Category Archives: General Surgery

General Surgery, Press Release

PUBLISHED: Robotic Abdominoperineal Resection (APR) with Bilateral Gracilis Muscle Flaps

Robotic Abdominoperineal Resection (APR) with Bilateral Gracilis Muscle Flaps
Eleanor Tomczyk, MD; Todd Francone, MD
Newton-Wellesley Hospital

Robotic APR with bilateral gracilis flap reconstruction is a vital procedure for managing advanced and metastatic rectal cancer. It offers a precise, minimally-invasive approach that addresses both tumor removal and functional reconstruction, providing significant benefits for patients requiring complex oncological and reconstructive surgery. This step-by-step video guideline is crucial for advancing surgical techniques in complex rectal cancer treatment. It serves as a vital educational resource for surgeons at all levels, demonstrating the combination of APR with gracilis flap reconstruction. The video’s importance lies in its ability to standardize the procedure, showcase innovative techniques, and highlight critical aspects that are difficult to convey through text alone. Providing detailed visual instruction on navigating challenges helps prevent complications and improve patient outcomes.

General Surgery, Print Release

PUBLISHED: Robotic End Colostomy Reversal

Robotic End Colostomy Reversal
George Velmahos, MD, PhD
Massachusetts General Hospital

The case presented in the video illustrates a complex clinical scenario involving a young male patient who sustained multiple traumatic injuries in a motorcycle collision. Following initial emergency management that included an exploratory laparotomy with sigmoid transection and subsequent end colostomy, the patient now undergoes robotic-assisted colostomy reversal. This approach represents an advanced surgical technique that uses minimally-invasive technology to address challenging postoperative reconstructive needs. Robotic-assisted surgery offers several advantages in colostomy reversal, such as better dissection precision and improved surgical field visualization. This video shows how cutting-edge technology improves surgical outcomes, reduces recovery time, and solves complex challenges. It is a valuable resource for medical professionals, especially surgeons and trainees, looking to deepen their understanding of advanced colorectal surgical interventions.

General Surgery, Print Release

PUBLISHED: Open Epigastric Hernia Repair Without Mesh for a 1-cm Incarcerated Hernia

Open Epigastric Hernia Repair Without Mesh for a 1-cm Incarcerated Hernia
Shirin Towfigh, MD
Beverly Hills Hernia Center

Epigastric hernias, predominantly described in the literature as small defects containing mostly preperitoneal fat, are located in the linea alba between the xiphoid process and the umbilicus. The risk of incarceration in epigastric hernias is influenced by the size of the defect. It has been observed that smaller epigastric hernias, particularly those less than 1 cm in diameter, have a higher risk of incarceration compared to larger ones. Various treatment options are available for epigastric hernias, including laparoscopic and open surgical approaches. This video describes an open epigastric hernia repair without mesh for a 1-cm incarcerated hernia. The technique demonstrated addresses both the correction of the hernia and the prevention of recurrence, which is crucial given the higher incarceration rates associated with smaller hernias. This video demonstration of an open epigastric hernia repair without mesh for a 1-cm incarcerated hernia provides valuable insights for surgical trainees, general surgeons, and hernia specialists. The technique showcased is particularly useful for small epigastric hernias and in cases where a rectus diastasis is present.

Acute Care Surgery, General Surgery, Print Release

PUBLISHED: Repeat Exploratory Laparotomy for Encapsulating Peritoneal Sclerosis

Repeat Exploratory Laparotomy for Encapsulating Peritoneal Sclerosis
Joshua Ng-Kamstra, MD, MPH
Massachusetts General Hospital

Encapsulating peritoneal sclerosis (EPS), also known as encapsulating sclerosing peritonitis is a rare but serious condition that is characterized by the formation of a thick, fibrotic layer encasing the small bowel. The pathophysiology involves an inflammatory process that triggers excessive fibrin deposition and collagen production, resulting in the development of a thick, cocoon-like membrane around the intestines. This video is an in-depth demonstration of a complex surgical case involving a repeat exploratory laparotomy for bowel obstruction, with a focus on careful dissection of adhesions, managing serosal tears, and ensuring hemostasis. It is particularly valuable for surgeons, surgical trainees, and medical professionals specializing in emergency abdominal surgery.

General Surgery, Print Release

PUBLISHED: Open Umbilical Hernia Repair Without Mesh for a 1-cm Hernia

Open Umbilical Hernia Repair Without Mesh for a 1-cm Hernia
Shirin Towfigh, MD
Beverly Hills Hernia Center

Umbilical hernias are common abdominal wall defects that occur when intra-abdominal contents protrude through the umbilical opening in the abdominal muscles. This article focuses on the detailed surgical technique for open umbilical hernia repair without mesh for a 1-cm hernia, emphasizing both functional and aesthetic outcomes. This video demonstration and accompanying description serve as valuable educational resources for surgical trainees, general surgeons, and plastic surgeons seeking to refine their techniques for small umbilical hernia repairs. The step-by-step approach, rationale for each decision, and emphasis on both functional and cosmetic outcomes provide insights that can help surgeons optimize their results in umbilical hernia repair.

General Surgery, Print Release

PUBLISHED: Complex Abdominal Wall Reconstruction with Transversus Abdominis Release (TAR)

Complex Abdominal Wall Reconstruction with Transversus Abdominis Release (TAR)
Michael J. Rosen, MD, FACS
Cleveland Clinic

This video demonstrates a case involving an open complex abdominal wall reconstruction with transversus abdominis release. The case involves an obese patient with a multiply recurrent incarcerated incisional hernia. The CT scan shows a complex defect involving the midline, right linea semilunaris, and inter-rectus hernia. The use of a retromuscular procedure with a posterior component separation will be highlighted and its advantages of allowing wide mesh overlap without creation of subcutaneous tissue flaps to repair defects with these challenging characteristics.

