Completely Thoracoscopic Diaphragmatic Plication

Background

Thoracoscopic diaphragmatic plication for diaphragmatic paralysis with consecutive eventration and respiratory compromise is a desirable alternative to standard thoracotomy. Since minimally invasive techniques usually involve suturing of the diaphragm, most surgeons use a video-assisted approach with a minithoracotomy. Herein we describe our completely thoracoscopic technique for diaphragmatic plication including outcome.

Methods

We present our technique and experience for completely thoracoscopic diaphragmatic plication for the treatment of symptomatic diaphragmatic paralysis in six consecutive patients. The surgical technique basically consisted of stapling of the abundant diaphragm and reinforcement of the staple line using a self-locking thread. Primary outcome measure was the postoperative result (flattened diaphragm) and resolution of symptoms. Secondary outcome was improvement of lung function values 3 months after surgery.

Results

Between June 2015 and March 2016, six patients have been operated for symptomatic diaphragmatic paralysis, with one of them suffering from additional transdiaphragmatic hernia. Flattening of the diaphragm was achieved in all 6 patients with resolution of their pre-existing symptoms within days after surgery and without any surgical complications. Lung function volumes measured 3 months postoperative improved markedly with an increase in FEV1 as well as FVC of 540 ml (SD ± 193 ml) and 776 ml (SD ± 121 ml), respectively.

Conclusions

In our experience, the presented technique is a safe and simple minimally invasive way to perform a completely thoracoscopic diaphragmatic plication with excellent results so far.

     

Congenital intrapericardial diaphragmatic hernia with omphalocele

Congenital intrapericardial diaphragmatic hernia with omphalocele is very rare. Few cases have been reported in the literature. The embryologic mechanism of this is considered to be abnormal development of the ventral mesoderm at 3–4 weeks after conception. Sometimes, omphalocele is repaired, rather than intrapericardial diaphragmatic hernia, thus causing serious consequences because of the high intra-abdominal pressure. In this paper, we present a case who underwent successful open repair.     

Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients

Background

The newest trend in the field of thoracic surgery, thoracic natural orifice transluminal endoscopic surgery (NOTES), is still in the early stages of development and limited to animal experiments. Transumbilical endoscopic surgery could work as a viable intermediate step before pure NOTES. We describe our experiences performing transumbilical–diaphragmatic thoracic sympathectomy with an ultrathin flexible endoscope for palmar and axillary hyperhidrosis in human patients.

Methods

From April 2010 to January 2012, a total of 38 patients underwent transumbilical–diaphragmatic thoracic sympathectomy. Through the incision in the umbilicus, a newly developed long trocar was inserted into the abdominal cavity. An ultrathin endoscope was introduced through the long trocar and then passed through the rigid incision made in the left and right diaphragm and into the thoracic cavity. The ganglion was ablated at the desired thoracic level.

Results

Sympathectomy was performed successfully in all patients. Mean operation time was 68 ± 16 (range, 48–107) minutes. There was no mortality and no conversion to open surgery during the operation of any patient. At a median follow-up of 11 (range, 4–12) months after surgery, no diaphragmatic hernia was observed. The rate of palmar hyperhidrosis and axillary hyperhidrosis resolution was 100 and 75 %, respectively.

Conclusions

Transumbilical endoscopic thoracic sympathectomy is technically feasible and safe, which has the possible advantages of pure NOTES and can be performed in routine clinical practice.     

Blunt Diaphragmatic Injuries: Pericardial Ruptures

Blunt traumatic diaphragmatic injuries (BTDIs) can be misdiagnosed. Careful evaluation of associated injuries in BTDI is important. In this study, we evaluated treatment options and difficulties in the diagnosis of patients with BTDI. We evaluated ten patients retrospectively with BTDI admitted to our departments, between January 2004 and 2015. Age, gender, trauma type, symptoms, radiological findings, diagnosis time, location and grade of the diaphragmatic injury, surgical type of repair, associated injuries and pericardial rupture, and morbidity and mortality rates were recorded. The mean age of the patients was 46.7 years, and all were males. Ninety percent of BTDI was left sided, and 10 % was on the right side. The diagnosis was confirmed with chest radiograph in 50 % and computed tomography in 70 %. Radiological examination revealed hemothorax in 80 %, the loss of diaphragmatic shadow in 60 %, and visceral organ herniation to the thorax in 60 %. Multiple organ injuries were present in 90 % of cases. Pericardial rupture seen in 30 % was remarkable. Early surgery was performed for eight patients and late surgery for two patients. There were six patients with grade 4 or 5 central diaphragmatic injuries (CDIs). Multiorgan injury was present in all patients developing acute CDI. Multiple organ injury is much higher in patients with severe acute blunt trauma with CDI. Pericardial rupture rate is high in cases with acute BTDI and CDI. Proper diagnosis and early surgical management reduce morbidity and mortality.     

