This video demonstrates an algorithm for evaluating suspected vascular injury secondary to penetrating extremity trauma on a 42-year-old man who sustained a gunshot wound to his left lower extremity. Descriptions of how to perform an arterial-brachial index (ABI) and arterial-pulse index (API) are reviewed, along with criteria to determine if a CT angiography is indicated. Relevant imaging is reviewed with a radiology resident with descriptions of how to systematically assess the scans for injury. Lastly, a tibial traction pin is placed as a temporizing measure for long bone fractures to prevent shortening and to help with pain management.
This case describes an 85-year-old gentleman with significant peripheral arterial disease and lifestyle-limiting claudication who had previously undergone an unsuccessful attempt at endovascular treatment of his significant right common femoral artery stenosis.
A right common femoral endarterectomy was performed to remove this patient’s significant plaque burden. Postoperatively, the patient noted significant improvement in his right lower extremity claudication, and his postoperative pulse volume recordings showed improved arterial inflow.
Anterior Skull Base Resection of Esthesioneuroblastoma (Endoscopic)
David W. Jang, MD¹; Ali R. Zomorodi, MD¹; Feras Ackall, MD¹; Josef Madrigal, BS²; C. Scott Brown, MD¹ ¹Duke University Medical Center ²David Geffen School of Medicine at the University of California, Los Angeles
First described by Berger in 1924, esthesioneuroblastoma (ENB) remains a rare sinonasal tumor believed to originate from specialized sensory olfactory cells. To date, the literature includes 1,000 recorded cases of ENB. Patients with ENB often present with non-specific symptoms, most often chronic nasal obstruction or epistaxis. Careful examination may reveal a pink or brown polyploid mass in the nasal cavity. Overall, ENB may demonstrate various growth patterns ranging from slow, indolent progression to aggressive invasion with widespread metastasis.
Current literature indicates that ENB should be treated with a combination of surgical resection and postoperative radiation therapy with or without chemotherapy. However, significant controversy remains regarding the appropriate surgical approach. This video demonstrates a transnasal endoscopic approach, which has gained significant popularity over the previous two decades compared to classic “open” approaches. Although this approach demonstrates improved perioperative outcomes while still achieving oncologic margins, further work is required to evaluate long-term survival.
Primary hyperaldosteronism, or Conn’s syndrome, is a disease in which one or both adrenal glands produce excess amounts of aldosterone, leading to hypertension and hypokalemia. High blood pressure may cause headaches or blurred vision. Low potassium may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis.
Primary hyperaldosteronism is diagnosed by measuring serum levels of aldosterone, renin, and potassium. Patients classically have high aldosterone levels, suppressed renin levels, and low potassium levels. Once the diagnosis is established, the localization of the source is performed using imaging studies. Adrenal vein sampling is also performed to determine more precisely and directly the side that is producing excess aldosterone.
Primary hyperaldosteronism caused by an adrenal gland tumor is treated with adrenalectomy. This is the case of a 58-year-old female with hypokalemia and long-standing hypertension refractory to medical treatment. Her blood tests showed high aldosterone levels and low renin levels, confirming the diagnosis of hyperaldosteronism. On CT scan, an adrenal nodule was noted on both sides. Adrenal vein sampling identified the right adrenal nodule as the cause. Laparoscopic access was gained, the adrenal gland was dissected and exposed, the adrenal vein ligated, and the adrenal gland was removed.
Laparoscopic Nissen Fundoplication
Ciro Andolfi, MD¹; Marco Fisichella, MD, MBA, FACS² ¹University of Chicago Pritzker School of Medicine ²VA Boston Healthcare System
This is the case of a 63-year-old man with a long-standing history of gastroesophageal reflux disease, refractory to medical management with high-dose proton pump inhibitors and H2-blockers. The preoperative workup consisted of: 1) an upper endoscopy, which was normal; 2) a barium swallow, which showed a normal anatomy (no hiatal hernia or diverticula); and 3) esophageal function tests, including high-resolution esophageal manometry, which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of gastroesophageal reflux disease.
Considering the amount of pathologic reflux, and the normal anatomy and esophageal peristalsis, it was decided to proceed with a laparoscopic Nissen (360°/total) fundoplication. The operation went well and lasted less than 90 minutes. The patient was discharged the following morning after resuming a light diet, and recovered quickly. With this surgical approach, complete control of reflux was achieved, and the patient was able to discontinue his treatment with proton pump inhibitors.
Osteoarthritis commonly impacts the finger distal interphalangeal (DIP) joints. The prevalence of DIP joint arthritis is high, with more than 60% of individuals older than 60 having DIP joint arthritis.
Operative treatment for arthritis of the DIP joint is indicated for pain, deformity, dysfunction, and instability in patients who are recalcitrant to conservative measures. Arthrodesis, or the fusion, of the DIP joint is a widely accepted surgical treatment for DIP joint arthritis.
Several surgical techniques have been historically described, with headless compression screw (HCS) fixation being a particularly common technique because of its advantages, including reliable compression, rigid fixation, lack of prominence, and no need for removal. This video demonstrates arthrodesis using HCS for arthritis in the right ring finger DIP joint.
Otosclerosis can lead to progressive conductive hearing loss, significantly affecting quality of life. For patients who choose surgery, the tympanic membrane is elevated, and the middle ear space is explored. If the surgeon confirms that the stapes is fixed in the oval window, either a stapedotomy or stapedectomy can be performed.
In the stapedotomy, the surgeon removes the stapes superstructure, creates a fenestration in the footplate, and places a prosthesis from the incus through the fenestration into the vestibule. In this instance, the patient was able to regain nearly all of the hearing that had been lost as a result of stapes fixation.
Triceps Repair for Acute Triceps Tendon Rupture
Gregory Schneider, BS¹; Asif M. Ilyas, MD, MBA, FACS¹’² ¹Sidney Kimmel Medical College at Thomas Jefferson University ²Rothman Institute at Thomas Jefferson University
The patient in this case suffered an acute triceps tendon rupture and opted for surgical repair to restore function. His physical exam findings of tenderness at the olecranon and weakness against resistance during elbow extension, combined with plain film imaging revealing a positive fleck sign representing an avulsion the triceps tendon off of the olecranon, gave the diagnosis of acute triceps tendon rupture.
The patient underwent surgical repair under general anesthesia in lateral decubitus position with a sterile tourniquet applied for hemostasis. The treatment goal was re-approximating the distal triceps tendon to the olecranon in order to restore elbow extension strength and upper extremity function. The surgical technique demonstrated in this video is the suture bridge technique.
Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals.
In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.
This is the case of a 74-year-old female who presented with bothersome stage III pelvic organ prolapse. She desired definitive surgical management for her prolapse and opted for total vaginal hysterectomy, uterosacral ligament suspension, and anterior/posterior vaginal repairs. She had urodynamic testing before the surgery that showed no stress urinary incontinence, no detrusor overactivity, and normal bladder capacity. The surgery was uncomplicated. She was discharged home the same day as surgery, and her postoperative recovery was unremarkable.