General Surgery, Print Release, Thoracic Surgery

PUBLISHED: Left Tube Thoracostomy for Pneumothorax

Left Tube Thoracostomy for Pneumothorax
Ryan Boyle1; Elliot Bishop, MD2; Peter Bendix, MD2
1 Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University
2University of Chicago Medicine

The clinical presentation of pneumothorax ranges from no symptoms to life-threatening tension physiology requiring emergent intervention. The thoracic cavity is lined with parietal while the lungs and mediastinal structures are lined with visceral pleura. Normally in apposition, a potential space exists between these two layers where fluid, air, or a combination of the two may accumulate. If this potential space fills with fluid or air, subsequent collapse of the lung tissue causes symptoms such as shortness of breath and tachypnea. If the fluid or air accumulate to the degree that venous cardiac return is impeded, tension physiology ensues with hypotension, tachycardia, and eventual cardiovascular collapse if the pressure is not relieved. Tube thoracostomy remains the treatment of choice for managing pneumothorax. This article presents the management of a traumatic pneumothorax with tube thoracostomy in a 51-year-old male injured in a motor vehicle collision.

General Surgery, Print Release

PUBLISHED: Whipple Procedure for Carcinoma of the Pancreas

Whipple Procedure for Carcinoma of the Pancreas
Martin Goodman, MD1; Vahagn G. Hambardzumyan, MD2
1Tufts University School of Medicine
2Yerevan State Medical University, Heratsi Hospital Complex

Pancreatic ductal adenocarcinoma (PDAC) is the ninth most common cancer in the United States, but due to symptoms—such as back pain, jaundice and unexplained weight loss—usually only presenting when the disease has already moved beyond the pancreas, it is highly lethal, representing the fourth most common cause of cancer death. As a result of widespread abdominal imaging, more early stage pancreatic cancers are being diagnosed, and these patients are candidates for a pancreaticoduodenectomy, more commonly known as the Whipple procedure.

The Whipple procedure is used to treat four types of cancer—periampullary, cholangiocarcinoma, duodenal, and pancreatic ductal adenocarcinoma—but is most well known in the setting of PDAC. Although there are only a few basic steps to the procedure—removal of  the pancreatic head, distal bile duct, duodenum, and either distal gastrectomy or pyloric preservation. Next is the reconstruction with bringing up the stapled end of jejunum to the pancreas, then the hepatic duct, and lastly to the stomach. The multiple crucial anatomic structures in the same region, as well as the unforgiving nature of the structures involved in the operation itself, lead to high morbidity and necessitate complex postoperative care. Due to this, most Whipple procedures are performed at higher volume centers.

Basic Skills for the OR, General Surgery, Print Release

PUBLISHED: Nasogastric (NG) Tube Insertion

Nasogastric (NG) Tube Insertion
Deanna Rothman, MD
Massachusetts General Hospital

Nasogastric (NG) tube insertion is a crucial skill in medical practice that involves the placement of a flexible tube through the nasal passage into the stomach, serving multiple purposes in patient care. This video article aims to provide a detailed overview of NG tube insertion, including its indications, contraindications, necessary materials, and the step-by-step process of placement.

General Surgery, Pediatrics, Print Release, Urology

PUBLISHED: Cloacal Exstrophy Repair

Cloacal Exstrophy Repair
William Remley1; Howard Jen, MD2; Carl-Christian A. Jackson, MD2; Jeremy Wiygul, MD2
1Lake Erie College of Osteopathic Medicine
2Tufts Medical Center

Cloacal exstrophy is congenital malformation marked by an abdominal wall defect with open and exposed hindgut and bladder. It is the most severe birth defect within the exstrophy-epispadias complex, and when spinal defects are also present, it is called the OEIS (omphalocele, exstrophy, imperforate anus, and spinal defect) complex. Cloacal exstrophy is rare, occurring in 1/200,000–400,000 births, but it can be diagnosed on prenatal ultrasound. The defect results in two exstrophied hemibladders separated by an exposed cecal plate, with the distal hindgut being foreshortened and blind-ending, resulting in an imperforate anus. There is diastasis of the pubic symphysis, and the genitalia are separated. In males, the phallus is usually split in half, flattened and shortened, with the inner surface of the urethra exposed. In females, the clitoris is split, the labia are widely separated, and there may be two vaginal openings. Cloacal exstrophy is also highly associated with other birth defects, especially spina bifida, which coexist in up to 75% of cases. Multidisciplinary care followed by surgical management should begin immediately following the baby’s delivery.

Surgical goals in the neonatal period include closure of the meningocele and repair of the exstrophy and omphalocele, resulting in approximation of the bladder halves and repair of the hindgut defect with colostomy creation. Closure of the bladder, with positioning within the pelvis, can either occur at the initial operation or be staged to occur after a period of monitored growth, and is best performed with pelvic osteotomies to protect the closure from tension. Subsequent surgeries over several years will address genital reconstruction and colonic pull-through for fecal continence, if the patient is a candidate. Here, we present a patient diagnosed with OEIS complex by prenatal ultrasound, with a postnatal exam confirming the diagnosis and demonstrating a closed (covered) myelomeningocele. The cloacal exstrophy and omphalocele were repaired in one stage, with primary closure of the involved bowel and the bladder, facilitated by pelvic osteotomies.