ePTFE soft tissue patch reconstruction of hemidiaphragmatic agenesis with late clinical presentation

In this paper we describe a case of a 71-year-old man affected by left hemidiaphragm agenesis who presented an extensive enterothorax after an asymptomatic history for many years. The patient had late development of severe constipation and occasional episodes of bowel obstruction and vomiting. The surgical correction of this congenital anomaly consisted of restoring the continuity of the diaphragmatic barrier with a 2-mm-thick expanded polytetrafluoroethylene soft tissue patch(Gore-Tex^®) after the herniated viscera have been replaced into the abdominal cavity. At 26 months' follow-up no recurrence has been observed. We would suggest that this is the first known elderly patient surgically treated and the eighth case reported in the literature. The use of a single-layer ePTFE mesh allows a good anatomical and functional repair. An overview of the literature is also reported.     

Iatrogenic diaphragmatic hernia complicating nephrectomy: top-down or bottom-up?

Hernias of the diaphragm are rarely reported as a complication of abdominal surgery. We review a case of a 47-year-old female who presented with dyspnoea and chest pain one day after left radical nephrectomy for renal cell carcinoma. Plain and cross-sectional imaging identified a large left-sided diaphragmatic hernia containing omentum, spleen, splenic flexure, and stomach. Our patient underwent a thoracotomy and, after hernia reduction, the diaphragmatic defect was repaired using non-absorbable sutures and a mesh. She made an uneventful recovery. The potential cause is discussed and the published literature on this rare complication is reviewed briefly.     

Fatal pulmonary embolism following spinal surgery in a patient with permanent inferior vena cava filter placement

It has been proven that the use of an inferior vena cava filter (IVCF) is effective in decreasing the incidence of pulmonary embolism (PE) in high-risk spinal surgery patients. A case of fatal PE after spinal surgery in a 78-year-old woman who had a history of pulmonary hypertension due to peripheral PE treated with a permanent IVCF and anticoagulant therapy for 3 years is reported. The patient had experienced an episode of recurrent PE during the withdrawal of anticoagulants, but she had uneventfully undergone two orthopedic surgeries with a preoperative unfractionated heparin infusion instead of oral warfarin. Three months after the second operation, she underwent posterior lumbar spinal fusion. The following morning, she suddenly complained of chest discomfort and dyspnea with SpO₂ 78 %. An electrocardiogram showed a right bundle branch block. Then, 30 min later, she suddenly lost consciousness, and her carotid pulse was not palpable. The patient died 2 h and 30 min after onset. Acute PE probably occurred because of a massive thrombus above the IVCF. This case suggests that the efficacy of long- term use of a permanent IVCF is limited in cases when anticoagulants must be withdrawn, such as for orthopedic surgery.     

High-power diode laser in the circumvestibular incision for Le Fort I osteotomy in orthognathic surgery: a prospective case series study

The incisions during orthognathic surgery are classically performed with conventional scalpel or electrocautery. Considering that the high-power diode laser surgery may provide advantages when compared to conventional incision techniques, the current study aimed to present a prospective case series of patients submitted to circumvestibular incision for Le Fort I osteotomy. Ten patients with dentofacial deformities who underwent to rapid assisted maxillary expansion or bimaxillary orthognathic surgery were enrolled in the study. All incisions were performed by a single surgeon using an 808-nm diode laser, with an optical fiber of 600 μm, at a power of 2.5 W, in a continuous-wave mode. The performance of the incision was evaluated by incision velocity, bleeding, edema, secondary infection, clinical healing, and pain. The velocity of the incision ranged from 0.10 to 0.20 mm/s (mean 0.13 ± 0.03 mm/s). Considering bleeding during the soft tissue incision, all surgeries were classified as absent bleeding. All patients presented a clinical healing of the surgical wound in a period that range from 3 to 5 weeks and experienced swelling during the follow-up period. On average, approximately 50% of the swelling had resolved after the third postoperative week, and 28.8% of swelling remained after 2 months after the surgery. The pain decreased after 2 and 3 days, and 90.0% of the patients reported no pain after 7 postoperative days. High-power diode laser is effective and safety during circumvestibular incisions for Le Fort I osteotomy in orthognathic surgery decreasing bleeding, surgery time, pain, and edema after orthognathic surgery.     

