Current evidence supports the use of robotic surgery as a method of minimally-invasive treatment for adrenal masses. This article presents the case of a robotic adrenalectomy (RA) for an adrenal tumor. Upon examination of the extracted 1.5-cm specimen, it exhibited typical characteristics of aldosterone-producing adenoma, including a golden tan color, well-circumscribed borders, and surrounding normal adrenal gland tissue and fat. The detailed demonstration of this surgical procedure in the accompanying video provides a thorough understanding of the latest advancements in robotic adrenal surgery, offering comprehensive insights into the nuanced techniques and emerging trends in the field.
This video describes the surgical technique for an open duodenal resection and antrectomy, which was performed for a neuroendocrine tumor of the duodenal bulb. In this procedure, an upper midline laparotomy is first made, followed by mobilization of the distal stomach, duodenum, and head of the pancreas. Next is to Kocherize the duodenum, then ligate that right gastric artery and dissect the gastrohepatic ligament, followed by ligation of the right gastroepiploic vessels and taking down the gastrocolic ligament exposing the lesser sac. Once the structures are adequately mobilized, the first portion of the duodenum is dissected off of the head of the pancreas and transected with a TA stapler. The antrectomy is performed next, removing the specimen. For the reconstruction, a retrocolic end-to-side hand-sewn gastrojejunostomy was performed. This technique can be used for multiple indications, including peptic ulcer disease and other mass lesions of the antrum, pylorus, or duodenal bulb.
Patients who undergo longitudinal sleeve gastrectomy (LSG) may develop de novo or worsening of existing gastroesophageal reflux (GERD) symptoms, which include postprandial retrosternal burning, food refluxing, or dysphagia. Often patients with GERD following LSG present with a concomitant hiatal hernia. Workup serves to characterize a patient’s GERD disease burden by way of fluoroscopic upper gastrointestinal (UGI) series, pH studies, manometry, or esophagogastroduodenoscopy (EGD). Treatment first involves medical management with lifestyle modifications followed by use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If GERD symptoms remain intractable to medical management, surgical intervention can be pursued.
Historically patients would undergo a conversion to a Roux-en-Y gastric bypass (RYGB). New data demonstrate comparable outcomes regarding GERD symptoms and improvements in anti-reflux medication use in patients status-post LSG who undergo ligamentum teres cardiopexy with hiatal hernia repair. This article describes a robotic ligamentum teres cardiopexy with hiatal hernia repair in an adult patient who previously underwent LSG and was experiencing intractable GERD symptoms despite lifestyle modification and optimization on anti-reflux medications.
Intraperitoneal Mesh Repair for Incisional Hernia William B. Hogan1; Yoko Young Sang, MD2; Shabir S. Abadin, MD, MPH3 1Warren Alpert Medical School of Brown University 2Louisiana State University Shreveport 3World Surgical Foundation
Incisional hernias remain an important postoperative complication of any procedure involving a laparotomy incision. Although most incisional hernias remain asymptomatic, incarceration and strangulation are emergent complications requiring prompt diagnosis and intervention. Mesh repair has become widely favored over simple suture repair of abdominal fascial defects in recent decades, though recurrence of incisional hernias remains high. Despite the advent of laparoscopic approaches to hernia repair, open approaches are utilized when numerous adhesions are encountered, laparoscopic access is unsafe, or when laparoscopy is not readily available. We present an open surgical repair of a large incisional hernia involving the abdominal midline and parastomal site in a woman with a history of laparotomy and colostomy with a subsequent reversal for a perforated colon.
Airway Management: Techniques and Equipment Dany Accilien, MD*, Dexter C. Graves, MD*, Nicholas Ludmer, MD†, Stephen Estime, MD†, Abdullah Hasan Pratt, MD UChicago Medicine
This video article discusses airway management techniques in trauma resuscitation. It outlines the preparation and equipment used in patients with impending airway failure that require airway protection and ventilatory support. We discuss the innovative airway towers used in the University of Chicago emergency room as well as the general approach to airway management. We also go over the different types of laryngoscopy, assist devices, and cricothyroidotomy surgical airway procedures.
