Subcranial approach to tumors of the anterior cranial base: analysis of current and traditional surgical techniques.

Tumors of the anterior cranial base have previously required a craniofacial resection to allow adequate tumor extirpation. An analysis of current and traditional techniques demonstrates a significant reduction in operative time, complication rate, and intensive care unit and total hospital length of stay with the use of the subcranial approach as compared with the traditional frontal craniotomy and lateral rhinotomy approach. The subcranial approach is both cost and time efficient and provides comparable morbidity and mortality rates.     

Subcranial approach in the surgical treatment of anterior skull base trauma

Summary Fractures of the anterior skull base, because of the regions anatomical relationships, are readily complicated by neurological damage to the brain or cranial nerves. This review highlights the use of a subcranial approach in the operative treatment of injuries of the anterior skull base and compares it to the more traditional neurosurgical transcranial approach. The extended anterior subcranial approach takes advantage of the specific features of injuries in this region and allows direct access to the central anterior cranial base in order to repair fractures, close CSF fistulae and relieve of optic nerve compression. It avoids extensive frontal lobe manipulation. The success of the approach in achieving the aims of surgery with low morbidity is reviewed.     

Sacro-coccygeal cyst: surgical techniques and results]

69 patients with a chronic inflamed pilonidal sinus were reviewed. They were operated either with a deep excision to sacrum (37 patients) or with the Lord Millar technique (32 patients). 66 patients (87%) were controlled at a mean follow-up of 3.7 years after the operation. The socio-economical advantage of the Lord Millar operation is demonstrated by the shorter hospital stay (4.9 vs 7.6 days) and the shorter period of disability (14 vs 26 days). 5 recurrent episodes were observed among the 31 patients followed-up after an excision (16%) and 7 among the 29 followed-up after a Lord Millar operation (24%). In the later group one recurrence was seen in the sub-group of the 16 patients regularly epilated after the operation (6%) and 6 in the sub-group of the 13 who were not controlled (46%). We conclude that the Lord Millar operation is an alternative to the deep excision operation provided the patients is motivated enough to come regularly to the control for an epilation.     

Femoral venous trauma: techniques for surgical management and early results

During a 4 year period (1979 through 1983), 181 major arterial (69 percent) and 81 venous (31 percent) injuries were treated surgically. Of the venous injuries, 24 (30 percent) involved the femoral veins (9 common femoral, 15 superficial femoral). Management of these femoral venous injuries included lateral venorrhaphy in 10 cases (42 percent), venous patch angioplasty in 5 cases (21 percent), end-to-end anastomosis in 4 cases (17 percent), interposition autogenous saphenous vein grafts in 3 patients (12 percent), and ligation in 2 cases (8 percent). One case that included common femoral venous ligation and one that included a failed interposition saphenous vein graft in the superficial femoral vein subsequently were managed with in situ saphenous vein bypass. For one interposition saphenous vein graft repair of the common femoral vein we utilized the spiral vein graft technique. Excluding one early death from associated injuries and one superficial femoral venous injury managed by ligation without postoperative complications, 17 of 23 (74 percent) femoral venous repairs were judged patent postoperatively (13 confirmed by venography and 4 by noninvasive testing). The adjuvant use of intermittent pneumatic calf compression and low molecular weight dextran appears to have been beneficial in maintaining patency of the femoral venous repairs. Early clinical follow-up demonstrated the presence of edema in 6 of 8 cases (75 percent) initially treated by ligation or complicated by postoperative occlusion. Early postoperative edema, present in 4 of 17 (24 percent) patients with patent venous repairs, had resolved by the time of discharge. We recommend routine repair of femoral venous injuries. When significant edema or ischemia develop following obligatory venous ligation or postoperative occlusion of a venous repair, revision or venous bypass should be considered.     

Complete rotator cuff rupture--differential surgical techniques and intermediate-term results

QUESTIONS: What is the mid term result of open rotator cuff repair? What are the criteria for a good surgical result? METHODS: Between February 1988 and December 1993 130 patients (135 shoulders) underwent surgery for rotator cuff repair. All surgical techniques were combined with a acromioplasty--transosseous refixation, transtendinous suture, isolated or combined transfers of tendons. The retrospective analysis consisted of clinical examination including the Constant score, X-rays and sonograms of the shoulder before and after surgery. RESULTS: 95 patients (98 shoulders) were controlled 4 years and 8 months after surgery by clinical, radiological and sonographical examination. 80% of all cases showed good or very good long term results by chiefly transosseous refixation alone or in combination with tendon transfer. Analysis of all data made it possible to create simple prognostic criteria. These criteria can help preoperatively to give an idea of the expected outcome. CONCLUSION: The best preoperative criteria for a prognostic good surgical result were an acromion-humeral head distance in the native true a.p.-X-ray of more than 7 mm, a rotator cuff defect of less than 2 x 3 cm and a passive free range of motion.     

