Primary leiomyosarcomas of the inferior vena cava (IVC) are rare tumors with complex anatomical relationships. Surgical resection remains the primary approach for management, with selective use of preoperative radiation and chemotherapy. Given the propensity for local invasion of these tumors, radical resection of surrounding structures is often required.
This article describes the presentation, work-up, operative management, and outcomes of these lesions through the case of a patient with a tumor involving the middle segment of the IVC. Given the extent of involvement, IVC resection with en bloc right nephrectomy, right adrenalectomy, and partial left renal vein resection was performed with vascular reconstruction using a prosthetic graft. With appropriate preoperative planning and a well-coordinated multidisciplinary approach, aggressive surgical resection can be safely performed and patients can benefit from favorable long-term survival.
The primary survey of every trauma patient begins with ABC: airway, breathing, circulation. If the patient is deemed to require airway management, endotracheal intubation may be performed utilizing rapid sequence intubation (RSI). In RSI, an induction agent and a rapid-acting neuromuscular blocking agent (NMBA or paralytic) are administered and intubation is performed as soon as unconsciousness and paralysis are achieved. Trauma patients may require intubation for a number of reasons. This video review focuses on the pharmacology, dosing, and other considerations for use of common medications for pretreatment, paralysis with induction, and post-intubation management in trauma patients.
A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within this space as a sequelae of chest trauma (penetrating or blunt), iatrogenic injury (e.g., vascular access injuries), or spontaneously (e.g., due to malignancy). To treat the condition, a chest tube is inserted into the thoracic cavity on the affected side of the body. In addition to evacuating blood from the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space) and pleural effusion (e.g., empyema or chylothorax), and to insert medications into the pleural space. Depending on the specific pathology, a tube or catheter may be utilized.
Central venous access is a crucial aspect in the management of patients requiring long-term therapies, particularly surgical patients. These therapies include the administration of therapeutic agents, fluid administration, antibiotic therapy, parenteral nutrition, etc. The procedure involves the placement of a catheter into a venous great vessel. Three main sites for central venous access are: internal jugular vein, common femoral vein, and subclavian veins.
In resource-constrained settings, healthcare professionals must rely on their clinical practice and proficiency in performing procedures without the aid of advanced imaging modalities. One such procedure is the infraclavicular subclavian vein cannulation, which can be performed without ultrasonographic guidance, providing a reliable means of obtaining central venous access. Here, this is demonstrated on a pediatric preoperative patient during a surgical mission in Honduras.
Coronal Approach (Cadaver) Felix L. Hong, DDS; Mark R. Rowan, MD, DDS; R. John Tannyhill, III, MD, DDS, FACS Harvard Medical School
For treatment of facial trauma such as a frontal sinus fracture, orbital fractures, or zygoma fractures, the coronal or bi-temporal approach is used. The approach can also be used for superficial temporal artery biopsy. This approach exposes the anterior cranial vault, forehead, and upper and middle regions of the facial skeleton including the zygomatic arch. It provides access to these areas with minimal complications and cosmetically acceptable hidden scars. The subperiosteal or subgaleal planes are commonly used for coronal flap dissection. This article presents a demonstration of the coronal approach to exposing the upper or middle facial skeleton in a cadaver.
Open Distal Gastrectomy Andrea L. Merrill, MD; John T. Mullen, MD Massachusetts General Hospital
A complete margin-negative (R0) resection remains the only potentially curative treatment for gastric adenocarcinoma. The choice of operation depends on the location of the tumor as well as the stage of disease. This patient presented with symptomatic anemia, and workup demonstrated gastritis and a small tumor in the distal stomach. Biopsies confirmed adenocarcinoma, and an endoscopic ultrasound (EUS) staged this tumor as T2 N0. Staging scans showed no evidence of distant metastatic disease. Given that this patient had a relatively early stage tumor, they elected to proceed with upfront surgery, which in this case entailed a distal gastrectomy. This video shows an experienced gastric surgeon’s technique for performing an open distal gastrectomy with an “extended” D1 lymph node dissection.
Pediatric burns are one of the most common forms of injury affecting children worldwide. Of these, hand involvement occurs in 80–90% of such incidents. With the skin in children already diffusely thinner throughout the body than adults, this provides a particular challenge for areas naturally possessing thinner skin, such as the dorsal hand. There, the cutaneous tissue is the only protection for vital structures in the hand that allow full function, such as extensor tendons, nerves, and vessels. Injury to this area early in life can have a detrimental impact on how the survivor interacts with the physical world, affecting their functional capacity and quality of life.
Here presents a case of burn contractures on the right hand of an 8-year-old boy that will be released using a split-thickness graft, along with a pigment transfer graft for his left knee and fractional CO2 laser therapy over areas of hypertrophic scar tissue on his bilateral upper extremities. The split-thickness graft will greatly decrease the tension built up from the burn contracture, while the fractional CO2 laser procedure can soften the surrounding scar, allowing mild remodeling and increased range of motion.
Laparoscopic lysis of adhesions is a minimally-invasive approach to the resolution of a closed loop small bowel obstruction (SBO) due to adhesions. A patient with an SBO can present with nausea, vomiting, abdominal pain, and obstipation. History of prior abdominal surgeries serves as a significant risk factor for development of intra-abdominal adhesions. Imaging using either plain abdominal radiography or computed tomography (CT) can be diagnostic for closed loop SBOs. Conservative management with gastrografin can be considered in some SBOs, but closed loop SBOs are considered surgical emergencies. Utilization of specific signs (two transition points, pneumoperitoneum, signs of bowel ischemia) on imaging and patient presentation can facilitate earlier intervention.
Laparoscopic lysis of adhesions can resolve symptoms through releasing the bowel from the adhesion to improve flow. Lysis of adhesions can be performed open, laparoscopically, or with robotic techniques. This case presents a laparoscopic lysis of adhesions in a patient with a closed loop small bowel obstruction.
This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.
With the increasing use of computed tomography (CT) for screening and diagnostic workup, increasing numbers of patients are found to have pulmonary nodules. The patient in this case presented with vision changes, neck weakness, and dysphagia. Workup revealed non-thymomatous myasthenia gravis as well as an incidental right lower lobe lung nodule that was suspicious for malignancy based on imaging characteristics, interval growth, and history of breast cancer.
She required a lung resection for diagnostic and therapeutic purposes. Additionally, a thymectomy was indicated to help control her myasthenia gravis symptoms. Consequently, a combined approach was conducted.
