A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within this space as a sequelae of chest trauma (penetrating or blunt), iatrogenic injury (e.g., vascular access injuries), or spontaneously (e.g., due to malignancy). To treat the condition, a chest tube is inserted into the thoracic cavity on the affected side of the body. In addition to evacuating blood from the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space) and pleural effusion (e.g., empyema or chylothorax), and to insert medications into the pleural space. Depending on the specific pathology, a tube or catheter may be utilized.
Ganglion cysts are benign, mucinous-filled swellings that overly tendons and joints. They are the most common soft tissue mass found in the hand and wrist but also commonly encountered in the knee and foot. Presenting as a palpable knot, the cyst is asymptomatic until it impinges on local neurovasculature causing pain, numbness, tingling, and/or motor deficits. Pediatric ganglion cysts have different epidemiological characteristics than adults, with the majority found on the volar aspect on the wrist.
Treatment of ganglion cysts is most often observation due to the 50% chance of resolution over time. Activity causes the cyst to increase in size, and thus more aggressive treatment is often desirable. If the cyst recurs or symptoms are not relieved with observation alone, a more aggressive treatment such as surgical excision is often desirable. This article presents a female pediatric patient undergoing surgical excision of a large ganglion cyst on the dorsum of her right wrist. With the treatment options explained to her, she chose excision for the lower rate of recurrence.
Deltoid Ligament Repair William B. Hogan1; Eric M. Bluman, MD, PhD2 1Warren Alpert Medical School of Brown University 2Brigham and Women’s Hospital
Injury to the medial deltoid ligament complex is rare as it is the strongest of the ankle ligaments. However, damage to this structure can occur, often in association with an avulsion fracture of the medial malleolus due to the ligamentous strength of the complex. Deltoid ligament repair remains a primary option for patients with severe acute injuries, or patients with chronic instability who have failed conservative measures.
Repair of the medial ankle ligaments provides improved stability with reduced risk of recurrent sprains and potential damage to local cartilage. This article presents a case of a young woman with concomitant medial and lateral ankle instability who successfully underwent deltoid ligament repair for her medial ligament injury.
Robotic Thymectomy for Myasthenia Gravis Constantine M. Poulos, MD1; Tong-Yan Chen, MD2; Lana Schumacher, MD, MS, FACS1 1Tufts Medical Center 2Massachusetts General Hospital
Myasthenia gravis is an autoimmune disease affecting acetylcholine transmission involved in skeletal muscle contraction. The approach to myasthenic patients is complex as optimal treatment involves a multidisciplinary technique of combined medical and surgical therapies. Medical therapy with acetylcholinesterases and immunomodulators can provide symptom relief and eliminate feelings of fatigue and weakness.
Surgical thymectomy can help by reducing symptoms, preventing recurrence, and reducing daily medication requirements. Thymectomy was traditionally performed via a transsternal approach, but minimally invasive and robotic techniques have become increasingly common. This article presents a robotic total thymectomy through a left-sided approach.
Cardiovascular disease is a leading cause of morbidity and mortality in the United States and abroad, manifesting as shortness of breath, exercise intolerance, palpitations, and chest pain. While the majority of cases are treated medically, more advanced or severe cases are treated surgically or endovascularly, warranting an open discussion between the provider and the patient to decide the most appropriate treatment modality given the specific characteristics and preferences of the procedure and the patient.
The Cox-MAZE IV combined with CABG and Mitral Valve Replacement is a singular surgical procedure that is carefully planned and executed to address arrhythmic, coronary, and valvular disease while minimizing time on cardiopulmonary bypass with an arrested heart.
Central venous access is a crucial aspect in the management of patients requiring long-term therapies, particularly surgical patients. These therapies include the administration of therapeutic agents, fluid administration, antibiotic therapy, parenteral nutrition, etc. The procedure involves the placement of a catheter into a venous great vessel. Three main sites for central venous access are: internal jugular vein, common femoral vein, and subclavian veins.
In resource-constrained settings, healthcare professionals must rely on their clinical practice and proficiency in performing procedures without the aid of advanced imaging modalities. One such procedure is the infraclavicular subclavian vein cannulation, which can be performed without ultrasonographic guidance, providing a reliable means of obtaining central venous access. Here, this is demonstrated on a pediatric preoperative patient during a surgical mission in Honduras.
Laryngeal granulomas present with clinical signs and symptoms including dysphonia, hoarseness, discomfort or pain in the throat, and dyspnea. Notably, vocal granuloma, despite its name, pathologically is not a true granulomatous process. Instead, it is characterized as a reactive/reparative process where intact or ulcerated squamous epithelium is underlaid by granulation tissue or fibrosis. Although granulomas are typically of benign nature, they often require surgical treatment. Other options for treatment include proton-pump inhibitors (PPIs) and steroid inhalations, botulinum neurotoxin injection, and phonotherapy. Nearly half of the cases usually remit through clinical management involving PPIs, topical inhalant steroids, and phonotherapy.
The following case describes a 91-year-old woman with no significant past medical history who presented to her primary care physician with several months of cough and progressive dyspnea. After appropriate workup she was found to have a stage IVa lung adenocarcinoma with an associated malignant pleural effusion that contributed to her symptoms. There are several therapeutic options for treating a malignant pleural effusion. An indwelling tunneled pleural catheter (PleurX catheter) is a reliable way to manage a chronic pleural effusion. The device is most commonly used to manage malignant pleural effusions, but the same technique may be applied for a range of benign, non-infectious indications as well.
PleurX catheters may be inserted in an outpatient clinic, interventional radiology suite, inpatient setting, or operating room under local or general anesthesia. Once in place, they are designed to be managed in an outpatient setting either by the patient’s caregivers or by the patient themselves and serve to palliate the respiratory symptoms of a large effusion without the need for repeated thoracenteses. They can remain in place for several months, and removal in an outpatient setting with local anesthetic is trivial. Following placement of the PleurX catheter, the patient reported symptomatic improvement in her dyspnea, and she was started on dose-reduced Mobocertinib under the guidance of thoracic oncology.
Coronal Approach (Cadaver) Felix L. Hong, DDS; Mark R. Rowan, MD, DDS; R. John Tannyhill, III, MD, DDS, FACS Harvard Medical School
For treatment of facial trauma such as a frontal sinus fracture, orbital fractures, or zygoma fractures, the coronal or bi-temporal approach is used. The approach can also be used for superficial temporal artery biopsy. This approach exposes the anterior cranial vault, forehead, and upper and middle regions of the facial skeleton including the zygomatic arch. It provides access to these areas with minimal complications and cosmetically acceptable hidden scars. The subperiosteal or subgaleal planes are commonly used for coronal flap dissection. This article presents a demonstration of the coronal approach to exposing the upper or middle facial skeleton in a cadaver.
Open Distal Gastrectomy Andrea L. Merrill, MD; John T. Mullen, MD Massachusetts General Hospital
A complete margin-negative (R0) resection remains the only potentially curative treatment for gastric adenocarcinoma. The choice of operation depends on the location of the tumor as well as the stage of disease. This patient presented with symptomatic anemia, and workup demonstrated gastritis and a small tumor in the distal stomach. Biopsies confirmed adenocarcinoma, and an endoscopic ultrasound (EUS) staged this tumor as T2 N0. Staging scans showed no evidence of distant metastatic disease. Given that this patient had a relatively early stage tumor, they elected to proceed with upfront surgery, which in this case entailed a distal gastrectomy. This video shows an experienced gastric surgeon’s technique for performing an open distal gastrectomy with an “extended” D1 lymph node dissection.
