经前路颈胸联合切口治疗C7—T2椎病变

Ｃ７～Ｔ２椎病变经前路显露，按通常用的手术切口，显露是有困难和有限制的，尤其是行前 路植骨更是如此。作者改良了Ｓｕｎｄａｒｅｓａｎ的手术方法，从左侧作“Ｌ”形联合切口。切除左锁骨内侧 １／３、同侧胸骨柄的一部分，本组共做１２例，显露良好、安全、有效。     

A novel technique of exposure during radical retropubic prostatectomy

PURPOSE: We describe a novel technique of enhanced exposure during radical retropubic prostatectomy in cases with significant cartilage overgrowth at the junction of the symphysis pubis. MATERIALS AND METHODS: At our institution 74 radical retropubic prostatectomies were performed between July 1, 1998 and June 30, 1999. In 9 cases (12%) exposure was limited by overgrowth of cartilage at the posterior aspect of the pubic symphysis. Electrovaporization of this cartilaginous outgrowth was performed using an extended Bovie tip on cut settings of approximately 250 W. using the Bard System 5000, Birtcher 5000 and 6400 series (Valley Lab, Boulder, Colorado). The cartilage was vaporized until flush with the pubic bone. RESULTS: This technique provided optimal exposure for direct visualization during the most critical part of the procedure. Added operative time was only 1 to 3 minutes. No intraoperative or postoperative complications were associated with this technique. CONCLUSIONS: We recommend this technique of vaporization when surgical exposure is limited by overhanging pubic symphysis cartilage. This technique enables better visualization during apical dissection, control of the dorsal vein complex and division of the urethra without additional operative time or surgical complications.     

Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius

Intra-articular incongruity of the distal radius at the radiocarpal joint is a bad prognostic feature; reduction by closed or open operative techniques is important. However, both techniques have limitations. We describe a new technique of reduction of the lunate facet under radiographic control, with very limited operative exposure and tissue trauma. In two cases anatomic restoration of the radiocarpal joint was obtained by this technique and maintained with external and limited internal fixation. Follow-up results are very encouraging. Currently we suggest use of this simple technique when faced with an incongruous radiocarpal joint after unsatisfactory attempts at closed reduction.     

Tongue base exposure during TORS without the use of a mouth prop

This study describes a novel exposure technique for base of tongue trans-oral robotic surgery (BOT TORS) and early experience with it. The technique discussed involves placement of a suture through the mobile tongue with distraction and suspension of the tongue to the operating table. TORS is then performed per previously described techniques. In our series, 13 patients with either benign or malignant mass lesions involving the tongue base were treated with TORS at a tertiary academic medical center. We reviewed the rates of adequate exposure, console time, adequacy of resection (in malignant cases), complication rates, and costs associated with this technique. In our series, adequate exposure was achieved in 92.3 % of patients. Mean console time was 36 min. Negative surgical margins were achieved in all cancer resections. Five minor complications (tongue lacerations) were observed. Per-case cost attributable to this technique is $3.81. We conclude that BOT TORS is feasible without the use of a mouth prop. Operative times are consistent with those reported by centers that routinely use mouth props for BOT TORS. This technique does not appear to compromise margin adequacy during oncologic resections. Its use may result in a significant cost savings when compared to the FK and other similar retractors.     

Evaluation of personal,environmental and biological exposure of paediatric anaesthetists to nitrous oxide and sevoflurane

Paediatric anaesthetists are at higher risk of exposure to waste anaesthetic gases, which often exceed set safety limits. Recommended personal diffusive sampling techniques for monitoring exposure to waste anaesthetic gases may not give a true profile of exposure and hence biological sampling may also be necessary. We evaluated the exposure of paediatric anaesthetists to nitrous oxide and sevoflurane as assessed by personal environmental and biological samples. The influence of venue and technique, and the strength of the relationship among the various sampling techniques were analysed. The study found that exposure to nitrous oxide during paediatric anaesthetic inductions is still a major problem, although exposure to sevoflurane was usually within the accepted limits. The type of breathing system used and the presence of scavenging seem to influence this exposure, though surprisingly, the induction technique or the methods of airway control do not. No significant relationship was found between the various biological indicators measured.     

