Category Archives: Fundamentals

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: 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: Drainage of Cystic Mass on First Left Toe

Drainage of Cystic Mass on First Left Toe
Jasmine Beloy1Jaymie Ang Henry, MD, MPH2Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2Florida Atlantic University
2Philippine Children’s Medical Center

Cutaneous cysts are closed, sac-like, or encapsulated structures that may be filled with air, liquid, or semi-solid material, and are generally benign. Many types of cysts can occur in almost any place throughout the body and can form in all ages. They are seen as slow-growing and painless lumps underneath the skin. However, some cysts may be painful if they are particularly large. Treatment depends on several factors including the type of cyst, location, size, and the degree of discomfort caused. Large, symptomatic cysts can be removed surgically, while smaller, asymptomatic cysts can be drained or aspirated. Here, we present the case of a 12-year-old male with a pus-filled cystic mass on his first left toe and discuss surgical management and follow-up.

PUBLISHED: Lipoma Excision

Lipoma Excision
John Grove1Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2
1Lincoln Memorial University – DeBusk College of Osteopathic Medicine
2Philippine Children’s Medical Center

Lipomas are slow-growing lumps that occur as a result of overgrowth of fat cells. They present as doughy, moveable, and non-tender lumps usually found underneath the skin; however, they may occasionally be deeper. Lipomas occur in 1 in every 1,000 people and commonly grow on the upper back, shoulders, and abdomen. In most cases, lipomas are painless unless they affect joints, nerves, or blood vessels. A physical examination is the easiest way to diagnose a lipoma; however, imaging studies and biopsy may aid in the diagnosis when they are large, have unusual features, or appear deep.

No treatment is usually necessary for a lipoma; however, if a lipoma is painful or growing, removal may be recommended by excision or liposuction. Here, we present a 35-year-old male who has a large and deep 8-year-old lipoma on his upper back. The lipoma was excised and sent for biopsy.

PUBLISHED: Sebaceous Cyst Excision

Sebaceous Cyst Excision
Casey L. Meier, RN¹; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES²
¹Lincoln Memorial University, DeBusk College of Osteopathic Medicine
²Philippine Children’s Medical Center

Sebaceous cysts are closed sacs filled with foul-smelling, cheese-like material found underneath the skin. They form when a gland or hair follicle becomes blocked and are commonly found on the scalp, face, neck, or torso. Sebaceous cysts are non-cancerous and usually present as painless lumps, but can become tender when infected.

In most cases, smaller sebaceous cysts may be ignored as they do not cause any symptoms; however, larger cysts may need to be removed with complete excision recommended to prevent recurrence. Oral antibiotics may be required when a sebaceous cyst becomes infected. Here is the case of a 33-year-old male patient who underwent complete resection of a 2-year-old cyst.

PUBLISHED: Ulnar Nerve Transposition (Cadaver)

Ulnar Nerve Transposition (Cadaver)
Irene Kalbian; Asif M. Ilyas, MD, MBA, FACS
Rothman Institute

Ulnar nerve transposition is a surgical procedure performed to treat ulnar nerve compression of the elbow, also known as cubital tunnel syndrome. This procedure is utilized after both non-operative management and in situ decompression fails, or if these procedures are deemed inappropriate based on patient pathology or ulnar nerve instability.

Transposition of the ulnar nerve involves not only decompression of the nerve but also its anterior repositioning to reduce compression and irritation while maintaining nerve integrity. This video demonstrates, on a cadaver arm, the operative technique for performing an ulnar nerve transposition using either a subcutaneous or a submuscular technique.

PUBLISHED: Excision of Epidermal Inclusion Cyst

Excision of Epidermal Inclusion Cyst

John Grove
Lincoln Memorial University – DeBusk College of Osteopathic Medicine

Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES
Philippine Children’s Medical Center

Epidermal inclusion cysts, also called keratin or epithelial cysts, are benign lumps that develop beneath the skin. They present as a slow-growing, painless lumps, usually with a punctum in the middle that represents the blockage of keratin excretion. Here, Dr. Lester Suntay with the World Surgical Foundation presents the case of a 64-year-old male with a mass on his upper back. It was noted to be gradually enlarging, and thus excision was performed in order to prevent further growth and infection.

PUBLISHED: Cubital Tunnel Release (Cadaver)

Cubital Tunnel Release

Asif M. Ilyas, MD
Professor of Orthopaedic Surgery
Program Director of Hand Surgery
Rothman Institute, Thomas Jefferson University

Cubital tunnel syndrome is a condition that affects the ulnar nerve as it crosses the medial elbow through the retrocondylar groove. It is the second most common compressive neuropathy, causing tingling and numbness in the ring and small fingers. In advanced cases of symptomatic cubital tunnel syndrome, weakness, altered dexterity, and atrophy of the intrinsic muscles of the hand may develop. Cubital tunnel syndrome can be treated with either a cubital tunnel release or an ulnar transposition. In this case, the former is demonstrated on a cadaveric arm using the mini-open technique.

PUBLISHED: Carpal Tunnel Release (Cadaver)

Carpal Tunnel Release (Cadaver)

Asif M. Ilyas, MD
Professor of Orthopaedic Surgery
Program Director of Hand Surgery
Rothman Institute, Thomas Jefferson University

Carpal tunnel syndrome (CTS) is the most common peripheral compression neuropathy and results in symptoms of numbness and paresthesia in the thumb, index finger, middle finger, and half of the ring finger. When CTS symptoms progress and can no longer be managed with nonoperative measures, carpal tunnel release (CTR) surgery is indicated.

In this case, Dr. Asif Ilyas at the Rothman Institute performs CTR surgery on a cadaveric arm via the mini-open CTR technique. A 2-cm longitudinal incision was placed directly over the carpal tunnel, the transverse carpal ligament was exposed and then released, and the wound was closed. Patients are typically sent home with instructions to use their hand immediately postoperatively, while avoiding strenuous use until the incision has healed. Splinting and therapy are not required postoperatively.

PREPRINT RELEASE: Sebaceous Cyst Excision

Sebaceous Cyst Excision
Romblon Provincial Hospital

Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES
World Surgical Foundation, Philippines
Training Officer of the Division of Pediatric Surgery
Philippine Children’s Medical Center

In this case, Dr. Lester Suntay performs an excision of a 2-year-old sebaceous cyst from the face of an adult male.