Laparoscopic appendectomy (LA) is a minimally-invasive technique distinguished by the utilization of small incisions through which an endoscopic camera and specialized instruments are introduced to facilitate the excision of an inflamed vermiform appendix. This LA video serves as an educational tool, offering unique insights into complex surgical scenarios. It demonstrates real-time decision-making in the face of adhesions from previous surgery, showcasing how to adapt standard techniques to challenging anatomy. The video provides a clear visualization of advanced laparoscopic skills, including safe adhesiolysis, cautious dissection, and proper use of surgical devices. It emphasizes critical aspects of surgical safety, team communication, and complication management.
Percutaneous Endoscopic Gastrostomy (PEG) is a minimally-invasive medical procedure that creates a safe and effective route for enteral nutrition, fluid administration, and medication delivery. PEG tubes are primarily used for long-term enteral nutrition in patients with impaired swallowing or inadequate oral intake, decompression of the gastrointestinal tract, and administration of medications. This detailed video demonstration of the PEG tube placement procedure is a crucial educational resource for medical professionals. It provides comprehensive visualization of a complex procedure, demonstrates real-time problem-solving, emphasizes safety considerations, and offers valuable tips for practitioners.
Radical neck dissection was once the standard of care for the surgical management of patients with thyroid cancer and cervical lymph node metastases. However, due to the significant morbidity of this procedure, the development of cervical lymphadenectomy procedures that could provide oncologic cure while minimizing morbidity was undertaken by many surgeons. Such an investigation has led to the development of the modified radical neck dissection (MRND). Still, many institutions are not familiar with performing a comprehensive MRND in the setting of thyroid cancer metastatic to the lateral lymph node compartments. This article presents such an operation under general anesthesia.
Uterine fibroids, also known as leiomyomas, are usually benign masses that are most commonly found in women of reproductive age. Fibroids are usually asymptomatic and tend to be incidental findings on ultrasound. When clinically relevant, however, patients report symptoms such as menorrhagia, pelvic pain, and bulk-related symptoms.
Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally-invasive uterine artery embolization, but the treatment is largely surgical.
There are many different surgical approaches that can be utilized, including myomectomy or hysterectomy. Treatment of choice depends on multiple factors, including the severity of symptoms, size of fibroids, and patient’s desire to preserve fertility. However, out of all of the different surgical techniques available, hysterectomy is the only definitive treatment for these patients. Here, an abdominal hysterectomy was performed on a 45-year-old patient with symptomatic uterine fibroids.
An inguinal hernia (IH) is a protrusion of intra-abdominal contents through the inguinal canal that can arise at any time from infancy to adulthood. It is more common in males with a lifetime risk of 27% as compared to 3% in females. Most pediatric IHs are congenital and caused by failure of the peritoneum to close, resulting in a patent processus vaginalis (PPV). IH present as a bulge in the groin area that can become more prominent when crying, coughing, straining, or standing up, and disappears when lying down. Diagnosis is based on a thorough medical history and physical examination, but imaging tests such as ultrasound can be used when the diagnosis is not readily apparent. IHs are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring. In infants and children, IH are always operated on to prevent incarceration.
Surgical correction in infants and children is done by high ligation of the hernia sac only, called a herniotomy. Here, we present a female infant with bilateral IH. Upon exploration, a hernia sac was found, and ligation was performed bilaterally. In female patients, it is believed that failure of the closure of the canal of Nuck alongside the round ligament of the uterus is the etiology. Oftentimes there is a “sliding hernia” where the ovary and or the fallopian tube is attached to the sac, sometimes the uterus itself is attached.
Gastrogastric fistula is a rare complication following a Roux-en-Y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy.
Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. This article presents a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.
Thyroidectomy (Cadaver) Kristen L. Zayan, BS1; Adam Honeybrook, MBBS2; C. Scott Brown, MD2; Daniel J. Rocke MD, JD2 1University of Miami Miller School of Medicine 2Duke University Medical Center
Thyroidectomy may be performed for various pathologies, consisting of either thyroid lobectomy or total gland removal. Both benign and malignant disease processes necessitate surgical intervention. Thyroid nodules, compressive thyroid goiter, or persistent thyrotoxicosis represent some of the benign indications. Malignant conditions affecting the thyroid include papillary, follicular, medullary, and anaplastic carcinomas. In the present case, a thyroidectomy via standard cervical incision is performed on a cadaver with overlying animations to emphasize the key anatomy. The discussion is in relation to a patient with obstructive goiter presenting with worsening wheezing, cough, and dysphagia, with the ultimate goal of relieving the compressive symptoms through the removal of the gland.
Pleural effusions are frequently observed in a variety of conditions. Reasons for intervention include obtaining an underlying diagnosis as to the cause and providing symptom relief. One of the most frequent causes of a recurrent pleural effusion is malignancy, which will typically continue to accumulate for as long as the cancer is progressing. When patients have a rapidly recurring effusion, requiring frequent intervention by way of thoracentesis or chest tube, other options for management are considered. An indwelling pleural catheter (IPC) can be offered to a patient to help drain the effusion on a regular basis, without requiring repeat thoracentesis. The goal of the drain placement is to provide symptom relief, and it is often in place for as long as the patient has an appreciable effusion that can be drained intermittently by vacuum canisters.
This case presentation involved a female patient with breast cancer who underwent a lumpectomy and sentinel lymph node biopsy using the Lumicell system for intraoperative detection of residual cancer. The aim was to detect residual tumor cells during the initial operation and avoid subsequent surgeries. This video provides a thorough presentation of lumpectomy and sentinel lymph node biopsy utilizing the Lumicell system to detect any remaining cancer during surgery. The video covers the entire process, from preoperative preparation to the final step of skin closure.
Cystic Fibrosis (CF) is an autosomal recessive genetic disorder characterized by mutations in the cystic fibrosis transmembrane regulator gene. The pathophysiology is based on abnormal chloride secretion from columnar epithelial cells. As a result, patients with CF have symptoms related to their inability to hydrate secretions in the respiratory tract, pancreas, and intestine, among other organs. In the lung, thick, inspissated secretions give rise to chronic obstructive pulmonary disease characterized by severe pulmonary infections, culminating in respiratory failure. Subacute exacerbations of CF lung disease are treated with antibiotics and various forms of chest physiotherapy. When large areas of the lung develop abscesses or necrosis, surgical treatment is often indicated. Options include lobectomy as a temporizing measure and lung transplantation for end-stage CF lung disease.
This article presents an unusual case of a man with CF whose lung function had remained relatively good until adulthood. His left upper lobe became chronically infected and progressively non-functional. Because the patient’s overall lung function was moderately preserved, an open left upper lobectomy was performed to prevent recurrences of subacute infections and subsequent damage to the left lung.