Combined hepatocellular–cholangiocarcinoma producing parathyroid hormone-related protein: report of a case

Combined hepatocellular–cholangiocarcinoma (CHCC) is an uncommon form of primary liver cancer. A 57-year-old man was readmitted to our hospital for treatment of recurrent CHCC, 12 months after central bisegmentectomy and 4 months after limited hepatic resection. Magnetic resonance imaging (MRI) revealed multiple hepatic nodules. Laboratory data showed increased serum levels of α-fetoprotein (AFP), calcium, and parathyroid hormone-related protein (PTH-rP), to 5,571 ng/mL, 17.0 mg/dL, and 16.1 pmol/L, respectively. Palliative mass reduction surgery was indicated by the fact that the hypercalcemia was difficult to manage medically. Thus, we performed lateral segmentectomy with partial resection of segment 7 and the caudate lobe, and microwave coagulation therapy for multiple recurrent CHCC. Thereafter, the serum PTH-rP and AFP levels decreased remarkably and the hypercalcemia was controlled for the next 3 months. He died of disease progression 9 months after the last hepatic surgery. To our knowledge, this is only the second reported case of CHCC producing PTH-rP in the English-language literature.     

Spontaneous biliopneumothorax (thoracobilia) following gastropleural fistula due to stomach perforation by nasogastric tube

Gastropleural fistula may occur after pulmonary resection, perforated paraesophageal hernia, perforated malignant gastric ulcer at the fundus, or gastric bypass surgery for morbid obesity. We describe a case of gastropleural fistula after stomach perforation by a nasogastric tube in a patient who underwent Billroth II gastric resection for adenocarcinoma. Left biliopneumothorax occurred and was treated by thoracic drainage with -20 cm H₂O aspiration. As gastropleural fistula persisted, laparotomy was repeated and gastric and diaphragmatic perforations were sutured. Gastropleural fistula is rare and, to our knowledge, this is the first reported case of gastropleural fistula and biliopneumothorax caused by gastric and diaphragmatic perforation by a nasogastric tube.     

Reanimation durch präkordialen Faustschlag

The case of 16-year-old, ASA I classified patient who suffered cardiac arrest during orthopedic surgery is reported. Return of spontaneous circulation was achieved with a precordial thump. The patient was discharged from hospital without any neurological deficits 10 days after the event.     

Transient large urinoma following hysterectomy

This case report describes the formation of a very large urinoma 1 day after vaginal surgery. A 59-year-old woman was diagnosed with a urinoma measuring 30.5 cm in length, 23 cm in the transverse plane and 12 cm in the anteroposterior dimension on day 1 after a vaginal hysterectomy and prolapse repair surgery. The urinoma resolved completely after trans-abdominal catheter drainage. This case demonstrates that even a large urinoma can initially be managed conservatively. Furthermore, it emphasizes the importance of the early detection and management of urinary tract injuries after vaginal surgery.     

A late complication of transobturator tape procedure: vaginocutaneous fistula formation with vaginal mesh erosion

Transobturator tape procedures are a common treatment modality in patients with stress urinary incontinence (SUI). Various complications have been reported related to this procedure. We present a rare case of vaginocutaneous fistula formation 5 years after transobturator tape surgery. A 56-year-old woman presented with complaints of increased vaginal discharge, difficulty in coitus, and serosanguineous discharge from the left groin 5 years after transobturator tape surgery for SUI. Pelvic examination revealed 2–3 cm of extruded mesh at the anterior vaginal wall. The vaginocutaneous fistula was detected at surgery. The suburethral tape was removed, and the fistula tract was excised and repaired primarily. Postoperative period was uneventful, and the patient was still continent 6 weeks postoperatively. With widespread use of mesh for treating SUI, we will likely see a variety of complications in the long term.     

