Derek J. Erstad, MD
Massachusetts General Hospital
Richard Hodin, MD
Chief, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital
The patient in this case is a 29-year-old female who had a long history of medically refractory ulcerative colitis. Three months previously, she had undergone a laparoscopic proctocolectomy with ileoanal J-pouch reconstruction and loop ileostomy. Here, Dr. Richard Hodin at MGH reverses the ileostomy.
J. Corbin Norton
Department of Urology, University of Arkansas for Medical Sciences
Amrit Singh, MD
Department of Pathology, University of Arkansas for Medical Sciences / Arkansas Children’s Hospital
Laura L. Hollenbach, MD
Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences
Georgia Gamble, MD
Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences
Laura A. Gonzalez-Krellwitz, MD
Department of Pathology, University of Arkansas for Medical Sciences / Arkansas Children’s Hospital
Stephen J. Canon, MD
Department of Pediatric Urology, Arkansas Children’s Hospital
The patient in this case is a 15-year-old female who presented with primary amenorrhea and who on work-up was found to have complete androgen insensitivity syndrome. Here, Dr. Canon at the University of Arkansas for Medical Sciences performs a prophylactic laparoscopic bilateral gonadectomy to reduce her future risk for intra-abdominal testicular malignancies. Final pathology results showed a rare case of bilateral germ cell neoplasia in situ and bilateral paratesticular leiomyomas and reinforced the decision to intervene early allowing for the removal of the gonads prior to their conversion to formal germ cell tumors.
Trigger Finger Release (Cadaver)
Rothman Institute
Asif Ilyas, MD, FACS
Orthopaedic Surgeon
Vivian Xu
Stenosing flexor tenosynovitis of the digital flexor tendon sheath, also known as trigger finger, occurs when there is a size mismatch between the flexor tendon and the surrounding retinacular pulley system at the first annular (A1) pulley. When the flexor tendon thickens or becomes inflamed, its ability to properly glide through the flexor tendon sheath becomes impaired. Thus, the tendon catches as the finger is flexed and extended. Conservative management includes activity modification, splinting, short-term NSAIDs, corticosteroid injection, and other adjuvant therapies. In this video, Dr. Asif Ilyas at the Rothman Institute demonstrates a surgical approach to the treatment of trigger finger via the open A1 pulley release procedure on a cadaver.
Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)
Yale School of Medicine
Courtney Gibson, MD, MS, FACS
Assistant Professor of Endocrine Surgery
Yale School of Medicine
Tobias Carling, MD, PhD, FACS
Chief of Endocrine Surgery
Yale School of Medicine
In this case, Dr. Tobias Carling and Dr. Courtney Gibson at Smilow Cancer Hospital at Yale New Haven perform a TOETVA on a 45-year-old patient who presented with a growing thyroid nodule that was shown to be a Hurthle cell neoplasm on fine-needle aspiration.
Numerous minimally-invasive approaches to thyroidectomy have been developed over the years to minimize the neck surgical scar, many of which are performed using endoscopic or robotic assistance. However, a more diminutive anterior cervical scar still remains a problem for some patients, as well as more extensive dissections for remote access operations. Therefore, natural orifice surgery was adopted at select institutions in an effort to perform a truly scarless thyroidectomy. Trans-oral endoscopic thyroidectomy has been the latest approach developed, known as the natural orifice transluminal endoscopic thyroidectomy, which is categorized as a natural orifice transluminal endoscopic surgery (NOTES) procedure. There are several ways to perform the natural orifice transluminal endoscopic thyroidectomy. Here, the authors present the TOETVA under general anesthesia.
Robotic eTEP Retrorectus Rives-Stoppa Repair for Ventral Hernia
Alta Bates Summit Medical Center
Rockson C. Liu, MD, FACS
In this case, Dr. Rockson Liu with Epic Care at Alta Bates Summit Medical Center performs a robotic eTEP retrorectus Rives-Stoppa repair of an upper midline primary ventral hernia that was partially reducible but mostly incarcerated, and greater than 6 cm in a 63-year-old female. Robotic ports were placed directly into the retrorectus space. Using the crossover technique, the retrorectus spaces were combined with a preperitoneal bridge of the peritoneum. The defects were closed robotically, and a medium-weight, macroporous polypropylene mesh was placed within the retrorectus space.
