The supraorbital approach—a minimally invasive approach to the superior orbit

Background  We present a minimally invasive approach to the superior orbit via an eyebrow incision with a small osteotomy, minimal orbital rim resection and small frontal craniotomy. Methods  This approach was used in 20 patients with a well-defined intra-and extraconal lesion superior to the optic nerve, who underwent surgery between 2000 and 2007. Results  This approach is purely extradural with minimal brain and orbital retraction. The size of the lesion was not a limiting factor. Sensory deficits in the territory of the supraorbital nerve resolved within 7 months on average. Conclusion  This approach presents a combination of an extra-and transcranial approach, which is indicated in all orbital lesions superior to the optic nerve. The clinical and cosmetic results are excellent.     

Rhinoplasty—A new approach in the repair of the hump

A variation in Cottle's technique is presented in which the hump is preserved and the difficulties arising out of making fractures in different levels are avoided. A natural look is obtained for the operated nose, mainly from a frontal view.Paper presented at the Fourth International Congress of Aesthetic Plastic Surgery, Mexico City, Mexico, April 1977.     

Mediastinal goitres: when the transthoracic approach?

The correct surgical approach to mediastinal goitre is not always well defined. We reviewed why and when our patients required a transthoracic approach. From 1979 to 1998, on 7.480 patients who underwent thyroid surgery in our hospital, 374 (5%) had a goitre whose greater bulk was inferior to the thoracic inlet; 43 patients of these last ones (11%) required a transthoracic approach. General anaesthesia was performed in all patients and orotracheal intubation was selective in 11 cases (double lumen tube of Carlens). In 34 cases, the first approach was a cervicotomy, followed by sternotomy in 23 cases or right posterolateral thoracotomy in 11 cases. Three patients underwent a sternotomy and 6 a thoracotomy only. We had neither perioperative mortality nor major complications. The mean hospital stay was 5 days. Mean goitre weight was 430 g and on average the greater diameter was 13 centimetres. The removal of a substernal goitre can be difficult and risky via the cervicotomy only. A transthoracic approach is often required in the case of greater secondary, primary and recurrent mediastinal goitres.     

Is the laparoscopic approach to colectomy safe for the morbidly obese?

Background

The feasibility and safety of laparoscopic colectomy (LC) for morbidly obese patients has not been reported previously. This study aimed to assess the clinical outcomes of patients with a body mass index (BMI) of 40 kg/m³ or more who undergo laparoscopic colorectal surgery.

Methods

Prospectively accrued data for patients with a BMI of 40 kg/m³ or more (group A) who undergo LC were compared with those for patients with BMI lower than 30 kg/m³ (group B) matched for year of surgery, indication, operating surgeon, and type of procedure.

Results

Each group had 36 patients. The group A patients were significantly younger (54 vs. 61 years; P = 0.04), had higher American Society of Anesthesiology (ASA) scores (P = 0.001), and had diabetes mellitus (P = 0.04). The indications for surgery and the operations performed were similar. The two groups had similar operating times (177.9 vs. 136.4 min; P = 0.12), estimated blood losses (222.3 vs. 157 ml; P = 0.1), median lengths of hospital stay (LOS) (4.5 vs. 4 days; P = 0.2), and returns of bowel function (4.2 vs. 3.9 days; P = 0.45). Group A had significantly longer incisions (6.9 vs. 5 cm; P = 0.02). Conversions (5 vs. 3 patients; P = 0.7), readmissions (12 vs. 6 patients; P = 0.46), reoperations (5 vs. 3 patients; P = 0.17), wound infections (7 vs. 2 patients; P = 0.14), anastomotic leaks (3 vs. 2 patients; P = 0.7), and abdominal abscesses (3 vs. 2 patients; P = 0.7) were more predominant in group A, although the differences did not reach statistical significance.

Conclusions

Laparoscopic colectomy is feasible for morbidly obese patients and results in recovery of intestinal function and LOS equivalent to that for nonobese patients. As expected, morbidity and conversion rates are higher for morbidly obese patients undergoing LC than for nonobese patients.     

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.     

Does the extraperitoneal laparoscopic approach improve the outcome of radical prostatectomy?

Laparoscopic radical prostatectomy (LRPE) became the operative procedure of choice for patients with clinically localized prostate cancer in selected urologic centers around the world. Principal advantages are the minimal invasive nature of the procedure, a superior visualization of the operative field because of the magnification of the optical system, an exact and watertight anastomosis, the possibility of early catheter removal, and a potentially reduced amount of blood loss. Recent data show that oncologic outcome is not compromised by the minimal invasive nature of the procedure. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. Therefore, principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy is a further advancement of minimal invasive surgery because it overcomes the limitations of LRPE by the strictly extraperitoneal route of access, combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. This article reviews the literature on minimally invasive (laparoscopic and endoscopic-extraperitoneal) radical prostatectomy.     

Is the laparoscopic approach appropriate for porcelain gallbladder?

