Migrated Sternal Wire into the Right Ventricle: Case Report in Cardiothoracic Surgery

Abstract Migrating wires as a result of sternal nonunion present clinical challenges. Cardiac Computed Tomographic Angiography helps locate these wires precisely, enabling detailed surgical planning. Sternal wire migration is an infrequent complication following median sternotomy. It is usually encountered among patients with sternal dehiscence. Understanding the location and spatial relationships of structures to the wire can be challenging. (64 slice) with high spatial and temporal resolution affords the possibility of enhancing presurgical planning. (J Card Surg 2010;25:161‐162)     

Minimally Invasive Endogastric Removal of Migrated Gastric Band After Endoscopic Failure: How I Do It

Intragastric band migration is a rare and late complication of laparoscopic -adjustable gastric banding and should be recognized by all digestive surgeons. Endoscopic removal is most commonly performed, but surgery is an alternative in cases of endoscopic failure. Many different procedures have been reported. We show here (see Video) a fully laparoscopic endogastric procedure through two 5-mm antral gastrotomies. This technique can also be used to remove benign endogastric tumors. The procedure is safe and provides a large endogastric operative area, with no particular morbidity. Endogastric removal through a fully laparoscopic approach should be considered as the first alternative to endoscopic approach.     

Elective Surgical Removal of Migrated Intrauterine Contraceptive Devices From Within the Peritoneal Cavity: A Comparison Between Open and Laparoscopic Removal

Background:

Intrauterine contraceptive devices (IUCDs) comprise the most popular form of reversible contraception. Uterine perforation is a rare but potentially serious complication associated with their use. We examined all reported cases of elective surgical removal of peritoneally migrated IUCDs, to compare laparoscopic and open approaches, and to identify beneficial surgical techniques.

Database:

MEDLINE and Embase were searched using the following medical subject heading terms: (IUCD or IUD or IUS or intrauterine device or intrauterine devices, copper or intrauterine devices, medicated) AND (migrated or displaced or foreign-body migration or intrauterine device migration) AND (peritoneal or peritoneal cavity). The Cochrane Library was searched using the terms IUCD, IUD, IUS, and intrauterine device. Additional studies were identified by manually searching the reference lists of the studies found through database search. Studies were included irrespective of language or publication type.

Discussion:

We identified 129 cases, reported in 30 studies. In the majority of cases (93.0% [120/129]), surgery was attempted laparoscopically; however 22.5% (27/120) of surgeries were converted to open operations, giving an overall rate of open surgery of 27.9% (36/129). This systematic review supports the use of laparoscopic surgery for elective removal of migrated IUCDs from the peritoneal cavity. With complications rarely reported, it is also likely the procedure could be undertaken in an outpatient setting. The use of intraoperative adjuncts (ie, cystoscopy) and the rate of conversion to open surgery are influenced by the site of the IUCD. Therefore, accurate preoperative localization of the device is advised.     

Surgical Treatment of Primary Sternal Osteomyelitis

Four patients with primary sternal osteomyelitis are described. Pseudomonas aeruginosa was the infective organism. Three of the 4 were heroin addicts. Limited surgical resection with preservation of the posterior periosteum is recommended for an infected sternum. Postoperative antibiotic therapy for a period of six weeks is also recommended. Preservation of the posterior sternal periosteum rather than conventional radical excision is important for maintaining physical stability and avoiding chest wall deformity in this group of patients.     

