Maintenance of intact skin throughout the body is essential to prevent dehydration, to act as a barrier to infection, to allow unrestricted movement, and to provide a normal appearance. A flap is a piece of body tissue, usually skin and fat, that always has its own blood supply. Therefore, a flap can be moved anywhere it can reach without worrying about the circulation present at the place that needs it, which is called the recipient site. When compared with all other possible choices, a flap best meets all the requirements for any area needing skin replacement.
The keystone type flap as one such option is so named because its design has the shape of the keystone of a Roman arch. If taken from loose tissues adjacent to a defect, it can be simply cut and advanced for any necessary skin coverage. Direct closure of the donor site where this flap comes from is possible so that usually a quite good overall cosmetic result is also obtained. These virtues are shown as an overview in this video where a keystone flap is transferred after removal of a common basal cell skin cancer from the lower lip.
Open Cholecystectomy for Gallbladder Disease Jacob C. Mesiti1; Yoko Young Sang, MD2; Peter F. Rovito, MD2; 1Lake Erie College of Osteopathic Medicine 2World Surgical Foundation
Gallbladder diseases are a subset of a spectrum of pathologies of the biliary system and are a particularly common etiology of abdominal pain encountered in modern medicine. These pathologies most often share a similar underlying mechanism of disease: obstruction of a portion of the biliary tree by cholelithiasis, or gallstones.
Gallstones, for the most part, form initially in the gallbladder with the exception of primary common bile duct (CBD) stones that form primarily in the CBD. Risk factors include a wide variety of conditions both pathologic and physiologic, including hyperlipidemia, hemolysis, and pregnancy. The resulting obstruction creates a state of biliary stasis, eventually leading to inflammation, pain, and an increased risk of infection. The anatomical location of the obstruction contributes greatly to both the clinical presentation and the ultimate treatment of the disease.
A hallmark of the treatment of gallbladder disease, ranging from simple biliary colic to life-threatening emphysematous cholecystitis, is the cholecystectomy. In modernized countries, this procedure is almost invariably performed laparoscopically. However, in certain clinical scenarios, such as when a patient cannot tolerate the pneumoperitoneum associated with laparoscopic surgery or when the procedure takes place in a developing country with limited access to laparoscopic capabilities, an open approach is preferred.
Colonic polyps are projections from the surface of the colonic mucosa. Most are asymptomatic and benign. Over time, some colonic polyps develop into cancers.
Carcinoid tumors develop from cells in the submucosa. They are slow-growing neoplasms. Carcinoid tumors of the colon are rare, comprising less than 11% of all carcinoid tumors and only 1% of colonic neoplasms. The majority of patients diagnosed with carcinoid tumors have no symptoms, and their tumors are found incidentally during endoscopy.
This is the case of a middle-aged male who had an unresectable polyp in the ascending colon and a carcinoid tumor in the ileocecal valve. The patient underwent laparoscopic right colectomy with ileocolic anastomosis to remove both lesions.
This is the case of a 66-year-old man with a history of colon polyps, who undergoes colonoscopy every 3 years for surveillance. During the last colonoscopy, he was found to have a polyp at the appendiceal orifice. The biopsy showed the presence of adenoma.
Therefore, the patient underwent a laparoscopic appendectomy with wedge resection of the cecum. The operation went well and took less than an hour. The specimen was opened, and the adenoma was found within the lumen of the appendix, with at least 1.5 cm of clear margin. The patient was sent home the same day, and resumed regular diet and physical activities the following morning.
Gunshot wounds to the abdomen are one of the most classic trauma cases a surgeon will come across in their career. The high velocity of a bullet can cause massive internal and external trauma to the abdomen. Exploration of the small bowel using laparotomy is often indicated after a penetrating traumatic injury or when peritoneal signs are present.
This video article shows the most common techniques for performing an exploratory laparotomy. In this case, the abdomen was explored and was revealed to show a through-and-through gunshot wound to the jejunum, as well as a partial-thickness tear of the proximal cecum; the abdomen was explored for any smaller bleeds or leaks, and the abdomen was closed.
Acute appendicitis is a medical condition where the appendix becomes inflamed and causes pain in the lower right quadrant of the abdomen. In addition to pain, appendicitis can cause peritonitis, perforations, and can lead to death if left untreated. Laparoscopic appendectomy is the standard surgical procedure to treat the symptoms of appendicitis as well as prevent further spread of infection. While appendicitis typically advances in an irreversible fashion necessitating surgery, conservative management with antibiotic therapy can sometimes resolve symptoms.