The value of lateral spread response monitoring in predicting the clinical outcome after microvascular decompression in hemifacial spasm: a prospective study on 100 patients

Microvascular decompression represents an effective treatment for hemifacial spasm. The use of lateral spread response (LSR) monitoring remains a useful intraoperative tool to ensure adequate decompression of the facial nerve. The aim of this study was to assess the value of LSRs intraoperative monitoring as a prognostic indicator for the outcome of microvascular decompression in hemifacial spasm. Our study included 100 patients prospectively. The patients were classified into four groups whether LSRs were totally, partially, not relieved, or not detected from the start. According to clinical outcome, the patients were classified into four groups depending on the clinical course after surgery and the residual symptoms if any. Then, correlations were made between LSR events and treatment outcome to detect its reliability as a prognostic indicator. LSRs were relieved totally in 56 % of the patients, partially relieved in 14 %, not relieved in 10 %, and were not detected in 20 % of the patients from the start. HFS was relieved directly after operation in 62 % with clinical improvement of 90–100 %. Thirty-one percent described 50–90 % improvement over the next 3 months after surgery. Almost all of these 31 % (28 out of 31 patients) reported further clinical improvement of 90–100 % within 1 year after surgery. Three percent suffered from a relapse after a HFS-free period, and 4 % reported minimal or no improvement describing 0–50 % of the preoperative state. The percentage of the satisfied patients with the clinical outcome who reported after 1 year a clinical improvement of 90–100 % was 90 %. Statistical analysis did not find a significant correlation between the relief of LSRs and clinical outcome. LSRs may only represent an intraoperative tool to guide for an adequate decompression but failed to represent a reliable prognostic indicator for treatment outcome.     

Semitendinosus ligamentoplasty of the forearm interosseous membrane in a case of Essex-Lopresti syndrome

The case of a 39-year-old patient with an Essex-Lopresti syndrome is reported. The radial head fracture was comminuted and the distal radio-ulnar joint was dislocated. The patient underwent an orthopaedic treatment and a 7-month long rehabilitation. Motions were assessed with 20–140° elbow flexion, 0° supination, 40° pronation, 40° wrist flexion, and 45° extension wrist. Jamar^® measurement was 18 kg (40 kg for the opposite limb). X-rays displayed a radial ascension with an ulno-carpal impingement syndrome. Surgical procedures were a shortening of the ulna, a radial head arthroplasty, and a ligamentoplasty using the semi-tendinous muscle. Two months after surgery, the patient worked again. The last follow-up was 13 months after surgery. Motions were assessed with 30–130° elbow flexion, 45° supination, and 60° pronation. Jamar^® measurement was 40 kg (50 kg for the opposite limb), with a painless forearm or wrist. Our technique of ligamentoplasty is original, with the type and the course of the transplant. Its indications would be in radial head lesions associated with a longitudinal forearm instability. The ligamentoplasty would prevent from overloads of radial head osteosyntheses or arthroplasties.     

Bilateral diaphragmatic paralysis after open heart surgery.

The purpose of the present case report is to present a case of bilateral diaphragmatic paralysis as a complication of open-heart surgery. A 47-year-old male was operated for aortic and mitral valve replacement. After discontinuation of sedation, bilateral diaphragmatic paralysis as well as motor and sensitive dysfunction in the four extremities was observed. The patient remained with mechanical ventilation support for twenty months. Two years after the operation a complete normalisation of the diaphragmatic motion was observed. Although uncommon, bilateral diaphragmatic paralysis after open-heart surgery could take place, being necessary long term mechanical ventilation support until recovery.     

Langzeitergebnisse nach offener Rotatorenmanschettenrekonstruktion mittels Flaschenzugnaht

Aim

There are various techniques for the reconstruction of a torn rotator cuff. The reference for any new operation method is the approved open transosseous suture. The following study presents the long-term results of 100 rotator cuff defects, which were treated using this method, regarding the function and the integrity of the tendon. The refixation technique used in this study comes close to the McLaughlin technique, but differs in that the special pulley block suture was used.

Method

From a series of 116 patients of the years 1995 to 1999 who underwent rotator cuff surgery using the above mentioned technique with at least one pulley block suture, the post-operational results of 96 patients (51 m, 45 f, 4 had a defect on both sides, the average age at the date of surgery was 59 years) have been analyzed. Clinical and sonographic examination took place on average 7.5 years after surgery, and the age- and gender-adjusted Constant Murley Score (ACS) was ascertained. These results were compared with the score results documented by the surgeon prior to surgery. The rotator cuff was examined by ultrasound for potential defects.