The Safest Method of Sternal Wire Extraction Post-Midsternotomy Closure

Abstract   Background: An incident of fatal pericardial bleeding immediately after the extraction of a sternal wire prompted a search for the most appropriate method for removing sternotomy wire sutures. A model sternum was devised to explore this problem, and several commonly used techniques for wire extraction were evaluated. Methods: A wooden sternal model was constructed to simulate the dimensional properties of a sternum overlying the mediastinal cavity, and to imitate its tensile characteristics. A Monofil CrNi-316L (Johnson & Johnson, Brunswick, NJ, USA), No. 7 CCS, 9 metric, 4×45-cm wire was passed vertically through drilled holes. The suture was then crossed and pulled, thus joining the two boards and approximating the wire to their deep surface. A latex balloon filled with dye was placed inside under the boards. Wire holders were used to extract the wires, using a linear pulling technique and a coiling around the wire-holder tip technique. Sixty repetitions were performed for each method. Results: In 60 trials of direct linear wire pulling, balloon rupture occurred in 33 (55%), whereas tearing was noted only 15 times out of 60 attempts (25%) when the tense coiling method was used. Conclusions: Sternotomy wire sutures should be extracted using a controlled technique that ensures safety to vital tissues in close proximity to the sternal bone. The tense coiling procedure offers superior safety when compared to the direct pulling process, demonstrated by a lower incidence of balloon rupture because of the lesser degree of wire flexure. This technique has become the method of choice in our medical center.     

Midterm Results of Sternal Band Closure in Open Heart Surgery and Risk Analysis of Sternal Band Removal

Sternal dehiscence, which is responsible for the development of mediastinitis, is a serious complication after cardiothoracic surgery. We retrospectively compared the results of two methods for sternal closure after cardiothoracic surgery performed during January 2009 to May 2012. The methods comprised closure with sternal bands and steel wires (group A, n = 92) versus conventional closure using steel wires alone (group B, n = 442). Although not significantly different between the two groups, no patients undergoing sternal band closure experienced dehiscence or mediastinitis. The incidence of having to remove materials used for sternal closure was significantly higher in group A than in group B. In each case of removal in group A, the materials removed were sternal bands whose tips had caused direct cutaneous irritation. Thus, although sternal bands may be effective for rigid sternal closure, they must sometimes be removed because of chest discomfort caused by the tip of the band.     

NOTES Rectosigmoid Resection Using Transanal Endoscopic Microsurgery (TEM) with Transgastric Endoscopic Assistance: A Pilot Study in Swine

Introduction  Transanal endoscopic microsurgery (TEM) provides direct endoscopic access to the rectum and peritoneal cavity. The feasibility of natural orifice translumenal endoscopic surgery (NOTES) rectosigmoid resection using TEM was evaluated in swine. Transgastric endoscopic assistance to extend transanal colon mobilization was also investigated. Full-thickness circumferential rectal dissection was performed and extended proximally. After maximal sigmoid mobilization, the specimen was exteriorized and transected, and the proximal colon was stapled to the distal rectum. In a subset of animals, transgastric endoscopic access was used to mobilize the colon further. Results  Rectosigmoid resection using TEM was performed in two non-survival and seven swine cadavers (n = 9). The mean procedure time was 3 h (2.5–4 h), and mean length of resected colon was 16.7 cm (10–25 cm). Transgastric endoscopic assistance was used in three cadavers and two non-survival swine (n = 5) with a mean operative time of 3.5 h (3.5–3.75 h). The mean length of colon mobilized with transgastric and transanal endoscopic access was 24.4 cm (20–27 cm) vs. 16.7 cm which mobilized the transanal approach alone (p = 0.016). A posterior anastomotic defect was noted in two animals. Conclusion  Transanal rectosigmoid resection with TEM is feasible in swine. Combined transgastric and TEM access is a promising new technique for NOTES colorectal resection. Meeting presentations This study was accepted for presentation at the SSAT Plenary Session May 20, 2008 at Digestive Disease Week in San Diego, CA.     

Migration of a Broken Trochanteric Wire to the Popliteal Fossa

Wires used in fracture fixation or elective procedures can migrate within the body, and some lethal complications have been reported in the literature. We report a case of knee discomfort caused by a broken cerclage wire that has migrated from the hip region to the popliteal fossa after trochanteric osteotomy used in revision hip surgery. The authors point to the potential risks of broken orthopedic hardware.     