Contrary to the fears raised in surgical publications of the 1950's and 60's, the prognosis of porcelain gallbladder is not automatically associated with an increased risk of gallbladder carcinoma. Two recent cohort studies have allowed a better definition of the appropriate therapeutic attitude for a patient with a calcified gallbladder. In cases of "true" porcelain gallbladder, i.e., the presence of complete transmural calcification of the entire gallbladder wall, indications for cholecystectomy are based on biliary symptoms, all the more so since choledocholithiasis is often associated with porcelain gallbladder. In the case of partial calcification of the gallbladder, i.e., focal plaques of calcification involving the mucosa, prophylatic operative treatment is indicated. In these cases, the incidence of malignancy is markedly increased (14 times that of a control population). Cholecystectomy can still be performed laparascopically as long as the rules for prevention of peritoneal dissemination of tumor cells are scrupulously observed--the gallbladder should not be opened nor bile spilled, the specimen should be placed in a bag for removal through the abdominal wall, the pneumoperitoneum should be evacuated with the trocars still in place and the specimen should be opened and examined after removal with immediate frozen section pathologic exam if there is any question of tumor.     

Does the reductive mastopexy with implant approach prevent the late bottoming out?

Background

After breast surgery, the late upward rotation of the nipple–areola complex and the increased of the fullness at the lower pole of the breast have been defined as a Bottoming out. Although several studies have focused on the safety and complication rate of the one-stage augmentation/mastopexy, there is no clear recommendation how to prevent the late complication of “bottoming out”.

Methods

A retrospective review was conducted of 48 consecutive patients who underwent one-stage mastopexy/augmentation using the reductive approach. Data collected included the following: patient's characteristics implant information, operative technique and postoperative results. Complication and revision rates were assessed to determine the efficacy of the reductive mastopexy/augmentation.

Results

All patients (N?=?48) were available for follow-up, an average 18 months postoperatively. Overall complication rate was 14.5%. No severe complications were recorded. The most common complication was wound separation (2), followed by capsular contracture (2), and bottoming out (1). Seven patients (14.5%) underwent some form of revision surgery following the one-stage procedure. The revision rate due to bottoming out was 2.2%.

Conclusions

When performing the one-stage augmentation/mastopexy procedure, using the reductive mastopexy approach does effectively reduce the internal tension from the lower pole of the breast and helps to prevent the occurrence of bottoming out. Level of Evidence: Level IV, therapeutic study     

Incidental gall bladder carcinoma: does the surgical approach influence the outcome?

BACKGROUND: The aim of the study was to evaluate the outcome in patients with unsuspected gall bladder carcinoma diagnosed after cholecystectomy, comparing the laparoscopic approach with open surgery. METHODS: A retrospective study was done of 16 patients who were diagnosed with unsuspected gall bladder carcinoma out of the 2850 who had undergone cholecystectomy for symptomatic cholelithiasis at our institution between 1990 and 2004. Eight cases (seven women and one man, mean age 63 (range 49-75 years) ) were diagnosed after laparoscopic cholecystectomy (group A) and eight cases (six women and two men, mean age 63 (range 50-79 years) ) after open cholecystectomy (group B). We evaluated the outcome in the two groups correlating the cumulative survival rates with tumour stage and surgical technique. RESULTS: In group A, three patients had port-site recurrence (1 pT1a and 2 pT1b tumours) after 6, 7 and 9 months, one had intraperitoneal dissemination (pT2) after 3 months, and four had no recurrence (1 pTis, 2 pT1a and 1 pT1b). In group B, five patients had recurrences (4 pT1b and 1 pT2) after an average of 8 months (range 5-11) and three had no recurrence (1 pTis and 2 pT1a). Survival rate was statistically correlated with tumour stage but not with the surgical approach used to perform cholecystectomy. CONCLUSIONS: The surgical approach used for cholecystectomy would seem not to influence the outcome in patients with unsuspected gall bladder carcinoma. The tumour stage is the most important prognostic factor.     

Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?

BACKGROUND: The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer. STUDY DESIGN: Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months. RESULTS: Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers. CONCLUSIONS: Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.     

The medial approach open reduction for developmental dysplasia of the hip: do the long-term outcomes validate this approach? A systematic review of the literature

Introduction

Developmental dysplasia of the hip (DDH) is one of the most commonly diagnosed and treated paediatric orthopaedic conditions.

Objective

To systematically identify, appraise and synthesise the best evidence for the long-term outcomes of the medial approach open reduction (MAOR) for DDH.

Methods

MEDLINE, EMBASE and the Cochrane databases were searched up to July 2013. All study designs that reported on the long-term outcomes of the MAOR as the primary treatment modality for DDH were included. The risk of bias in each study was evaluated using the Cochrane risk of bias assessment tool with some modification to accommodate different study designs.

Results

From the 162 citations screened, five retrospective observational studies that fulfilled the eligibility criteria were included. The mean age at surgery varied from 10 to 17 months with an average follow-up period of 16–25 years. Acetabular development, as defined by the Severin Classification, was reported as satisfactory (Severin I/II) in between 38 and 79 % of study cohorts. However these good and excellent outcomes were less promising when patients who had additional operations were considered as unsatisfactory results. Avascular necrosis, as predominantly defined by the Kalamchi criteria, varied from 5 to 43 %. Negative prognostic factors implicated were mean age at surgery >17 months, the absence of the ossific nucleus and eccentric posturing of the femoral head postoperatively. The rate of secondary operations reported varied from 11 to 50 %. There were no reported total hip replacements.

Conclusion

There is a paucity of robust evidence pertaining to the long-term outcomes of the MAOR for developmental dysplasia of the hip. The trends from observational studies suggest that the long-term outcomes are not as positive as short- to intermediate-term studies suggest. Further prospective, controlled and rigorously designed studies are required to validate this approach.