In patients with difficult gallbladders due to anatomy prohibiting a clear critical view of safety, a subtotal cholecystectomy can be considered as a safer alternative to a total cholecystectomy. Subtotal cholecystectomies can be divided into “reconstituting” or “fenestrating.” Subtotal reconstituting cholecystectomies include closing off the lower end of the gallbladder to create a remnant gallbladder, while subtotal fenestrating cholecystectomies do not occlude the gallbladder and instead may involve suturing the cystic duct. The most common indication for subtotal fenestrating cholecystectomy is inflammation in the hepatocystic triangle, and subtotal fenestrating cholecystectomy has proven to be useful specifically for patients with a history of cirrhosis.
This case report describes the performance of a subtotal fenestrating cholecystectomy for the management of acute on chronic cholecystitis in a patient with cirrhosis initially managed with transcystic stent placement endoscopically. Management of this patient’s omental adhesions to the gallbladder required alterations to typical surgical technique, which will be described in this report. Additionally, the indications for subtotal fenestrating cholecystectomy will be discussed alongside the benefit of this technique to specific patient populations presenting with acute on chronic cholecystitis.
Rotator Cuff Repair (Cadaver Shoulder) Patrick Vavken, MD1; Sabah Ali2 1Smith and Nephew Endoscopy Laboratory 2University of Central Florida College of Medicine
Rotator cuff tears represent the vast majority of shoulder disorders treated by orthopaedic surgeons. From partial-thickness tears in overhead throwing athletes to full-thickness tears in the elderly, the prevalence of rotator cuff tears continues to increase over time. While some cases are asymptomatic, most patients with rotator cuff tears report shoulder pain, limited range of motion, and nighttime pain with difficulty sleeping on the affected shoulder. When nonsurgical treatment is insufficient in relieving the symptoms, arthroscopic rotator cuff repair becomes a viable option for many patients.
This is the case of a rotator cuff repair of a full-thickness tear that extends into the infraspinatus on a cadaver shoulder in the beach chair position. The tear was repaired by placing an anchor, retrieving and passing three suture arms, and tying the suture. This article outlines the natural history, preoperative care, intraoperative technique, and postoperative considerations of rotator cuff repairs.
A diaphragmatic hernia (DH) is characterized by protrusion of abdominal organs into the chest cavity through an opening in the diaphragm. A sliding or paraesophageal hernia is the most prevalent type, characterized by its occurrence near the esophageal hiatus. Typically present since birth, it can also develop later in life, occasionally arising as a result of severe trauma or iatrogenic injury. Less often, congenital DHs protrude through posterolateral or substernal diaphragmatic defects, referred to as Bochdalek and Morgagni hernias, respectively.
DH can remain asymptomatic and is commonly detected as an incidental finding during evaluation for other medical issues. Hiatal hernias differ from abdominal wall hernias in that they are influenced by the constant motion of the diaphragm, which exerts continuous friction and pressure changes on the esophagus and the stomach. As a result, hiatal hernias have a higher likelihood of recurrence following surgical correction in comparison to abdominal hernias.
This is the case of an exploratory laparotomy for bowel obstruction and primary pledgeted repair of two diaphragmatic hernias.
In contemporary healthcare settings, the need to balance efficiency, cost-effectiveness, and environmental responsibility has led to the widespread adoption of reusable containers for surgical instruments. This video demonstrates the advantages of employing reusable rigid containers for surgical instruments, using a laparoscopic set from Baptist Hospitals of Southeast Texas as a case study.
Surgical site infection (SSI) poses a significant risk to patients undergoing surgery. The prevalence of SSI is influenced by various factors. Within an ideal perioperative environment, exclusively sterile surgical instruments are employed. Care should be taken to thoroughly explore all methods of maintaining a contamination-free operating room (OR) environment.
The proper opening of sterile surgical instrument packs has critical importance in maintaining aseptic conditions in the OR. This video demonstrates all the nuances of this process, emphasizing the importance of package integrity checks and adherence to strict protocols for sterile surgical attire.
Reconstruction of external ear defects often poses various challenges due to the complex anatomy of the ear and its significant role in overall facial aesthetics. The location of the defect independently impacts the repair as various locations present distinct, additional factors to consider during planning. Specifically, defects of the superior auricle complicate the reconstructive process, due to the role of the helical root and superior rim in providing mechanical support for facial accessories such as glasses or hearing aids. The approach to reconstruction must be systematic while also being individually tailored in order to appropriately restore both optimal cosmesis and function.
