尿道下裂伴阴茎阴囊转位的诊治(附83例报告)

目的:通过分析尿道下裂伴阴茎阴囊转位的诊治,总结手术方式及经验。方法:回顾性分析2003年1月至2009年6月间收治的尿道下裂合并阴茎阴囊转位的83例病例资料,并分析手术方式、诊治情况及术后随访外观情况。结果:矫治尿道下裂时同期或分期作阴囊成形术,术后随访6个月至5年。术后81例阴茎阴囊矫正外观满意,仅2例重度尿道下裂复位不满意需再次行阴茎阴囊复位手术。所有患者在阴茎阴囊复位后经同期或分期尿道成形术后最终均达到尿道下裂修复的标准。结论:本手术方法术后阴茎伸直好,阴茎阴囊复位整形效果满意,最终尿道成形术后预后良好,术后并发症少。     

In the footsteps of senning: lessons learned from atrial repair of transposition of the great arteries

The Senning operation has evolved from being the initial surgical correction that allowed survival in complete transposition of the great arteries to an integral part of the anatomic repair of congenitally corrected transposition. In patients with complete transposition, the Senning operation has given satisfactory initial and long-term surgical results, but the potential for right ventricular failure and atrial arrhythmias have drastically reduced its indications in the current era. The long-term follow-up and pertinent postoperative issues of the Senning operation will be reviewed, along with its newfound role in the anatomic repair of congenitally corrected transposition.     

The failed ulnar nerve transposition. Etiology and treatment

Various procedures have been recommended for the treatment of cubital tunnel syndrome. Simple decompression in situ, medial epicondylectomy, subcutaneous transposition, intramuscular transposition, and submuscular transposition all have their advocates. The results of the surgical treatment for cubital tunnel syndrome are related to the severity of the compressive neuropathy at the time of diagnosis and to the adequate decompression of the nerve at all sites of potential compression at the time of surgical treatment. Fourteen patients who had previously undergone surgical treatment for cubital tunnel syndrome were evaluated because of persistent pain, paresthesia, numbness, and motor weakness. All patients had documented persistent compression of the ulnar nerve on clinical and electromyographic evaluation. The indication for repeat surgical exploration in all patients was unremitting pain despite nonoperative treatment. All patients had been treated by neurolysis and submuscular transposition of the ulnar nerve as described by Learmonth. The causes of continued pain after initial surgery included retention of the medial intermuscular septum, dense perineural fibrosis of the nerve after intramuscular and subcutaneous transposition, adhesions of the nerve to the medial epicondylectomy site, and recurrent subluxation of the nerve over the medial epicondyle after subcutaneous transposition. Revision surgery was found to be highly successful for relief of pain and paresthesias; however, the recovery of motor function and return of sensibility were variable and unpredictable.     

Recurrent cubital tunnel syndrome. Etiology and treatment.

Controversy surrounds the treatment of recurrent cubital tunnel syndrome after previous surgery. Irrespective of the surgical technique, namely pure decompression in the ulnar groove and the cubital tunnel distal of the medial epicondyle, and the different methods of volar transposition (subcutaneous, intramuscular, and submuscular), the results of surgical therapy of cubital tunnel syndrome are often not favorable, especially in cases of long-standing symptoms and severe deficits. Twenty-two patients who had previously undergone surgical treatment for ulnar nerve entrapment at the elbow were evaluated because of persistent or recurrent pain, paresthesia, numbness, and motor weakness. Ten patients had undergone a nerve transposition, 5 patients underwent a simple decompression of the ulnar nerve, and 7 patients experienced two previous operations with different surgical techniques. Two patients underwent surgery at our hospital, whereas 20 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external neurolysis, subcutaneous anterior transposition, and subsequent transfer of the nerve back into the sulcus. The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial intermuscular septum. The average follow-up after the last procedure was 7 months (2 - 20 months). All 7 patients with subsequent transfer of the ulnar nerve back into the sulcus became pain-free, whereas only 11 of 15 patients who had external neurolysis or subcutaneous transposition became free of pain or experienced reduced pain. The recovery of motor function and return of sensibility were variable and unpredictable. In summary, reoperation after primary surgery of cubital tunnel syndrome gave satisfactory results in 18 of 22 cases. Subsequent transfer of the ulnar nerve back into the sulcus promises to be useful in cases in which subcutaneous transposition had not been successful.     