Entrapping of the clotted intra-aortic balloon in the descending aorta

Percutaneous insertion of a catheter for intra-aortic balloon pumping (IABP) was introduced in 1979 by Bregman and Casarella and has become a popular technique. Rupture of the balloon, allowing clot to form inside it, is rare. When the clot is large, it may cause entrapping of the balloon. This is a potentially dangerous complication of IABP. We are aware of only one case report of this complication, by Aru and co-workers. The entrapping of the balloon in their report occurred at the site of insertion in the femoral artery. We report here a case in which the entrapping occurred in the descending aorta, and its removal required extensive exposure of the aortic bifurcation.     

Autologous chondrocyte implantation at the knee using a bilayer collagen membrane with bone graft. A preliminary report

Autologous chondrocyte implantation (ACI) is a technique used for the treatment of symptomatic osteochondral defects of the knee. A variation of the original periosteum membrane technique is the matrix-induced autologous chondrocyte implantation (MACI) technique. The MACI membrane consists of a porcine type-I/III collagen bilayer seeded with chondrocytes. Osteochondral defects deeper than 8 to 10 mm usually require bone grafting either before or at the time of transplantation of cartilage. We have used a variation of Peterson's ACI-periosteum sandwich technique using two MACI membranes with bone graft which avoids periosteal harvesting. The procedure is suture-free and requires less operating time and surgical exposure. We performed this MACI-sandwich technique on eight patients, five of whom were assessed at six months and one year post-operatively using the modified Cincinnati knee, the Stanmore functional rating and the visual analogue pain scores. All patients improved within six months with further improvement at one year. The clinical outcome was good or excellent in four after six months and one year. No significant graft-associated complications were observed. Our early results of the MACI-sandwich technique are encouraging although larger medium-term studies are required before there is widespread adoption of the technique.     

Use of the F-Tool for the removal of a bent intramedullary femoral nail with a sagittal plane deformity

Locked intramedullary nailing is the current standard of treatment for femoral shaft fractures and has low complication rates. Bent femoral intramedullary nails resulting from secondary trauma are rare and technically challenging. This article describes a case of a 36-year-old man who presented with a bent femoral intramedullary nail following a motorcross accident. The patient had a previous femoral shaft fracture treated with an intramedullary nail. Previous reports outlined methods to remove bent femoral nails through the fracture site and proximally; however, this article describes a novel technique combining the use of a Midas Rex MR7 high-speed burr (Medtronic, Minneapolis, Minnesota) and the F-Tool (Synthes, West Chester, Pennsylvania) to facilitate nail extraction.The patient was placed in the lateral decubitus position. After limited exposure at the fracture site, the intramedullary nail was weakened at the apex of the deformity with a Midas Rex MR7 high-speed burr. We then used the F-Tool to straighten the nail to facilitate removal through the original proximal insertion site. The F-Tool allows forces to be concentrated at the apex of the deformity and minimizes soft tissue damage. Additional advantages of our technique include limited exposure and the ability to remove the nail in 1 piece.     

Regenerative surgery of the complications with Morton's neuroma surgery: use of platelet rich plasma and hyaluronic acid

Morton's neuroma is an entrapment neuropathy of the plantar digital nerve. We treated five patients with wound dehiscence and tendon exposure, after Morton's neuroma surgery excision using a dorsal approach. In this article we describe our technique. From July 2010 to August 2011, at the Department of Plastic and Reconstructive Surgery, University of Rome ‘Tor Vergata’, five patients (four females and one male), with ages ranging between 35 and 52 years, were treated with a combination of PRP (platelet rich plasma) and HA (hyaluronic acid). Thirty days following surgery, all patients showed a complete healing of the wound. The use of this technique for the treatment of postoperative wound dehiscence and tendon exposure has proven as satisfactory.     