完全腔镜治疗甲状腺疾病的适应证及手术技巧

完全腔镜甲状腺手术将传统的颈部手术切口转移至隐蔽部位,也称为颈部无瘢痕腔镜甲状腺手术（scarless endoscopic thyroidectomy, SET）。其具备卓越的美容效果和一定程度的微创特征,兼顾了治疗与美容效果,故称为甲状腺肿瘤美容手术（oncoplastic thyroidectomy）。回顾SET15余年的发展历程,其能够同时完成双侧甲状腺手术、中央区以及外侧区清扫。     

Thalamic Astrocytomas: Surgical Anatomy and Results of a Pilot Series Using Maximum Microsurgical Removal

Summary  Deep-seated astrocytomas within the basal ganglia and the thalamus are considered unfavourable for microsurgical removal since the circumferential neighbourhood of critical structures limits radical resection. On closer assessment, the thalamus has a unique configuration within the basal ganglia. Its tetrahedric shape has 3 free surfaces and only the ventrolateral border is in contact with vital and critical functional structures, e.g. the subthalamic nuclei and the internal capsule. The purpose of the present study was to investigate the feasibility of maximum microsurgical removal in a series of intrinsic thalamic astrocytomas.  14 patients with intrathalamic astrocytomas grades 1 to 4 as diagnosed by previous stereotactic biopsy or intra-operative frozen section were selected for maximum microsurgical removal. The infratentorial supracerebellar approach from the contralateral side was used for 4 limited neoplasms of the pulvinar. For the other 10 larger and more extensive processes a parieto-occipital transventricular approach was chosen.  Final histology gave the result of astrocytoma grade 1 or 2 in 4 patients, and of astrocytoma grade 3 or 4 in 10 patients. Postoperative MRI confirmed reduction of the tumor mass by 80 to 100% in 11 of 14 cases. Regional ancillary radiotherapy with 60 Gy was administered postoperatively for astrocytomas grades 3 and 4. Two patients operated on via the posterior transventricular approach had new postoperative partial hemianopia. Five of the 14 patients finally needed a ventriculo-peritoneal shunt. During the follow-up time of 6 to 52 months, tumor progression/recurrence was observed in 6 of the 10 high grade and none of the low grade neoplasms.  The present pilot series demonstrates the feasibility of the microsurgical concept. Comparison with other treatment modalities, such as brachytherapy, requires future consideration.     

Percutaneous Repair Technique for Acute Achilles Tendon Rupture with Assistance of Kirschner Wire

The aim of this study is to introduce a self‐designed, minimally invasive technique for repairing an acute Achilles tendon rupture percutaneously. Comparing with the traditional open repair, the new technique provides obvious advantages of minimized operation‐related lesions, fewer wound complications as well as a higher healing rate. However, a percutaneous technique without direct vision may be criticized by its insufficient anastomosis of Achilles tendon and may also lead to the lengthening of the Achilles tendon and a reduction in the strength of the gastrocnemius. To address the potential problems, we have improved our technique using a percutaneous Kirschner wire leverage process before suturing, which can effectively recover the length of the Achilles tendon and ensure the broken ends are in tight contact. With this improvement in technique, we have great confidence that it will become the treatment of choice for acute Achilles tendon ruptures.     

Small Incisional Esophagectomy with Endoscopic Assistance: Evaluation of a New Technique

Laparoscopic surgery now can be performed safely and efficiently for various types of cancer; however, reconstruction of the gastric tube may be technically demanding. We attempted to make a breakthrough by designing and employing a new technique for performing a small incisional operation with endoscopic assistance. A midline incision, 10 cm in length, was made in the upper abdomen. Some procedures were performed through the incision under direct vision, while other procedures required in the lateral extremes of the abdominal cavity, that are inaccessible by direct vision, were performed by laparoscopic-assisted surgery. Similarly, intrathoracic procedures were essentially performed through a minithoracotomy, 10–15 cm in length, made without dissection of the dorsal latissmus or anterior serratus muscles. The postoperative courses of 20 consecutive patients who underwent this procedure were generally uneventful, and significant improvements in terms of intensive care and analgesic requirements were observed. Received: December 22, 1999 / Accepted: November 20, 2000