This video demonstrates an algorithm for evaluating suspected vascular injury secondary to penetrating extremity trauma on a 42-year-old man who sustained a gunshot wound to his left lower extremity. Descriptions of how to perform an arterial-brachial index (ABI) and arterial-pulse index (API) are reviewed, along with criteria to determine if a CT angiography is indicated. Relevant imaging is reviewed with a radiology resident with descriptions of how to systematically assess the scans for injury. Lastly, a tibial traction pin is placed as a temporizing measure for long bone fractures to prevent shortening and to help with pain management.
Primary hyperaldosteronism, or Conn’s syndrome, is a disease in which one or both adrenal glands produce excess amounts of aldosterone, leading to hypertension and hypokalemia. High blood pressure may cause headaches or blurred vision. Low potassium may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis.
Primary hyperaldosteronism is diagnosed by measuring serum levels of aldosterone, renin, and potassium. Patients classically have high aldosterone levels, suppressed renin levels, and low potassium levels. Once the diagnosis is established, the localization of the source is performed using imaging studies. Adrenal vein sampling is also performed to determine more precisely and directly the side that is producing excess aldosterone.
Primary hyperaldosteronism caused by an adrenal gland tumor is treated with adrenalectomy. This is the case of a 58-year-old female with hypokalemia and long-standing hypertension refractory to medical treatment. Her blood tests showed high aldosterone levels and low renin levels, confirming the diagnosis of hyperaldosteronism. On CT scan, an adrenal nodule was noted on both sides. Adrenal vein sampling identified the right adrenal nodule as the cause. Laparoscopic access was gained, the adrenal gland was dissected and exposed, the adrenal vein ligated, and the adrenal gland was removed.
Laparoscopic Nissen Fundoplication
Ciro Andolfi, MD¹; Marco Fisichella, MD, MBA, FACS² ¹University of Chicago Pritzker School of Medicine ²VA Boston Healthcare System
This is the case of a 63-year-old man with a long-standing history of gastroesophageal reflux disease, refractory to medical management with high-dose proton pump inhibitors and H2-blockers. The preoperative workup consisted of: 1) an upper endoscopy, which was normal; 2) a barium swallow, which showed a normal anatomy (no hiatal hernia or diverticula); and 3) esophageal function tests, including high-resolution esophageal manometry, which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of gastroesophageal reflux disease.
Considering the amount of pathologic reflux, and the normal anatomy and esophageal peristalsis, it was decided to proceed with a laparoscopic Nissen (360°/total) fundoplication. The operation went well and lasted less than 90 minutes. The patient was discharged the following morning after resuming a light diet, and recovered quickly. With this surgical approach, complete control of reflux was achieved, and the patient was able to discontinue his treatment with proton pump inhibitors.
Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals.
In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.
This is the case of a 74-year-old female who presented with bothersome stage III pelvic organ prolapse. She desired definitive surgical management for her prolapse and opted for total vaginal hysterectomy, uterosacral ligament suspension, and anterior/posterior vaginal repairs. She had urodynamic testing before the surgery that showed no stress urinary incontinence, no detrusor overactivity, and normal bladder capacity. The surgery was uncomplicated. She was discharged home the same day as surgery, and her postoperative recovery was unremarkable.
Crohn’s disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract, with a propensity for the distal ileum. It causes transmural inflammation of the intestines, where it can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition.
There is no cure for Crohn’s disease; the goal of treatment is to palliate symptoms, accomplished with both medical and surgical options. Surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications.
Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn’s colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing; therefore, a total abdominal colectomy with ileorectal anastomosis was performed.
Robotic right hemicolectomy is a minimally invasive technique for right colon resections. The technique utilizes a robotic laparoscopic instrument to perform dissection of the right colon and to perform intracorporeal anastomoses, allowing for smaller abdominal incisions, quicker recovery times, and decreased short- and long-term complications.
In this case, a robotic right hemicolectomy was performed to remove an endoscopically unresectable mass at the ileocecal valve. An intracorporeal-stapled ileocolic anastomosis was performed, and the colon was removed through a trocar insertion site. The robotic-assisted minimally invasive technique allows for clear visualization of the dissection planes and facilitates intracorporeal anastomoses that would otherwise be difficult to perform using traditional laparoscopy.
There are over 1 million hernia repairs performed annually in the US, and robotics is revolutionizing the adoption of minimally-invasive hernia repairs. From 2015 to 2018, robotic laparoscopic hernia repairs have explosively grown from less than 2% to 20% of all hernia repairs performed in the US.
Hernia repairs are among the most basic procedures for general surgeons, and there is substantial enthusiasm on the part of surgeons regarding the rapid changes in techniques as well as the best methods of teaching them. Surgical training programs may find it difficult to maintain training for their residents and fellows in the face of rapidly evolving technology. Here, Dr. Lourié presents the case of a 28-year-old male with bilateral inguinal hernias that were repaired using a robotic-assisted laparoscopic approach.
Pilonidal disease is a chronic skin and subcutaneous infection emanating from the center of the natal cleft, often extending to the buttocks. Treatment depends on the disease pattern. An acute abscess is treated with drainage and antibiotics, while a complex or recurring infection is treated surgically with either excision of a cyst or unroofing of a sinus tract. Reconstructive flap techniques such as the Bascom cleft lift procedure, Karydakis flap, rhomboid, or Z-plasty can be done to reduce the risk of recurrence by leaving less scar tissue and flattening the region between the buttocks. Here, Dr. Reinhorn at Tufts University School of Medicine presents the case of a male patient who had previously had flap surgery for pilonidal disease, but experienced recurrence and the development of a sinus tract. Due to the extensive nature of the disease, a deep flap was required to mobilize tissues and close the eventual wound. A deep flap like this is often only required in re-do surgery, rather than for primary disease, for which only a 1-cm subcutaneous flap is required.
Hereditary Diffuse Gastric Cancer (HDGC) syndrome is due to a mutation in the CDH1 gene that predisposes patients to a high lifetime risk of developing gastric cancer. As such, a total gastrectomy is typically recommended for patients with this syndrome. In this case, the patient presented with an incidentally discovered CDH1 mutation on genetic testing obtained after she was diagnosed with early-onset rectal cancer. In this video, Dr. Mullen at MGH demonstrates his technique for performing an open prophylactic total gastrectomy with a Roux-en-Y esophagojejunostomy reconstruction.