A novel technique for the repair of lumbar hernias after iliac crest bone harvest

BACKGROUND: Lumbar hernia is a clinical entity that has been increasingly more common since the advent of iliac bone harvest for bone grafting procedures. These can be very technically difficult to repair and have a high recurrence rate. METHODS: Using a corkscrew anchor suture device, we have developed a novel and simple way to repair these hernias with no recurrence. Here we present our experience with the corkscrew suture anchor device. RESULTS: This technique has been performed in 2 patients at our institution, and in both cases, the hernia was successfully repaired. Our 1-year follow-up on this technique demonstrates intact repairs with no sign of recurrence. CONCLUSIONS: The placement of corkscrew suture anchors along the iliac crest remnant is a simple technique requiring minimal bony exposure. The anchors facilitate the long-term fixation of mesh despite the lack of fascia in this area. We conclude that this is a simple and effective approach for repair of these challenging hernias.     

Saccular aneurysms of the extracranial internal carotid artery. Experience and review of the literature

The aim of this study was to describe the surgical technique employed and our results in the treatment of saccular aneurysms of the internal carotid artery at the extracranial level. We describe 3 cases of patients with saccular aneurysms of the extracranial internal carotid who underwent surgery at our unit within the last 3 years. We report on indications for treatment, surgical technique and results in terms of morbidity-mortality and also review the pertinent literature. Surgical treatment was indicated on the grounds of the patients being symptomatic: 2 had a history of cerebral ischemia, and 1 showed local compression symptoms. The surgical approach was presternocleidomastoid cervicotomy extended distally, and in 2 patients was accompanied by nasotracheal intubation to achieve adequate exposure. In 2 cases, we performed an aneurysmectomy with end-to-end anastomosis. In the third patient, the aneurysm neck was ligated from within the sac followed by aneurysmectomy. There was no mortality or neurological morbidity (local or general). The patients remain free from neurological symptoms with a patent carotid axis. Our clinical experience suggests that, despite the anatomically unfavorable location of this type of aneurysm and the greater complexity of the surgical technique, this patient group can be effectively treated. The frequent presence of an elongated carotid axis and an aneurysmal neck means the surgeon can easily restore arterial continuity by direct procedures.     

A newly developed degradable stent for pancreaticojejunostomy after pancreatoduodenectomy

A novel technique of anastomosis with a short-term degradable stent for pancreaticojejunostomy has been developed and its shape-retentive capability evaluated under conditions of exposure to digestive fluid and its clinical feasibility. The stent was braided manually using Monocryl and PDS-II of 2-0 wire and heat treated at 80 degrees C for 3 hours under a vacuum. We measured its maximum resistance to compression strength and elastic modules of the stent. We evaluated the feasibility of the stent in 8 patients under pancreaticojejunostomy and hepaticojejunostomy. The compression strength of the stent was preserved for about 3 weeks, after which point it collapsed. The elastic features were retained under exposure to gastric fluid, but they were lost under an intestinal juice exposure. Using this stent, "suturing of tissue with the stent on" was possible as a novel technique of anastomosis and induced few complications.     

Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery

BACKGROUND: Intraoperative fluoroscopy is commonly used in surgical procedures on upper extremities. We compared radiation exposure from two possible positions of the mobile digital fluoroscopy unit (c-arm): (1) the standard technique, with the x-ray tube down (near the floor) and the image intensifier at the top of the c-arm, and (2) the inverted position, in which the image intensifier is used as a table and the x-ray tube is up. METHODS: A commercially available c-arm was used to irradiate a phantom hand in one of three configurations. In the first, the phantom hand was placed on an armboard equidistant from the x-ray tube and the image intensifier with the beam directed upward. In the second, the c-arm was inverted with the beam directed downward and the image intensifier used as a table. The third configuration was identical to the second except that a magnified image was used. Radiation exposure was measured at four locations corresponding to the approximate position of the surgeon's head, chest, and groin and the patient's hand. RESULTS: The amount of radiation exposure to both the surgeon and the patient was significantly less when the c-arm was used in the inverted position (p < 0.0001). The dose rate to the patient's hand was reduced by 59%. The radiation exposure to the surgeon's head, body, and groin with the inverted-c-arm technique was 67%, 45%, and 15% of the measured doses with the x-ray-tube-down configuration. When we used the magnification mode of the image intensifier, with its correspondingly smaller field size, the doses were further reduced to 46%, 32%, and 11% of the standard-configuration values. CONCLUSIONS: Use of the inverted-c-arm technique with the image intensifier as an operating table can significantly reduce radiation exposure to the surgeon and the patient during surgical procedures on upper extremities.     