Results

A rerupture was confirmed by ultrasound in 7 cases. The ACS improved in 5 cases despite rupture. There was one case where the ACS deteriorated and in one other case no comparison was possible. All of the reruptures occurred, when the lesion was at least 3 cm or when at least two tendons were involved. There was a significant improvement of the ACS from an average 43.5% before surgery to an average 98.2% after surgery. The female collective achieved a significantly better outcome than the male collective (female average after surgery: 103.5%; male average after surgery: 92.9%, without considerable differences with respect to age). Regarding the ACS, no significant difference between the operated shoulder and the contralateral shoulder could be ascertained (100.8%, p =0.21). Within all of the individual categories of the Constant Murley Score (CMS), significant improvement (p<0.001) was achieved by surgery (e.g., pain from 2.7 to 14 points after surgery, abduction 2.7 to 8.9 points, force 3.9 to 8.8 points). The postoperative comparison of the operated and the contralateral shoulder did not establish any significant differences.

Conclusion

The open reconstruction of the rotator cuff with a transosseous suture via pulley block proves to be a method with excellent long-term results after surgery and a low rate of rerupture even in the case of large lesions. It is, therefore, justified to apply this technique as a standard method of surgery especially with large rotator cuff defects.     

Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review

Background

Diaphragmatic endometriosis is a rare condition that may cause invalidating epigastric or thoracic pain and catamenial pneumothorax. During the past decades, laparoscopy has been proposed as an optimal tool for diagnosis and surgical eradication of the disease.

Methods

We present a retrospective series of consecutive patients affected by diaphragmatic endometriosis, treated by laparoscopy at our institution, during a period of 7 years.

Results

Among 3,008 patients with pelvic endometriosis, 46 cases with intraoperative diagnosis of diaphragmatic endometriosis were identified. Operative findings showed multiple diaphragmatic lesions in 32 (69.5 %) patients and single lesions in 14 (30.4 %). Diaphragmatic implants were distributed on the right side in 40 (86.9 %) patients; in 5 patients (10.8 %) they were bilateral and 1 patient had a single lesion on the left hemidiaphragm. Most of the symptomatic patients were treated by complete excision of the nodules, whereas only three patients referring right upper-quadrant abdominal pain and right shoulder catamenial pain had superficial diaphragmatic endometriosis and were treated by diathermocoagulation.

Conclusion

Diaphragmatic endometriosis should be included in the concept of complete eradication of endometriosis. This kind of surgery has been shown to be feasible and cost-effective; however, it should be managed in a referral center, by an expert laparoscopic gynecologist with knowledge of oncological surgical techniques, with the support of a general surgeon and a trained anesthesiologist.     

Successful treatment of nonunion with teriparatide after failed ankle arthrodesis for Charcot arthropathy

We describe a case of successful treatment to nonunion after multiple arthrodesis operations for Charcot arthropathy with teriparatide. We describe the case of a 25-year-old woman with severe Type I diabetes mellitus that resulted in nonunion after multiple arthrodesis operations for Charcot arthropathy. The woman sustained a femoral shaft fracture for which she underwent surgery with intramedullary nail fixation. Immediately after surgery, an empiric course of teriparatide was initiated. Femoral shaft fracture healing was observed after 2 weeks, and the woman was able to walk 12 weeks after the surgery, at which point plain film and computed tomography images revealed complete union of the ankle.     

Intramuscular myxoma in the chest wall

Intramuscular myxomas are benign soft-tissue tumors that often develop in the thigh. A 66-year-old woman was referred with an abnormal shadow on chest roentgenogram. The tumor was well defined and smooth and originated from the second intercostal space. Positron emission tomography showed no accumulation of 18F-fluorodeoxyglucose in the tumor. The patient attended the outpatient department for follow-up care. Because the mass grew slightly after 52 months, the patient underwent complete removal by video-assisted thoracoscopic surgery. On histopathological examination, the tumor was diagnosed as an intramuscular myxoma in the chest wall. The patient has had no recurrence 3 years after surgery. A case of intramuscular myxoma in the chest wall, completely resected by video-assisted thoracoscopic surgery, is reported. A well-defined, smooth, homogeneous mass in the chest wall may therefore be intramuscular myxoma.