Supraorbital ethmoidal cell: Anatomical prevalence and surgical significance

Objectives: Investigation of the prevalence and extent of supraorbital ethmoidal cells in relation to ethmoidal arteries.Methods: Paranasal sinus CT scans of 531 patients with various symptoms and diagnoses (headache, sinusitis, nasal polyposis, etc) were investigated regarding the presence and extent of supraorbital ethmoidal cells. Supraorbital ethmoidal cells were classified according to anteroposterior extension and superior extension in relation to ethmoidal arteries.Results: Supraorbital ethmoidal cells were present bilaterally in 299 cases (56.3%). The unilateral presence of supraorbital ethmoidal cells was seen in 25 cases (4.7%). When present on both sides, the cells showed symmetrical extension in the majority of the cases (78.9%), while in 63 cases (21.1%), the cellsdemonstrated asymmetric extension. Either one or both anterior ethmoidal arteries were exposed in 65.4% of the cases with supraorbital ethmoidal cells. Since more posterior extension of supraorbital ethmoidal cells is rare, the posterior ethmoidal artery was exposed in only 15 of the cases.Conclusions: The presence of supraorbital ethmoidal cells is not rare and evaluation of their extension is especially important to avoid complications during endoscopic sinus surgery. When the cells extend beyond the ethmoidal arteries, the high ethmoid roof will make these vessels open to laceration during surgical procedure. In order to avoid complications during endoscopic sinus surgery, thorough investigation of paranasal sinus CT scans is crucial.     

Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis

OBJECTIVE: To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis. METHODS: Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires. RESULTS: Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax. CONCLUSION: Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.     

Lower gastrointestinal bleeding: therapeutic strategies, surgical techniques and results

Lower gastrointestinal bleeding (LGIB) is normally treated conservatively or by noninvasive techniques. Emergency operations are only necessary when patients with severe hemorrhage cannot be stabilized by emergency endoscopy or angiography. To improve the postoperative outcome it is of importance to operate on the patients without any unnecessary time delay. If the preoperative localization of the bleeding source failed, a total or subtotal colectomy should be regarded as a safe procedure. A blind segmental resection should not be done. Alternatively, several ileotomies or colotomies might be performed in order to localize and treat the bleeding site. Elective surgery is indicated with chronic or recurrent bleeding that cannot be treated conservatively. A meticulous preoperative localization of the bleeding site, including anorectoscopy, endoscopy, angiography and nuclear scan is required. With reliable knowledge of the cause and localization of the suspected hemorrhage, a directed segmental bowel resection should be performed.     

Mitral valve repair for commissural prolapse: surgical techniques and long term results.

OBJECTIVE: The aim of this study was to describe the pattern of lesions responsible for commissural prolapse, the techniques of valve repair and their long-term results. METHODS: Between 1992 and 2004, 128 mitral valve repairs were consecutively performed for commissural prolapse. There were 86 males and 42 females, the median age was 57.5 years (range 14-84 years). Forty-six percent of patients were in NYHA III or IV, mean ejection fraction was 61+/-9.4%. The diagnosis of commissural prolapse was recognized by preoperative echocardiography in 32% of the patients and was revealed by intraoperative inspection of the valve in the other cases. The site of the prolapse was the posteriomedial commissure (n=94), the anterior commissure (n=30) or both (n=4). The aetiologies were: infective endocarditis (n=56), degenerative (n=46), ischemic (n=25), congenital mitral regurgitation (n=1). The commissural prolapse was associated with another mitral valvular lesion requiring a specific treatment in 61 cases (47.7%). An associated procedure was carried out in 45 patients. RESULTS: The operative treatment of the commissural prolapse included: commissural closure 65 (50.8%), leaflet resection 31 (24.2%), transposition or shortening of chordae 19 (14.8%), reimplantation or shortening of papillary muscles 3 (2.3%), and replacement of the commissural area by a partial mitral homograft 10 (8%). In-hospital mortality included three deaths (2.3%) and four patients (3.1%) were reoperated: three pericardial drainages for hemopericardium and one for mediastinitis. During the follow-up, one patient died (0.8%) from myocardial infarction and eight patients (6.3%) were reoperated including six (4.7%) for recurrent mitral regurgitation. After a median follow-up time of 76.9 months (range from 15 days to 160 months), 116 patients (90.1%) were in NYHA I. Echocardiographs showed no or minimal insufficiency in 112 patients (87.5%) and mild or moderate insufficiency in 10 patients (7.8%). CONCLUSIONS: The diagnosis of commissural prolapse is difficult by preoperative echocardiography. The aetiology of the mitral disease is variable (endocarditis, degenerative or ischemic mitral regurgitation). Using a variety of techniques, commissural prolapse can be repaired with excellent clinical and echographic long-term results.     

