PUBLISHED: Thumb Extensor Tendon Laceration Repair

Thumb Extensor Tendon Laceration Repair
Evan Bloom1Amir R. Kachooei, MD, PhD2Asif M. Ilyas, MD, MBA, FACS1,2
1 Sidney Kimmel Medical College at Thomas Jefferson University
2 Rothman Institute at Thomas Jefferson University

This case consists of repairing an extensor tendon laceration of a thumb. Extensor tendon lacerations are one of the most common soft tissue injuries of the hand. Surgical repair of the tendon was offered, and the operation was performed using wide-awake local anesthesia no tourniquet (WALANT) technique.

Intraoperatively, a complete laceration of the extensor tendon was confirmed repaired using a modified Kessler technique and reinforced with an epitendinous repair. Before closure, the patient tested competency of the repair with confirmation of restoration with the active extension to ensure proper function. The patient was placed in a reverse thumb spica splint following wound closure.

Postoperatively, the patient was immobilized in full thumb extension for approximately two weeks and then converted to a removable splint and prescribed supervised hand therapy for a total recovery of 8–12 weeks.

PUBLISHED: Lipoma Excision

Lipoma Excision
John Grove1Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2
1Lincoln Memorial University – DeBusk College of Osteopathic Medicine
2Philippine Children’s Medical Center

Lipomas are slow-growing lumps that occur as a result of overgrowth of fat cells. They present as doughy, moveable, and non-tender lumps usually found underneath the skin; however, they may occasionally be deeper. Lipomas occur in 1 in every 1,000 people and commonly grow on the upper back, shoulders, and abdomen. In most cases, lipomas are painless unless they affect joints, nerves, or blood vessels. A physical examination is the easiest way to diagnose a lipoma; however, imaging studies and biopsy may aid in the diagnosis when they are large, have unusual features, or appear deep.

No treatment is usually necessary for a lipoma; however, if a lipoma is painful or growing, removal may be recommended by excision or liposuction. Here, we present a 35-year-old male who has a large and deep 8-year-old lipoma on his upper back. The lipoma was excised and sent for biopsy.

PUBLISHED: Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula

Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula
Jennifer Shearer, MDBrooke Gurland, MD, FACS
Stanford University School of Medicine

Anorectal abscesses most commonly result from obstruction of glandular crypts in the anorectal canal. Abscesses are commonly diagnosed by clinical exam with fluctuance, induration, and tenderness around the perianal tissue.

Abscesses are managed with incision and drainage. For superficial perianal abscesses, bedside lancing can be performed, but for more complex or ischiorectal or postanal abscess, examination under anesthesia in the operating room is preferred. Complete evacuation of the abscess with breakdown of loculated abscess pockets is critical to fully control the infection. Drains may also be left in a deep abscess pocket to prevent the skin prematurely closing before the cavity has healed.

Imaging is selectively performed with CT or MRI to identify occult infections or further identify proximal extent of abscess cavity or associated fistula. For recurrent abscesses, associated fistula tracts should also be identified and, if possible, treated intraoperatively. Antibiotics are utilized for patients with cellulitis or those who are immunosuppressed. This video article presents an adult male with recurrent anorectal abscesses with a new anterior abscess collection, which was managed with anal exam under anesthesia with incision and drainage of abscess collection and drain placement.

PUBLISHED: Anal Examination Under Anesthesia and Botox Injection for Chronic Anal Fissures

Anal Examination Under Anesthesia and Botox Injection for Chronic Anal Fissures
Jennifer Shearer, MDBrooke Gurland, MD, FACS
Stanford University School of Medicine

Most individuals associate anal pain with hemorrhoids. However, there are many conditions that can cause anal pain and bleeding, and physical examination helps to differentiate between these diagnoses: anal fissures, hemorrhoids, or infections.

An anal fissure is a superficial tear in the anoderm. Fissures are diagnosed clinically by history and physical exam with careful spreading of the anus and direct visualization of a break in the mucosa and exposed sphincter fibers. Increased tone of the internal anal sphincter can inhibit fissure healing by decreasing blood flow to the mucosa.

Conservative management includes stool softeners and warm sitz baths to avoid traumatizing the fissure with hard stools and relaxing the sphincters with warm water. Topical nitrates or calcium channel blockers applied at the anal verge dilate and relax the internal sphincter muscle to promote healing.

Alternatively, injection of Onobotulinumtoxin A into the fissure and intersphincteric groove paralyzes sphincter muscle, decreasing muscle spasm and supporting healing of the fissure. For individuals who fail these conservative therapies, lateral internal sphincterotomy is considered. This procedure involves dividing the internal sphincter muscles but carries a small risk of fecal incontinence.

This video article presents the case of a young adult male with a history of a chronic anal fissure, who failed medical management. Anal fissure was appreciated on exam and treated with Onobotulinumtoxin A injection for relaxation of anal sphincter.

PUBLISHED: Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach

Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach
Prabh R. Pannu, MDDavid Berger, MD
Massachusetts General Hospital

Laparoscopic low anterior resection (LAR) is a complex surgical procedure used for resecting the distal sigmoid colon or rectum while preserving sphincter function. The patient is a 37-year-old, obese male with rectal cancer.

Abdominal access is gained through four laparoscopic port sites. The omentum is freed from the transverse colon to enter the lesser sac. The splenic flexure and descending colon are mobilized from the retroperitoneum. The left colic artery is identified and divided. Following proximal mobilization, the dissection is carried towards the pelvis. The sigmoid colon is mobilized, and the presacral space is entered. The inferior mesenteric artery is divided between clips. The dissection in this case could not be carried down low enough in a laparoscopic fashion, and a lower midline incision was made. A suitable area on the descending colon is identified and the marginal artery divided. The proximal bowel is then divided with a stapler. A flexible colonoscope is then used to confirm tumor location and the rectum is divided below the tumor. Finally, a Baker type side-to-end anastomosis is performed with a powered EEA stapler, and its integrity verified endoscopically under water. A diverting loop ileostomy is then created at a previously marked site and the abdomen closed.

