transected with an energy device, and the distal resection margin was stapled intracorporeally. Fourth, the specimen was extracorporealized through the umbilical port site, and the proximal transection was performed. Finally, an anvil was inserted, and the colon was placed back into the abdomen where a trans-anal, stapled end-to-side Baker-type anastomosis was performed and endoscopically tested for leaks.
Incision and Curettage on a Left Upper Eyelid Chalazion
1Vardanats Center for Innovative Medicine
A chalazion is a sterile granulomatous inflammation of the Meibomian or Zeiss glands. It results from the obstruction of gland orifices, which leads to accumulation of sebum in the tarsus and eyelid soft tissue. The resulting inflammation causes erythema, pain, and swelling. Patients may note a previous history of similar complaints, as well as a history of rosacea and chronic blepharitis.
Chalazion incision and curettage is a treatment of choice in unresolved chalazia or cases that do not respond to conservative treatments such as warm compress. Chalazion surgery aims to effectively drain the blocked gland and remove the inflamed tissue, providing relief to patients and restoring the natural appearance of the eyelid. This article discusses and demonstrates the preoperative assessment of the patient, the preparation, surgical procedure, and the postoperative care.
Recipient Kidney Transplant from a Living Donor
Massachusetts General Hospital
End stage renal disease (ESRD) is the final stage in the progression of chronic kidney disease (CKD). CKD has a multitude of etiologies, presents in a variety of ways, and progresses in a patient-dependent manner. Despite the heterogeneity of CKD, once ESRD ensues, patients require Renal Replacement Therapy (RRT). RRT is one of three prongs: hemodialysis, peritoneal dialysis, or kidney transplant.
Of these, kidney transplantation provides the patient with the best quality of life, an improved survival, and an opportunity for cure. However, the success of kidney transplantation with improved outcomes and tolerance to the required immunosuppression has led to an extreme organ shortage despite the increase in deceased organ donors. As a result, the push for living donors has become increasingly more important.
For recipients, the best outcomes are with transplants from a living donor due to superior graft quality and elimination of the need for waiting and dialysis. This article will present such a case and discuss the important considerations a physician must make preoperatively and intraoperatively when performing kidney transplantations.
Robotic Heineke-Mikulicz Pyloroplasty for Pyloric Stenosis
Jonathan Durgin, MD; ;
UMass Memorial Medical Center
Pyloric stenosis resulting in gastric outlet obstruction can present with nausea, vomiting, and early satiety. Imaging including fluoroscopic upper gastrointestinal series and computed tomography can diagnose gastric outlet obstruction. Upper endoscopy is included in the work-up to visualize the extent of stenosis and to obtain a tissue biopsy. After a malignancy is ruled out, treatment involves management of underlying causes.
This may include acid suppression, treatment of H. pylori, and dietary modification. Patients who fail conservative management may benefit from endoscopic therapies including pneumatic dilation and botulinum toxin injection. However, these therapies may not offer lasting symptomatic relief.
Pyloroplasty can be performed with the goal of widening the pylorus to improve gastric emptying. Pyloroplasty can be accomplished through open, laparoscopic, and robotic techniques. Here we describe a robotic-assisted Heineke-Mikulicz pyloroplasty in an adult patient with benign pyloric stenosis.
Rives-Stoppa Retromuscular Repair for Incisional Hernia
Katherine Albutt, MD;
Massachusetts General Hospital
There is no consensus on the optimal method of ventral hernia repair, and the choice of techniques is typically dictated by a combination of patient factors and surgeon expertise. Component separation techniques allow medial advancement of the rectus abdominis muscle to create a midline tension-free fascial closure.
In this case, we describe a posterior component separation with retrorectus mesh placement, also known as a Rives-Stoppa retromuscular repair. With low morbidity and mortality, this technique provides a durable repair with low rates of recurrence and surgical site infection while providing dynamic muscle support and physiologic tension, preventing eventration, and allowing incorporation of mesh into the existing abdominal wall.
Prostatic Artery Embolization (PAE)
1; 1; 2; 2
1Frank H. Netter, MD School of Medicine at Quinnipiac University
2Department of Radiology and Biomedical Imaging, Division of Vascular and Interventional Radiology, Yale University School of Medicine
Benign prostatic hyperplasia (BPH) is a common condition affecting the majority of men over 60 years of age. BPH incidence increases with age and often leads to lower urinary tract symptoms including frequency, urgency, and straining. In patients that do not respond to pharmacological therapy, options include transurethral procedures such as transurethral resection (TURP) or photovaporization, surgical prostatectomy, and prostate artery embolization (PAE).
The goal of PAE is to occlude arterial supply to the prostate by selective catheterization and subsequent embolization, most commonly with spherical tris-acryl gelatin microspheres. Over weeks to months, reduced blood flow leads to necrosis of prostatic adenomatous tissue, resulting in reduction of prostate size and decreased urethral impingement, eventually allowing for long-term resolution of symptoms in a majority of patients. Advantages of this technique compared with the standard surgical option, TURP, include faster recovery times, fewer side effects, and lower complication rates with near equal efficacy.
Hypoglossal Nerve Stimulator
1; 1; 2; 1
1 Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center
2 Lake Erie College of Osteopathic Medicine
Obstructive sleep apnea (OSA) is a common condition with several effective treatment strategies centered around relieving airway obstruction. The gold standard for OSA treatment remains continuous positive airway pressure (CPAP), but other options exist.
A recent therapy developed within the past decade utilizes hypoglossal nerve stimulation (HGNS) through a surgically implanted device. As the patient inspires, the device sends an electrical impulse similar to a cardiac pacemaker. The impulse activates targeted branches of the hypoglossal nerve, leading to stimulation of muscles that protrude the tongue and open the airway posteriorly. This mechanism has been shown to reduce airway obstruction by activating these muscles during inspiration.
Along with detailing the chronological order of events, this case outlines various complex anatomical structures that are identified in order to safely and effectively implant the hypoglossal nerve stimulator.
Open Cholecystectomy for Gallstone Disease
World Surgical Foundation
Gallstone disease is one of the most common disorders affecting the digestive tract. Most individuals with gallstones are asymptomatic and do not require treatment. For symptomatic patients, however, cholecystectomy is recommended.
Cholecystectomy is one of the most common abdominal surgeries performed worldwide. Indications include moderate-to-severe symptoms, stones obstructing the bile duct, gallbladder inflammation, large gallbladder polyps, and pancreatic inflammation due to gallstones.
Here, we report the case of a 53-year-old male with stones in his biliary duct. Despite having uncomplicated disease, the patient was treated with a primary open cholecystectomy because laparoscopy was not available.
Thumb Extensor Tendon Laceration Repair
1; 2; 1,2
1 Sidney Kimmel Medical College at Thomas Jefferson University
2 Rothman Institute at Thomas Jefferson University
This case consists of repairing an extensor tendon laceration of a thumb. Extensor tendon lacerations are one of the most common soft tissue injuries of the hand. Surgical repair of the tendon was offered, and the operation was performed using wide-awake local anesthesia no tourniquet (WALANT) technique.
Intraoperatively, a complete laceration of the extensor tendon was confirmed repaired using a modified Kessler technique and reinforced with an epitendinous repair. Before closure, the patient tested competency of the repair with confirmation of restoration with the active extension to ensure proper function. The patient was placed in a reverse thumb spica splint following wound closure.
Postoperatively, the patient was immobilized in full thumb extension for approximately two weeks and then converted to a removable splint and prescribed supervised hand therapy for a total recovery of 8–12 weeks.