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.
Minor lower extremity amputations typically involve either toe or ray resections. The first ray is an essential component in the normal anatomy and biomechanics of the foot. By definition, the first ray consists of the hallux and the first metatarsal. The surgical procedure discussed in this educational video is a left first toe ray amputation on a cadaver. Toe amputation is a significant predictor of future limb loss. Ray amputation appears to be preferred over finger amputation in selected cases. However, the literature does not provide precise indications on when to consider a ray over a toe amputation. The choice is therefore left to the operating surgeon, based on their clinical expertise and the patient’s conditions and expectations, taking into account the underlying pathology.
Open Proctocolectomy for Hirschsprung’s Disease Mudassir Shah Akhter, MD1; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2 1Oregon Health and Science University 2Philippine Children’s Medical Center
Hirschsprung’s disease is the main genetic cause of functional intestinal obstruction. Most cases are diagnosed in the first few months of life given classical presentation and ease of testing with rectal suction biopsy. The disease is due to the absence of enteric ganglion cells in the distal colon that results in functional constipation. Resection of the affected segment and bringing the normal bowel close to the anus has been the mainstay of treatment. Due to advances in surgical treatment over the past decades, a significant reduction in morbidity and mortality has been observed, and the previously multistage procedure can now be completed in one stage, as presented here.
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.