Thumb Ulnar Collateral Ligament Tear Repair
Rothman Institute at Thomas Jefferson University
Asif M. Ilyas, MD, MBA, FACS
Rothman Institute at Thomas Jefferson University
Alexander D. Selsky, BS
Lake Erie College of Osteopathic Medicine
The patient in this case was a 35-year-old male who presented to the clinic with pain of the right thumb but no numbness after a fall onto an outstretched hand that resulted in a forced hyperabduction of the thumb. There was mild weakness with thumb adduction due to significant pain, but there was no evidence of median or radial nerve injury, and the radial pulses were intact. A palpable mass was identified along the medial side of the MCP, suggestive of a Stener’s lesion, and he was ultimately found to have a complete UCL tear of the right thumb.
Here, Dr. Asif Ilyas at the Rothman Institute performs a repair of the UCL with the use of a 3-0 suture anchor placed in the anatomical footprint and a temporary 0.045 K-wire placed across the MCP joint for reinforcement.
Preview of the case: https://www.youtube.com/watch?v=JxdoYtjgZBE&ab_channel=JOMI-JournalofMedicalInsight
Subcutaneous Ulnar Nerve Transposition
Rothman Institute at Thomas Jefferson University
Jasmine Phun
Sidney Kimmel Medical College
Asif M. Ilyas, MD, MBA, FACS
Rothman Institute at Thomas Jefferson University
In this case, Dr. Ilyas at the Rothman Institute performs a subcutaneous anterior transposition on a patient with cubital tunnel syndrome. The patient’s ulnar nerve subluxed upon elbow flexion and extension upon physical examination, which was a primary indication for choosing this surgical approach over other techniques.
This procedure not only decompresses the affected nerve but also transposes the nerve anterior to the medial epicondyle so as to relieve strain on the nerve upon the full range of motion of the elbow.
Jersey Finger Repair
Rothman Institute at Thomas Jefferson University
Rachel M. Drummey, MSc
University of Central Florida College of Medicine
Asif M. Ilyas, MD, MBA, FACS
Rothman Institute at Thomas Jefferson University
Jersey finger refers to an avulsion of the flexor digitorum profundus (FDP) at its insertion on the distal phalanx, the weakest point of the tendon. The injury frequently occurs during contact sports while grabbing the jersey of an opposing player as the player pulls or runs away. Surgical repair is the definitive treatment for all cases of complete rupture of the FDP tendon.
In this video article, Dr. Ilyas at the Rothman Institute demonstrates the suture anchor technique to repair a jersey finger. This approach was selected in place of the more traditional pull-out button technique for potentially stronger repair, no presence of external fixation devices, avoidance of button-related complications, and ease of rehabilitation.
Bilateral Posterior Retroperitoneoscopic Adrenalectomy with Cortical Sparing on Right Side
Yale School of Medicine
Taylor C Brown, MD, MHS
Yale School of Medicine
Tobias Carling, MD, PhD, FACS
Yale School of Medicine
Cortical-sparing adrenalectomy allows for the resection of adrenal tumors while preserving unaffected adrenal tissue to prevent adrenal insufficiency. This is especially important in patients with bilateral adrenal tumors, typically pheochromocytomas.
Posterior retroperitoneoscopic adrenalectomy (PRA) allows for a minimally invasive approach to adrenal gland resection compared with the more traditional laparoscopic transabdominal adrenalectomy and open approaches. This approach is ideal to address patients with bilateral disease and was used in this case of a 31-year-old female patient presenting with bilateral pheochromocytomas in the setting of multiple endocrine neoplasia 2A syndrome and coexisting medullary thyroid carcinoma of the right thyroid lobe. A close review of her imaging demonstrated normal-appearing adrenal cortex tissue on the right side that allowed for cortical-sparing adrenalectomy on that side.
Left Lumpectomy with Wireless Seed Localization for Ductal Carcinoma In Situ
Massachusetts General Hospital
Bridget N. Kelly
MGH
Carson L. Brown
MGH
Michelle C. Specht, MD
Operating Surgeon, MGH
The patient in this case is a 58-year-old postmenopausal woman who was seen for consultation regarding the management of newly-diagnosed ductal carcinoma in situ (DCIS) of the left breast detected on routine screening mammogram with no clinical or radiological evidence of lymph node involvement.
Breast-conserving surgery with radiation for early-stage breast cancers provides equivalent survival rates to mastectomy when all surgical margins are clear of residual cancer. For patients whose tumors are not palpable upon physical examination, preoperative localization of the malignant tissue to be removed is necessary.
In this video, Dr. Specht at MGH performs and narrates a lumpectomy using wireless seed localization to target the lesion and taking shave margins to reduce the risk of recurrence.