Mitral exposure technique for redo cardiac surgery. A left mediastinal pleurotomy and minimal adhesiotomy method.

We report an improved mitral exposure technique for mitral valve re-operation. Left mediastinal pleurotomy through a median sternotomy achieves rotation of the heart and excellent exposure of the mitral valve allowing the apex to drop posteriorly. We employed this technique in redo mitral valve surgeries for over a 3-year period. This minimal adhesiotomy method is technically simple, safe and time-saving.     

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.     

A modification of the standard midline posterior approach to the intertransverse area of the lumbar spine

A midline approach to the lumbar region is most frequently used for posterior lumbar spine surgery. The exposure of the deeper layer of muscles, however, is imprecise and can entail substantial tissue damage and blood loss. During 10 years of operative surgical experience, we have developed an improved and less traumatic technique for exposure of the lumbar transverse processes and intertransverse region in which the tendons of multifidus and longissimus muscles are isolated at every level and divided laterally to the facet joints. This method eases identification and accurate cauterisation of the subjacent arteries, thereby reducing tissue damage and blood loss. It takes no more time and clarifies the exposure of the lumbar transverse processes and intertransverse region. Cadaveric dissection confirms the muscular and arterial anatomy of the region. We recommend use of this modified approach to improve standard practice.     

The use of a femoral arterial cannula for effective dilation for percutaneous femoral venous cannulation

We present a technique for percutaneous femoral venous cannulation for initiation of cardiopulmonary bypass in the setting of previous femoral vessel exposure in which previous scarring prevents safe dilation of the subcutaneous tissues using standard techniques. The technique presented may be particularly helpful when redo sternotomy is deemed hazardous and cardiopulmonary bypass is judged mandatory prior to redo sternotomy. The patient presented in this paper had two previous cardiac operations with prior surgical exposure of femoral vessels in whom institution of cardiopulmonary bypass prior to sternotomy was of paramount importance due to a 7-cm ascending aortic aneurysm.     

Exposure of splenic hilum increases safety of laparoscopic splenectomy

Laparoscopic splenectomy is becoming the gold standard technique for the treatment of hematological disorders of the spleen. Hemostasis is a fundamental step during laparoscopic splenectomy leading some authors to develop several techniques to control splenic vessels such as hand assistance, preoperative splenic artery embolization, and the use of vascular linear staplers. However, intraoperative bleeding is usually due to inadequate exposure of the hilar splenic vessels itself. The authors describe a standardized technique for the exposure of splenic pedicle using an endoscopic triangular retractor. We have been used this technique in 16 consecutive laparoscopic splenectomies with minimal blood loss. The present technique may increase the safety of laparoscopic splenectomy with adequate exposure of the splenic hilum reducing the conversion rate and intraoperative blood loss.     

A simple and safe technique for reconstruction of the acromioclavicular joint

Surgical reconstruction of the dislocated acromioclavicular joint often requires exposure and instrumentation of the coracoid. This carries risks to the surrounding neurovascular structures. We present a safe and simple technique of primary fixation of the acromioclavicular joint, relying on mechanical principles and biological repair, without the need for metalwork. By avoiding the coracoid we hope this approach will appeal to the general orthopedic surgeon. We have found that this technique is suited to both acute and chronic acromioclavicular joint dislocation.     

Pulmonary venous drainage into the left atrial appendage facilitates transplantation of the left lung with difficult exposure

Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.