In this case, a 24-year-old patient had a delayed presentation with acute perforated appendicitis. Following successful non-operative treatment with antibiotics, she presented for a laparoscopic interval appendectomy. She also had a non-symptomatic umbilical hernia, which was repaired following removal of the laparoscopic ports for the appendectomy.
Nipple-Sparing Mastectomies (NSMs) with breast reconstruction are commonly performed for both breast cancer treatment or risk-reducing prophylactic mastectomies and have superior aesthetic results compared to total mastectomy or skin-sparing mastectomy. Preservation of the Nipple Areolar Complex (NAC) results in a more natural aesthetic appearance of the reconstructed breast, as well as greater patient satisfaction, as indicated by improved psychosocial and sexual well-being compared to total mastectomy. Preservation of vascular supply is of utmost importance for NAC and mastectomy skin flap viability after surgery, since postoperative ischemic complications can significantly undermine the aesthetic outcomes.
This report describes a contemporary NSM surgical technique developed by the senior author (MK), to preserve the dominant NAC vascular supply, and decrease postoperative ischemic complications. A total of 114 NSM were performed from 2018 to 2020 by the senior author. Based on preoperative breast MRI with contrast visualization of the vascular supply to the NAC, the Internal Mammary Perforator (IMP) vessels exiting the pectoralis major muscle at the sternal border were found to provide the dominant blood supply to the NAC in 92% and could be preserved in 89% of cases.
The Internal Mammary Perforator Preserving Nipple-Sparing Mastectomy (IMP-NSM) surgical technique was developed to preserve this important IMP blood supply to the NAC, resulting in decreased postoperative ischemic complications. Following implementation of this surgical technique, NAC necrosis requiring NAC removal occurred in 0.9%, and mastectomy skin necrosis requiring reoperation in 1.8% of cases, resulting in successful NAC preservation in the majority of patients. Furthermore, due to the consistent anatomical location of the IMP vascular supply to the NAC, this critical vascular supply can routinely be preserved even without preoperative MRI, thereby improving clinical outcomes. The IMP-NSM surgical technique is described in detail in this report with a case example.
Laparoscopic sigmoid resection is indicated for disease of the distal sigmoid or rectum that requires resection, most notably diverticulitis and colorectal cancer. Here, we perform a sigmoid resection for diverticular disease. In this procedure, we used four laparoscopic port sites.
In the first step, we mobilized the splenic flexure and left colon to allow for a tension-free colorectal anastomosis low in the pelvis. Second, the mesorectum was dissected to mobilize the rectum down to the level of the pelvic floor. Third, the left colic and inferior mesenteric arteries were ligated, the colonic mesentery was transected with an energy device, and the distal resection margin was stapled intracorporeally. Fourth, the specimen was extracorporealized through the umbilical port site, and the proximal transection was performed. Finally, an anvil was inserted, and the colon was placed back into the abdomen where a trans-anal, stapled end-to-side Baker-type anastomosis was performed and endoscopically tested for leaks.
End stage renal disease (ESRD) is the final stage in the progression of chronic kidney disease (CKD). CKD has a multitude of etiologies, presents in a variety of ways, and progresses in a patient-dependent manner. Despite the heterogeneity of CKD, once ESRD ensues, patients require Renal Replacement Therapy (RRT). RRT is one of three prongs: hemodialysis, peritoneal dialysis, or kidney transplant.
Of these, kidney transplantation provides the patient with the best quality of life, an improved survival, and an opportunity for cure. However, the success of kidney transplantation with improved outcomes and tolerance to the required immunosuppression has led to an extreme organ shortage despite the increase in deceased organ donors. As a result, the push for living donors has become increasingly more important.
For recipients, the best outcomes are with transplants from a living donor due to superior graft quality and elimination of the need for waiting and dialysis. This article will present such a case and discuss the important considerations a physician must make preoperatively and intraoperatively when performing kidney transplantations.
Pyloric stenosis resulting in gastric outlet obstruction can present with nausea, vomiting, and early satiety. Imaging including fluoroscopic upper gastrointestinal series and computed tomography can diagnose gastric outlet obstruction. Upper endoscopy is included in the work-up to visualize the extent of stenosis and to obtain a tissue biopsy. After a malignancy is ruled out, treatment involves management of underlying causes.
This may include acid suppression, treatment of H. pylori, and dietary modification. Patients who fail conservative management may benefit from endoscopic therapies including pneumatic dilation and botulinum toxin injection. However, these therapies may not offer lasting symptomatic relief.
Pyloroplasty can be performed with the goal of widening the pylorus to improve gastric emptying. Pyloroplasty can be accomplished through open, laparoscopic, and robotic techniques. Here we describe a robotic-assisted Heineke-Mikulicz pyloroplasty in an adult patient with benign pyloric stenosis.