Occasionally, the treatment of breast cancer requires the removal of the breast while also leaving a large chest skin deficit. Especially if radiation has been done or is planned, the best way to restore the missing skin to preserve its essential function would be by the use of a vascularized flap. Sometimes this can be achieved while simultaneously providing a reconstruction of a very aesthetic breast mound. Depending on circumstances and the extent of disease, a simpler solution might be to just close only the chest wound that has been created.
A “workhorse” flap alternative that is almost always available to achieve this is the latissimus dorsi (LD) muscle from the back, as this can be moved to almost all regions of the chest. The LD muscle usually can be swung to the chest about its blood vessels that remain attached to the armpit, and so would be called a local flap that as such avoids the complexities of a transfer requiring microsurgery to reconnect the blood supply. The long-term experience by reconstructive surgeons in using the LD muscle as a local flap, not just for the chest but also the back, head, and neck, has proven its deserved accolade to be a versatile flap unparalleled by most other donor sites.
A left lower quadrant partial-thickness Spigelian-type incisional hernia resulting from wound complications after deep inferior epigastric perforator (DIEP) flap harvest is repaired in a minimally-invasive, robotic-assisted, transabdominal preperitoneal (TAPP) fashion. Utilizing robotic assistance, a large preperitoneal flap is created, fascial closure is achieved using barbed suture, and the hernia defect is reinforced widely with medium-weight polypropylene mesh. In this patient, this approach also allows for areas that had previously had mesh placed to be avoided, and for repair of a fat-containing indirect left inguinal hernia. Similar approaches can address primary or lateral incisional hernias. This patient had an uncomplicated postoperative course without early wound morbidity.
An open colectomy is the resection of all or part of the colon, typically through a midline incision in the abdomen. This procedure is often indicated for the treatment of colonic diseases such as bowel obstruction, diverticulitis, inflammatory bowel disease, and colon cancer. The patient in this case was a C6 quadriplegic male who presented with colon cancer near the splenic flexure. He also suffered from colonic dysmotility and severe constipation. He was treated with an open left colectomy through an upper midline laparotomy.
Regarding the procedure, once the abdomen was entered, the peritoneal cavity was explored, and the tumor was identified. The colon was mobilized, starting with the transverse colon, which was extended laterally to take down the hepatic flexure followed by mobilization of the right colon in a lateral-to-medial fashion. Next, the splenic flexure was mobilized followed by the descending colon, again in a lateral-to-medial fashion. Once mobilized, the margins of transection were identified, and the intervening mesocolon was ligated in a cut and tie fashion. The colon was then transected using and ILA stapler to include the distal transverse, descending, and proximal sigmoid colon. Finally, the proximal cut end of the transverse colon was brought up through a left-sided end colostomy. In this video, the key steps of the procedure are demonstrated, and analysis regarding intraoperative decision making is provided.
The submandibular approach, also known as the Risdon approach, is a well-established extraoral surgical technique employed for the treatment of complex mandibular fractures and pathologies. Despite the increasing popularity of intraoral approaches for open reduction and internal fixation, the submandibular approach remains a valuable option in the arsenal of maxillofacial surgeons. This approach offers several advantages, including superior access and visualization of the mandibular body and angle, facilitating better manipulation and reduction of fracture fragments. Furthermore, the submandibular approach enables direct access to the submandibular gland, facilitating its management in cases of pathology or injury. By providing a comprehensive understanding of this technique through cadaveric exploration, this video aims to contribute to the training and education of maxillofacial surgeons, ultimately enhancing patient care and outcomes.
Bilateral axillo-breast approach (BABA) is a contemporary technique for remote-access thyroidectomy. BABA robotic thyroidectomy (RT) offers a number of benefits over other remote-access thyroidectomy techniques, such as provision of a three-dimensional symmetric view of bilateral thyroid lobes and optimal visualization of important anatomical landmarks, including the recurrent laryngeal nerve (RLN), thyroidal vessels, parathyroid glands, and the trachea.
This educational video is a thorough demonstration of BABA RT performed on a young female patient diagnosed with a left-sided thyroid nodule in her early thirties. The thyroid fine needle aspiration biopsy of the 4-cm nodule was indeterminate. Additional molecular testing of the specimen had revealed one of the mutations associated with thyroid cancer. Therefore, a diagnostic thyroid lobectomy was planned. The patient had expressed a strong desire to avoid an obvious neck scar, and therefore, the BABA RT was offered.
