Category Archives: Content

PUBLISHED: Local Tissue Advancement: Reconstructing Superior Helical Rim Defect and Exposed Ear Cartilage After Mohs Surgery

Local Tissue Advancement: Reconstructing Superior Helical Rim Defect and Exposed Ear Cartilage After Mohs Surgery
Cheryl Yu, MD1Derek Sheen, MD2Katherine M. Yu, MD1Sarah Debs, MD1Peter Kwak, MD1Kevin J. Quinn, MD3Thomas Lee, MD, FACS1
1Virginia Commonwealth University Medical Center
2University of Texas Southwestern Medical Center
3Mass Eye and Ear/Harvard Medical School

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.

PUBLISHED: Cystoscopy and Placement of Ureteral Stents: Preoperative for HIPEC Surgery

Cystoscopy and Placement of Ureteral Stents: Preoperative for HIPEC Surgery
Francis McGovern, MD
Massachusetts General Hospital

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.

PUBLISHED: Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement
Katherine H. Albutt, MD
Massachusetts General Hospital

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.

PUBLISHED: Pulmonary AVM Embolization

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.

PUBLISHED: Epidural at T9-T10: Preoperative for HIPEC Surgery

Epidural at T9-T10: Preoperative for HIPEC Surgery
Xiaodong Bao, MD, PhD
Massachusetts General Hospital

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.

PUBLISHED: Portal Placement for Hip Arthroscopy

Portal Placement for Hip Arthroscopy
Steven D. Sartore1Scott D. Martin, MD2
1Lake Erie College of Osteopathic Medicine
2Brigham and Women’s/Mass General Health Care Center

Hip arthroscopy is a well-established technique that has become a mainstay in the repair of bony and ligamentous injuries when conservative methods fail to return adequate joint mobility and function. The technique has both diagnostic and therapeutic utility and its use as a minimally invasive orthopedic surgery continues to advance. Several studies have suggested that arthroscopic surgical management has more favorable outcomes in certain circumstances when compared to hip-specific conservative measures.

The approach to establishing adequate sites for portal placement is dependent upon recognizing the pertinent anatomy of the surgical site.  At the same time, the operator must be mindful of the desired views once access to the joint space has been obtained. Proper visualization of the desired joint region is critical to reducing the conversion of THAs into inherently riskier total joint procedures. Additionally, the neurovascular landscape of the groin presents technical challenges with the procedural approach, which requires significant skill to avoid vital structures in the area. Acetabular labral tears are frequently repaired with this type of operative management as techniques and approaches become more refined. Here, the authors present the case of a 24-year-old woman who is undergoing an arthroscopic anterior labral repair, highlighting both the anatomical landmarks and the access points for portal placement used in the procedure.

PUBLISHED: Left Laparoscopic Donor Nephrectomy

Left Laparoscopic Donor Nephrectomy
Shoko Kimura, MDTatsuo Kawai, MD
Massachusetts General Hospital

Over the past decade, laparoscopic donor nephrectomy has gradually replaced the conventional open approach and has become the standard of care in living donor kidney transplantations. Compared to open nephrectomy, laparoscopic nephrectomy reduces postoperative pain, shortens the length of hospital stay, and improves the cosmetic outcome. This article illustrates the author’s technique of pure laparoscopic donor nephrectomy.

PUBLISHED: Emergent Right Frontal Camino Bolt Placement for Intracranial Pressure Monitoring for a GCS Under 8

Emergent Right Frontal Camino Bolt Placement for Intracranial Pressure Monitoring for a GCS Under 8
Nathaniel D. Sisterson, MD, MScBrian Hsueh, MD, PhD; Katherine H. Albutt, MD
Massachusetts General Hospital

Intracranial hypertension is a critical concern in traumatic brain injury (TBI), with elevated intracranial pressure (ICP) significantly impacting patient outcomes. ICP monitoring is an essential component in managing patients with various brain pathologies that can lead to dangerously elevated intracranial pressure. In neurosurgical practice, accurate monitoring and timely intervention are critical when dealing with the challenges of intracranial hypertension, and its timely resolution is crucial for preventing severe neurological sequelae and fatal outcomes.

The risk of Infections or hemorrhage of significance associated with ICP devices, which can lead to patient morbidity, usually do not outweigh the benefit of continuous ICP monitoring in TBI. Therefore, these should not deter the decision to monitor ICP.

This video provides step-by-step visual guidance for placing a right frontal Camino bolt to guide optimal patient care. In this clinical case a patient presents without prior opportunity for clinical exam and with reported signs of a cranial hemorrhage, coupled with a right occipital fracture, thereby requiring ICP monitoring to proceed with further neurosurgical care.

PUBLISHED: Airway Assessment for Trauma Patients

Airway Assessment for Trauma Patients
Stephen Estime, MDAbdullah Hasan Pratt, MDNicholas G. Ludmer, MD
UChicago Medicine

Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.

In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․

PUBLISHED: Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis

Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis
Derek Sheen, MD1Cheryl Yu, MD2Sarah Debs, MD2Katherine M. Yu, MD2Alyssa N. Calder, MD2Kevin J. Quinn, MD3Dimitrios Sismanis, MD4Thomas Lee, MD, FACS2
1University of Texas Southwestern Medical Center
2Virginia Commonwealth University Medical Center
3Mass Eye and Ear/Harvard Medical School
4Virginia Oculofacial Surgeons

Orbital floor fractures represent common sequelae of facial trauma that may result in significant functional and aesthetic consequences. This article presents a comprehensive overview of the management of a revision case involving an orbital floor fracture, focusing on complications related to extruded, infected orbital hardware. In addition, common mistakes that involve improper placement of orbital floor implant, poor implant sizing, and lack of adequate implant fixation are discussed.

The featured case involves delayed wound healing and a sino-orbital cutaneous fistula (SOCF) due to infected orbital hardware from a previous orbital floor fracture repair. The discussion centers on preoperative planning, including the choice of surgical approach (transconjunctival with lateral canthotomy) and implant material. Intraoperative neuronavigation was utilized as an adjunctive tool to confirm the position of the newly placed orbital implant. This case provides valuable insight on preventable complications for this procedure, nuances in surgical approach, and uncommon challenges faced by providers who perform operative facial trauma repair.