MIS unicondylar knee arthroplasty: surgical approach and early results

Unicondylar arthroplasty of the knee has seen a resurgence of interest in the United States. The principles of unicondylar arthroplasty of the knee are different from those for total knee arthroplasty, allowing replacement of only the affected joint compartment with less bone loss. Minimally invasive surgery allows for less soft tissue dissection with the potential for less morbidity. The key question is: will the changes associated with the minimally invasive surgery procedure improve the clinical results of the standard unicondylar arthroplasty of the knee or will the changes make the procedure too difficult and lead to an increasing failure rate? This study reviews the surgical technique and presents the 2 to 4 year results of the minimally invasive unicondylar arthroplasty of the knee 47 knees in 41 patients. The average range of motion increased from 121 degrees -132 degrees . The Knee Society pain score improved from 45-80 and the function score improved from 47-78. Only one knee has been revised. With proper patient selection, minimally invasive unicondylar arthroplasty of the knee allows for results that are at least equal to those of the standard open procedure at 2 to 4 years after the surgery.     

Combined carotid and cardiac procedures: improved results and surgical approach

Severe cerebrovascular complications following cardiac surgical procedures remain a major concern, particularly in patients with significant carotid atherosclerotic involvement (14% of perioperative stroke). Operative mortality for carotid operations in patients with documented Coronary Artery Disease (CAD) may be as high as 20%. Seventy patients underwent combined operations (unilateral carotid stenosis >70%, unilateral stenosis >50% with ulcerated plaque or bilateral stenoses >50%; and this also included patients with unilateral occlusion). Cardiac procedures were 69 coronary artery bypass grafts, four left ventricular aneurysmectomies, three aortic valve replacements and surgery on two mitral valves. Seven perioperative deaths occurred, which were all caused by cardiac events. There were no perioperative strokes. Carotid endarterectomy immediately before cardiopulmonary bypass is a safe and expeditious approach to coexisting significant cardiac and carotid disease. In our experience, technical details in monitoring and minimizing cerebral ischemia are possibly more crucial in these severe vasculopathic patients. Moreover, it is probably advantageous from an economic standpoint compared with other therapeutic treatments.     

Improved results with intracavernous vasoactive drug infusion following new surgical techniques for vasculogenic impotence

Summary A large percentage of patients suffering from organic impotence will exhibit arterial insufficiency and/or compromise of the venous closure mechanism. In our institution, patients with organic impotence undergo penile Doppler studies, dynamic cavernosometry and cavenosography and when indicated, penile angiography. At present, patients with arterial insufficiency undergo either a single end-to-end anastomosis between the inferior epigastric artery and the distal segment of the dorsal artery of the penis or double end-to-end anastomosis utilizing both epigastric arteries to both the proximal and distal ends of the dorsal artery. In addition, patients receive post-operative cavenosal infusion of vasoactive agents. We have been able to increase our potency rate from 42% to 82% utilizing newer surgical techniques in combination with post-operative cavernosal infusion. In addition, we report on 234 patients in whom selective ligation of incompetent veins has been performed with a nine-month 55% potency rate. In selected patients with milder vasculogenic syndromes, cyclic cavernosal infusion of papaverine and phentolamine has produced a 40% potency rate.     

Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients

This report presents a new surgical method and the results in 10 patients with petroclival meningiomas extending into the parasellar region (sphenopetroclival meningiomas). Minimal but effective extradural resection of the anterior petrous bone via a middle fossa craniotomy offered a direct view of the clival area with preservation of the temporal bridging veins and cochlear organs. The dural incision was extended anteriorly to Meckel's cave, and in cases with invasion of the cavernous sinus, Parkinson's triangle was enlarged by mobilization of the trigeminal nerve. This approach offered an excellent view from the mid-clivus to the cavernous sinus. Extra-as well as intradural tumor masses and dural attachments could be cleared under direct view of the pontine surface. The risk of injury to the lower cranial nerve and of retraction damage to the temporal lobe and brain stem were kept minimal by this approach. Total tumor resection was achieved in 7 patients, with no resultant mortality. Eight patients had a satisfactory postsurgical course, extraocular paresis being their main complaint. The extent of tumor resection depended on the degree of tumor adhesion to the carotid artery, and operative morbidity on the degree of tumor invasion of the brain stem. Of the 3 patients in whom subtotal tumor removal was achieved, only one experienced regrowth of the tumor and underwent a second operation during the follow-up period (6 months-6 years).