In this video, the surgical steps of this procedure are demonstrated and insight is provided into intraoperative decisions.

PUBLISHED: Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy

Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Esophagogastroduodenoscopy
Hannah A. Bougleux Gomes, MD¹; Divyansh Agarwal, MD, PhD¹; Charu Paranjape¹’²
¹Massachusetts General Hospital/Brigham and Women’s Hospital
²Newton-Wellesley Hospital

A hiatal hernia occurs when part of an intra-abdominal organ, most commonly the stomach, migrates through the diaphragmatic crura. The condition can cause a range of uncomfortable symptoms, including heartburn, chest pain, and difficulty swallowing. While several individuals with a hiatal hernia can manage their symptoms with lifestyle changes and anti-reflux medications, some with refractory symptoms or complications secondary to the hernia require surgical treatment to repair the defect.

Here we present the case of a 60-year-old female with a paraoesophageal hiatal hernia and chronic gastrointestinal reflux disease (GERD) refractory to proton-pump inhibitors (PPI), dietary changes, and lifestyle modifications. She underwent an elective robotic hiatal hernia repair, fundoplication, and esophagogastroduodenoscopy (EGD) as a two-hour procedure with routine postprocedure recovery. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

PUBLISHED: Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair
Scott D. Martin, MD
Brigham and Women’s Hospital

Hip arthroscopy with femoral neck or acetabular osteoplasty with or without labral repair can be used for treatment of femoroacetabular impingement (FAI). Patients may present with insidious onset of hip pain and mechanical symptoms and pain worse with activity and sitting.

On physical exam hip flexion and internal rotation may be reduced and anterior impingement testing will produce groin pain in the majority of patients with FAI. Imaging may demonstrate lesions responsible for cam-type or pincer-type impingement, and MRI may demonstrate labral tear or cartilaginous lesions. Arthroscopic surgical treatment is indicated for patients who have failed conservative treatment.

PUBLISHED: Anal Fistulotomy

Anal Fistulotomy
M. Grant Liska, BS¹; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES²
¹University of Central Florida College of Medicine
²Philippine Children’s Medical Center

Fistula-in-ano is a chronic abnormal communication between the anal canal and, usually, the perianal skin. It can be described as a hollow tract that is lined with granulation tissue and connects a primary opening inside the anal canal to a secondary opening in the perianal skin. It usually originates from the anal glands and is frequently the result of a previous anal abscess. Anal fistulae present with pain, swelling, pruritus, skin irritation, and purulent or bloody drainage. Most anal fistulae are diagnosed based on clinical findings, but complex and deep anal fistulae usually require imaging studies such as CT scan or MRI to delineate the tract.

Currently, there is no medical treatment available and surgery is almost always necessary. A simple intersphincteric fistula can often be treated with fistulotomy or fistulectomy, while trans-sphincteric and suprasphincteric fistulae are treated by placement of a seton to maintain drainage and induce fibrosis. Extrasphincteric fistula treatment depends on the anatomy and etiology of the fistula.

This article presents the case of a 1-year-old male with a history of recurrent perianal infection, which led to the development of an anal fistula. The anal fistula was noted to be superficial, and a fistulotomy was performed.

PUBLISHED: Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision

Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision
Prabh R. Pannu, MD; David Berger, MD
Massachusetts General Hospital

Anterior component separation is an abdominal wall reconstruction technique used in the repair of ventral wall defects to avoid the use of prosthetic mesh. The procedure releases the external oblique fascia to provide a tension-free midline approximation.

The patient is a 72-year-old, obese female who has multiple large incisional hernias along an upper midline incision. An anterior component separation technique is used to repair the defect.

An incision is made over the previous abdominal scar. The dissection is carried down to the hernia sac. The hernia sac is then separated from the surrounding tissue to identify the fascial edges. The hernia sacs are removed from the fascia. Surrounding adhesions are lysed. A colotomy occurred, which was repaired in two layers: the outer layer with interrupted 3-0 silk suture, and the inner layer with running 3-0 Vicryl suture. The fascial incision is extended to ensure complete removal of the hernia sacs along with completion of adhesiolysis. Bilateral subcutaneous flaps separating the subcutaneous fascia from the external oblique fascia are developed. Perforating vessels are ligated with 2-0 or 3-0 silk. The dissection is carried laterally to the anterior axillary line. The external oblique fascia is released bilaterally using electrocautery. The midline defect is then closed with running #1 Prolene. After achieving hemostasis, two drains are placed, and the skin is closed.

PUBLISHED: Biceps Tenodesis for Distal Biceps Tendon Repair

Biceps Tenodesis for Distal Biceps Tendon Repair
Harish S. Appiakannan, BS¹; Amir R. Kachooei, MD, PhD²; Asif M. Ilyas, MD, MBA, FACS¹’²
¹Sidney Kimmel Medical College at Thomas Jefferson University
²Rothman Institute at Thomas Jefferson University

Distal biceps tendon ruptures can result in loss of supination and elbow flexion strength, for which surgical repair is often indicated to restore preinjury level of functionality. The distal biceps tendon can be repaired via single- or double-incision techniques using several associated implants, including endobuttons, suture anchors, or interference screws.

Here is the case of a middle-aged male presenting with an acute distal biceps tendon rupture. The tendon was repaired via a single-incision technique using an endobutton and an interference screw.

The New Gold Standard for Surgical Videos