The featured case involves the reconstruction of a full-thickness superior helix and auricular defect in a patient who wears eyeglasses with a cochlear implant on the same side. The discussion highlights the complexity of superior auricular reconstruction as well as the various surgical options used and challenges encountered.
This video provides a comprehensive overview of the prophylactic ureteral stenting and cystoscopy performed on a patient with advanced metastases of appendiceal cancer who is scheduled for cytoreduction and hyperthermic intraperitoneal chemotherapy. The video focuses on urethral instrumentation, identification of ureteral orifices, stent placement, and subsequent bladder inspection. The patient’s preoperative evaluation had revealed no evidence of ureteral involvement with the tumor.
The cystoscopic technique employed in this case allowed the surgeons to visualize the bulbar urethra, sphincter, and prostatic urethra, illustrating the step-by-step process of advancing into the bladder. Next, the vesical trigone is identified, aiding in the visualization of the ureteral orifices. The careful placement of stents into both ureters is demonstrated. No resistance was encountered in the process of stent placement, suggesting no involvement of the ureters with the tumor. A thorough bladder inspection revealed no unusual findings such as abnormal lesions, masses, or other pathology. The stents were secured with silk sutures to prevent inadvertent dislodgement.
For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation. PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications, laparoscopic-assisted PEG (LAPEG) was introduced.
LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.
Pulmonary AVM Embolization Jelena Ivanis1; Andrew Ding1; Dennis Barbon1; Fabian Laage-Gaupp, MD2; Jeffrey Pollak, MD2 1Frank H. Netter, MD School of Medicine at Quinnipiac University 2Yale School of Medicine
Pulmonary arteriovenous malformations (PAVMs) are rare fistulous connections between pulmonary arteries and veins that, as in this case, are commonly associated with hereditary hemorrhagic telangiectasia (HHT). Embolotherapy, the mainstay of treatment for PAVMs, is a procedure in which the feeding arteries of a malformation are endovascularly occluded under fluoroscopic guidance. Effective and well-tolerated, embolotherapy has been shown to decrease right-to-left shunting following treatment and decrease risks of paradoxical embolization and lung hemorrhage and to improve pulmonary gas exchange and lung function. Patients are selected for treatment according to clinical suspicion for the presence of a PAVM and feeding artery diameter. The occlusion of PAVMs with arteries that exceed 2–3 mm in diameter is recommended.
Diagnostic contrast-enhanced pulmonary angiography is performed via injection of contrast through a percutaneous catheter to characterize and confirm PAVMs suitable for embolization. Lesions are then treated by catheter-directed placement of embolic material— vascular plugs in this case—into the feeding artery, terminating blood flow to the area of the lesion. Although multiple PAVMs may be embolized during a single session, in patients with HHT, who may present with large numbers of PAVMs, treatment is limited by maximum contrast dosage, and additional sessions may be performed if PAVMs remain perfused.
Heated Intraperitoneal Chemotherapy (HIPEC) coupled with cytoreduction is increasingly being used to treat isolated peritoneal dissemination of intra-abdominal malignancies. Cytoreductive surgery (CRS) is initially performed using either a conventional open or laparoscopic approach. CRS includes removal of the main tumor, excision of any other visible tumors, peritonectomy, omentectomy, and intestinal resections, if necessary. Following CRS, a chemotherapeutic solution is administered at a temperature of 40 to 41.5 °C. Infusing chemotherapy immediately following CRS facilitates a uniform distribution of the solution throughout the entire peritoneal cavity. This strategy prevents localized spread that may arise from postoperative adhesion formation, ensuring that peritoneal surfaces are exposed to a concentrated chemotherapy dose while minimizing systemic toxicity.
Epidural analgesia provides effective pain management and is generally well tolerated by patients undergoing CRS in conjunction with HIPEC. This video provides a comprehensive step-by-step demonstration of the entire procedure. The epidural injection involves the delivery of anesthetic solution to the epidural space surrounding the spinal cord within the vertebral column, inducing anesthesia in the spinal segments below the site of catheter placement.
