Extended lateral parascapular approach for resection of a giant multi-compartment thoracic schwannoma

Background  Resection of giant thoracic schwannomas is challenging and usually requires a staged approach. The resection of the intraspinal component, usually via laminectomy, is done in one sitting and the intrathoracic component, via thoracotomy, follows at another. We describe the complete resection of a massive multi-compartmental thoracic schwannoma by an extended lateral parascapular approach. Method and findings  The tumor, which presented with local pain and scapular displacement, had intrathoracic paraspinal (10 × 5 × 4 cm), posterolateral upper thoracic paramuscular (19 × 7 × 4 cm), foraminal, and epidural components. It was removed at a single sitting, via a posterior extended lateral parascapular approach that did not require staged procedures, multiple incisions, or repositioning of the patient. This operation included resection of the thoracic, foraminal, and intraspinal components and posterior stabilization with pedicle screws and rods. There were no postoperative neurological complications. Conclusions  The extended lateral parascapular approach allows complete resection of giant multi-compartment schwannomas of the thoracic spine that extend from the canal into the thoracic cavity. It also permits posterior stabilization through the same incision used for tumor removal.     

A new approach for the surgery of large renal masses: abdominal wall flap incision

INTRODUCTION: The type of skin incision affects the course of surgery during radical nephrectomy. We investigated the efficacy of a new type of incision for the surgical approach to large renal masses. PATIENTS AND METHODS: Fourty patients (23 males and 17 females, mean age 63 years) who underwent radical nephrectomy in our department between 2002 and 2004 were evaluated. The outcomes in the groups with chevron incision and abdominal wall flap incision (AFI) were compared in terms of greatest tumor diameter, operation duration, perioperative blood loss, postoperative complications, and duration of hospitalization. Statistical analysis was made by independent-samples t test. RESULTS: Chevron incision was used in the first 15 patients, while subsequent 25 patients were operated via AFI. The operation duration was slightly longer in the AFI group (3.78 vs. 3 h); however, the mean largest tumor diameter was significantly greater in patients operated via AFI (11.3 vs. 7.4 cm, p < 0.05). The mean blood losses were 1,100 and 590 ml in the chevron incision and AFI groups, respectively (p < 0.05). There was no significant difference in terms of duration of hospitalization and postoperative morbidity. CONCLUSION: In our experience, AFI provides the best exposure and improved control of renal vessels and vena cava during radical nephrectomy and enables a safe dissection even in very large tumors with minimal blood loss.     

Interlaminar spinal anesthesia: An alternative lateral approach for subarachnoid puncture

An interlaminar approach for spinal subarachnoid puncture and its advantages are described. The method is recommended as an alternate to the usual interspinous mode of administering spinal anesthesia.     

Extended lateral approach for elective hind foot surgery—A safe and versatile incision

Aim

The aim of our study was to review our experience of the extended lateral approach to the hind foot in treatment of non-traumatic foot disorders with particular reference to wound complications.

Materials and methods

We retrospectively reviewed 51 consecutive patients who under went extended lateral approach to the hind foot for treatment of various non traumatic foot disorders. We documented the indication for surgery, co-morbidity, quality of wound healing and other wound related problems.

Results

The mean age was 47.9. There were three superficial wound infections (5.8%). One had slight sensory loss close to the scar, one developed hypersensitivity over the scar. There was no wound break down or any deep infection. No sural nerve deficit was noted. Six patients had the calcaneal screw removed due to prominent metal work (11.7%).

Conclusion

The extended lateral approach to hind foot is safe in the surgical treatment of a wide variety of non-traumatic foot conditions. Despite the larger deep dissection, the arterial anatomy ensures reliable wound healing and a low incidence of wound complications.     

Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor.

Transmanubrial osteomuscular sparing approach (TMA) has been recently proposed for the treatment of apical chest tumor to allow a safer subclavian artery control with a less invasive procedure for the patient. The present technique combines the antero-lateral muscle-sparing thoracotomy with TMA for lung cancer patients in whom extended resection of cervico-thoracic structures as well as anatomic lung resection and radical lymph nodes dissection are required.     

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTIONPosterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.PRESENTATION OF CASEA 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.DISCUSSIONIncisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.CONCLUSIONThoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.     

Extended lateral subtemporal approach for petroclival meningiomas: report of experience with 24 cases

Subtemporal craniotomy centred on the external ear canal and its basal extension, involving resection of the roots of the zygomatic arch, roof of the external ear canal and superior third to half of the mastoid bone was used to treat surgically 24 meningiomas located in the petroclival region, having their maximum bulk at the level of tentorium. The approach was found to be suitable for dealing with middle fossa extensions of the tumour in addition to the part extending up to the mid-clivus or vertebrobasilar junctional region. The direction of the approach to the petroclival region was the shortest and most perpendicular from surface and avoided any neural or vascular exposure or manipulation. The basal exposure was horizontally wide and significantly low, which reduced the operating distance, limited the extent of temporal lobe retraction and provided additional space for manipulation of instruments. The exposure was manoeuverable with anterior, posterior and medial expansion being possible during or prior to tumour resection. The approach had the advantage of being simple and relatively quick, and of its familiarity to general neurosurgeons. The experience with the approach with petroclival meningiomas and its possible advantages over other available approaches to these lesions are analysed in this report.     

An alternative to open incision and drainage for community-acquired soft tissue abscesses in children

Background

The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care.

Study Design

A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups.

Results

A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D.

Conclusions

Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.     