Identification of proximal landing zone limit for proper deployment of aortic arch stentgraft after supra-aortic great vessels transposition

The proper identification of the proximal landing zone prior to aortic stentgraft deployment is a key step that impacts the global outcome of the procedure. We report an intraoperative technique during total aortic arch transposition that facilitates subsequent endovascular arch exclusion thanks to a reliable radio-opaque marker. In patients who require an endovascular exclusion of the aortic arch, a total arch transposition can be performed through a median sternotomy prior to stentgraft deployment. During the surgical stage, a radio-opaque thread is pull out of a surgical sponge pad, looped around the ascending aorta just distal to the ostium of the aorto-innominate bypass and fixed in place by means of metal clips. The technique we describe increases the accuracy of stentgraft deployment in the ascending aorta after total arch transposition. It will potentially improve the outcome.     

Cubital tunnel syndrome: evaluation of anterior subcutaneous transposition of the ulnar nerve]

57 cases of cubital tunnel syndrome were treated by anterior subcutaneous transposition of the ulnar nerve. Physical examination showed that ulnar nerve function--motor and sensory improved after surgery treatment. Subcutaneous transposition is a reliable and effective surgical option.     

Correction of transposition of the great arteries in infants under surface-induced deep hypothermia

Thirty-five infants with transposition of the great arteries underwent primary surgical repair. There were 2 deaths in the 20 infants with uncomplicated transposition of the great arteries and 5 deaths among the 15 infants with complex transposition. Patients with pulmonary vascular disease and an intact ventricular septum present a higher risk, but it is our policy to repair the defect in these patients since normal hemodynamics and full oxygen saturations following correction protect them against cerebrovascular accidents.     

„Aortenbogen-Debranching“ mit Implantation von Stent-Prothesen

Endovascular repair of thoracic aortic disease requires implantation of stent grafts in the aortic arch to ensure secure anchoring and sealing in more than one third of cases. Occlusion of supra-aortic arteries is thus unavoidable. Debranching refers to the surgical transposition of supra-aortic arteries to safely extend the landing zone for stent grafts. After extending the occluded supra-aortic arteries the following surgical procedures are performed: extrathoracic carotid-subclavian bypass, subclavian-carotid transposition and carotid-carotid-subclavian bypass and intrathoracic double transposition of left subclavian and carotid arteries and complete debranching of all three supra-aortic arteries to the ascending aorta. The most important details of these surgical procedures as well as the special technical aspects of the implantation of stent grafts in the aortic arch in combination with debranching surgery are described. If the ascending aorta is exposed, antegrade implantation of the stent graft can avoid problems associated with the retrograde transfemoral route but this requires custom-made devices.     

Failed surgery for ulnar nerve compression at the elbow

Surgical procedures for the treatment of ulnar nerve compression at the elbow are well described. Studies have reported clinical outcomes after decompression of the nerve without transposition and decompression with transposition. Numerous preoperative, intraoperative, and postoperative factors contribute to failure of the surgical procedures. Although the techniques available for revision decompression of the ulnar nerve at the elbow are similar to those used in the primary setting, the results after repeat surgical intervention are less predictable.     

An anatomic factor significant in transposition of the ulnar nerve

Anterior subcutaneous or submuscular transposition of the ulnar nerve are recommended treatments for the cubital tunnel syndrome. Commonly encountered findings at submuscular transposition are the presence of a distinct fibrous septum within the main flexor-pronator origin, which arises from the proximal ulna and medial epicondyle and requires release to accomplish the transposition. Cadaver dissections were conducted to study the intermuscular fascial anatomy of the flexor-pronator origin. The surgical findings were confirmed. The fascial structure is the common aponeurosis between the flexor digitorum superficialis of the ring finger and the humeral head of the flexor carpi ulnaris. Failure to release this structure from the proximal ulna caused kinking and tethering of the nerve when transposition was attempted.     

Simple Transposition Technique for Microvascular Decompression Using an Expanded Polytetrafluoroethylene “Belt”: Technical Note

Microvascular decompression (MVD) is a standard surgical procedure for treating vascular compression syndromes. There are two basic ways to perform MVD: interposition using a prosthesis and transposition. With the transposition technique, adhesions and granuloma around the decompression site are avoided, but the required operation is more complex than that for the interposition method. We describe a simple, quick MVD transposition procedure that uses a small “belt” cut from a sheet of 0.3-mm-thick expanded polytetrafluoroethylene membrane. The belt has a hole at the wide end and the other end tapered to a point. The belt is encircled around offending vessels by inserting the pointed end into the hole. The pointed end is then passed through a dural tunnel over the posterior wall of the petrous bone and is tied two or three times. This method avoids the risks involved in handling a surgical needle close to the cranial nerves and vessels.     

Anatomic Correction in Transposition of the Great Arteries with Unusual Coronary Pattern and Side-by-Side Location

Switch operation is the treatment of choice in infants with transposition of the great arteries. The anatomic correction restores the left ventricle to its normal systemic function. In complete transposition, however, the diverse spectrum of coronary pattern influences the surgical outcome. We describe a successful arterial switch operation without LeCompte manoeuvre in a neonate with unusual coronary artery anatomy and side-by-side great arteries.     

The Green-Watermann procedure: geometric analysis and preoperative radiographic template technique.

The Green-Watermann procedure is indicated as surgical treatment of hallux limitus. The procedure requires five first metatarsal osteotomies, all of which interact to achieve the final surgical outcome. It is the unique interaction of each osteotomy that creates first metatarsal shortening, capital fragment plantar transposition, capital fragment lateral transposition, and proximal articular set angle (P.A.S.A.) correction. The geometry of the Green-Watermann procedure is reviewed. A preoperative radiographic templating technique is provided.     

Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition

OBJECT: Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition. METHODS: Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms. CONCLUSIONS: Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.     

Successful neonatal double switch in symptomatic patients with congenitally corrected transposition of the great arteries

Anatomic repair is the standard surgical approach to congenitally corrected transposition of the great arteries. However, timing to perform the procedure remains controversial. We present 2 cases of congenitally corrected transposition of the great arteries and Ebstein's-like anomaly of the tricuspid valve presenting with heart failure. Both cases had successful anatomic repair during the neonatal period.     

False aneurysm of the ascending aorta concomitant with chronic mediastinitis after tube graft replacement in octogenarian.

An 81-year-old man developed impending rupture of a false aneurysm of the ascending aorta concomitant with chronic mediastinitis lasting for 10 years after tube graft replacement. He had undergone various infection-related mediastinal surgical procedures. He was successfully treated by debridement of infected tissues, patch repair of the false aneurysm, and transposition of the right latissimus dorsi muscle flap. The postoperative course was uneventful except for seromas. A chest computed tomographic scan performed 5 and 24 months after surgery showed no signs of recurrent aneurysm formation. A conservative surgical treatment including muscle flap transposition was effective in octogenarian.     

Results of surgical treatment for cubital tunnel syndrome]

The aim of this study was to evaluate the results of surgical treatment of cubital tunnel syndrome (CTS) and asses the efficiency of surgical techniques implemented in our Department. Fifty-one patients with CTS were treated with 3 different surgical techniques: submuscular transposition, anterior transposition, and ulnar nerve decompression (UND). Thirty-one patients were evaluated post-op: 4 patients after ST, 21 patients after AT and 7 after UND. UND relieves the pain, but numbness, paresthaesia, and decreased muscle power were observed post-op. Post-op tenderness and hyperaesthesia of the medial epicondyle were noted after AT procedures. A decrease in nerve conduction in EMG studies is probably the best quantitation method of ulnar nerve neuropathies. Our study did not indicate which surgical technique was most effective in the treatment of CTS.     

Cardiac arrhythmias following the creation of an atrial septal defect in patients with transposition of the great arteries

In 64 children with transposition of the great arteries who underwent a Blalock-Hanlon procedure, pre- and postoperative electrocardiograms were studied regarding the incidence and nature of rhythm disturbances. In another group of 19 patients with transposition of the great arteries, the atrial septal defect was created by a different surgical technique (fossa ovalis resection); this group was studied in the same way and the results were compared.     

Complete correction of transposition of the great arteries with left juxtaposition of the atrial appendages.

Juxtaposition of the atrial appendages is an uncommon anomaly which is usually associated with transposition of the great arteries. Experience with five patients with transposition of the great arteries in combination with juxtaposition of the atrial appendages in whom Mustard's operation was performed is reviewed. Technically, the existence of juxtaposition of the atrial appendages in corrective surgery for transposition does not present any additional surgical problems. Emphasis is placed on the advantages of early complete correction, avoiding the need for palliative procedure.     

The surgical treatment of cubital tunnel syndrome: a decision analysis

The objective of our study was to use decision analysis to compare four common surgical treatments for cubital tunnel syndrome: simple decompression of the cubital tunnel, medial epicondylectomy, anterior subcutaneous transposition and anterior submuscular transposition. The variables used for this decision analysis model were based on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The highest expected utility, 0.973, was associated with simple decompression. The expected utility was 0.969 for subcutaneous transposition and 0.965 for submuscular transposition. Medial epicondylectomy had the lowest expected utility at 0.961. Simple decompression remained the preferred strategy in extensive one-way sensitivity analyses.