Nipple sparing mastectomy: an innovative skin incision for an alternative approach

Choice of the most appropriate surgical treatment for breast cancer patients can also be a technical issue. Cosmetic results after conservative surgery can be poor in certain instances and, at the same time, total mastectomy can appear as an over-treatment. For some selected patients, the "nipple sparing mastectomy" (NSM) is an alternative surgical treatment and more and more papers on this technique are appearing in the literature. One hundred and two NSMs have been performed in our department between June 2003 and October 2006, initially via periareolar skin incision, now through a skin incision on the lateral aspect of the breast to reduce the necrotic risk for the nipple. The lateral skin incision saves the integrity of skin blood supply, allows for a complete breast gland removal and saves the integrity of the body image of women who show no scars when seen upfront.     

Superior eyelid incision: an alternative approach for frontozygomatic dermoid cyst excision

Sixty-five children presenting with frontozygomatic (lateral brow) dermoid cysts were operated using an upper eyelid crease incision. There were 38 girls and 27 boys age 3 months to 13 years (mean age, 15 months). The lesions were left sided in 32 patients and right sided in 33 patients. Preoperative radiograph or computed tomographic scan performed for 25 children failed to demonstrate a bony defect in the area of the cyst. At surgery, 14% of the cysts were adherent to the periosteum and 5% were subperiosteal. One cyst extended through the bone into the orbit. All cysts were removed completely, and this was accomplished without rupture in 54 patients. The average operating time was 21 minutes. All children were seen within 1 month of surgery. The postoperative course was uneventful except for early swelling and erythema in 2 children. Thirty-six patients (55%) could be reached for long-term follow-up (range, 1-7.1 years) postoperatively. The authors found no lid or ocular dysfunction and excellent scar camouflage in all patients.     

锁骨上斜切口侧入路在甲状腺手术中的应用及与传统手术对比研究

目的 介绍锁骨上斜切口侧入路行甲状腺切除术的方法,探讨该入路在甲状腺手术中应用的可行性及其价值。 方法 回顾性分析2005年11月至2008年4月山东大学齐鲁医院普外科施行甲状腺切除术172例的临床资料。传统手术组102例,侧入路手术组70例,将两组资料进行对比分析。 结果 两手术组病人在一般资料、麻醉方式、失血量、手术时间、结节大小及术后并发症方面差异无统计学意义;两组的切口长度差异有统计学意义;病人对侧入路手术组切口的美容效果更为满意并愿意接受。 结论 经锁骨上斜切口侧入路行甲状腺切除术是安全可行的,与传统手术相比不增加术中风险及术后并发症发生率,适应证广泛,术后美容效果好。     

Descending thoracic aortobifemoral bypass: an alternative approach for difficult aortic revascularization

Descending thoracic aortobifemoral bypass is an alternative inflow operation in cases in which standard aortobifemoral or axillobifemoral bypass is not an option. We performed descending thoracic aortobifemoral bypass for failed inflow operations in four patients, prior abdominal/pelvic radiation in two patients, poor quality distal aorta (extensive atherosclerotic disease or poor tissue quality) in two patients, and abdominal sepsis in two patients. Eight have had excellent results with patency at a mean follow-up of 38 months. There was no limb loss. One patient died of organ failure, and one patient with hypercoagulability developed a graft clot. A literature review disclosed that a descending thoracic aortobifemoral bypass was reported to have been performed in 203 patients, with most cases reported in the last decade. This procedure was the primary inflow operation in 42 per cent of cases. Indications for the operation included failed aortic grafts (38%), "hostile" abdomen (21%), infected aortic grafts (18%), and other (23%). The patency rate was 95 per cent at 6 months. Few long-term results are known, but the results appear to be durable. Descending thoracic aortobifemoral bypass is a useful operation in highly selected circumstances in which conventional methods of aortic reconstruction are not available.     

Dysmorphology: An approach to diagnosing children with structural defects of the head and neck

In dealing with a child with a structural defect, an overall diagnosis must be formulated. Such a diagnosis makes it possible to provide genetic counseling for the parents and an accurate prediction relative to such a child's future development. Because there are a great many abnormalities involving the head and neck, it is hoped that the approach set forth in this article will allow for a systematic narrowing of the diagnostic possibilities. Nomenclature is established. Prenatal-onset defects are described, including both single primary defects (malformations and deformations) and multiple malformation syndromes (chromosomal abnormalities, genetic disorders, defects resulting from teratogenic factors, and disorders of unknown etiology). Genetic and environmental factors of postnatal developmental problems are also discussed.     

Posterolateral extradural approach for total excision of lateral thoracic meningocele: technical report

The author describes a posterolateral extradural approach for total excision of small to moderate symptomatic lateral thoracic meningoceles. Its advantages over the classical laminectomy, intradural repair, and thoracotomy excision are discussed.     

An alternative approach to diffuse thoracic aortomegaly: on-pump hybrid total arch repair without circulatory arrest

Diffuse thoracic aortomegaly has conventionally been managed with a two-stage elephant trunk procedure, requiring prolonged circulatory arrest, with an inherent risk of major morbidity and mortality. Recently, to improve outcomes, several hybrid arch procedures have been proposed using off-pump techniques. We have adopted an alternative, single-stage hybrid strategy using cardiopulmonary bypass without circulatory arrest to replace the ascending aorta and perform arch debranching and antegrade endovascular stent graft deployment. Unlike off-pump procedures, pathology of the aortic valve, root, and ascending aorta is addressed while avoiding the complications of stent graft placement in the native ascending aorta.