Technique to Facilitate Graft Passage in Posterolateral Reconstructions of the Knee

This report describes a novel technique to facilitate passage of the transtibial limb of grafts used for reconstruction of the posterolateral corner of the knee. This new method, which places and passes the graft within a 24F (8-mm) chest tube, eliminates the problem of graft impingement at the opening of the posterior tibial tunnel and the need to enlarge the tunnel to achieve graft passage. Enlarging the tunnel is detrimental to obtaining the snug fit that is necessary to maximize incorporation of the graft and minimize postoperative tunnel expansion. This chest tube technique, which has been used in 20 cases to date, makes graft passage expeditious and requires no special instrumentation.     

Emergencies in delayed diaphragmatic herniation due to blunt trauma

A transthoracic approach was used in the treatment of 2 patients with emergencies due to traumatic diaphragmatic hernia. Relevant symptoms began respectively 3 months and 8 months after closed injury. Strangulation and necrosis of abdominal organs herniated into the chest are associated with a high mortality. Awareness and early diagnosis will reduce mortality.     

A Practical Approach to Ethical Problems in Surgical Emergencies

Background : In this prospective non-randomized observational cohort study we evaluated: the feasibility and effectiveness of primary umbilical hernia repair with open tension-free and sutureless technique using a porcine small intestinal submucosa (Surgisis®) prosthesis, the quality of the treatment in terms of reduction of postoperative discomfort and the complications at early and long-term follow-up.

Methods : Thirty-six consecutive patients, mean age 45.25 ± 12.19 years, affected by primary umbilical uncomplicated hernia with a defect size < 3 cm, were treated in a day-surgery setting. A tailored flat Surgisis® graft was used to ensure an overlap of at least 2 cm; in all patients the mesh was fixed by fibrin glue.

Collected data included: visual analogic scale (VAS) pain scores at 24 hours, 72 hours, and 7, 15, and 30 days and number of analgesic medications after operation, complications rate, the quality of life measured by Short Form 36 health survey questionnaire (SF-36) before the operation and at long term follow-up.

Results : The mean follow-up time was 5.6 ± 1.4 years. Postoperative pain was low: the mean visual analogic scale (VAS) scores were 2.8 at 24 h, 1.8 at 72 h, and 0.9, 0.3, and 0.04 at 7, 15, and 30 days, respectively. 77.8% of the patients (28/36) did not use any analgesic drugs.

Seroma was reported in 13.8% of the patients (5/36); there were no hematomas, infection, chronic pain and no major complications or mortality (< 30 days). Recurrence rate was 2.8% (1/36). Patient satisfaction showed a significant improvement in all SF-36 domain scores (P < 0.001).

Conclusions : The biologic mesh seems to be a safe and reliable device for repairing primary umbilical hernia with high patient comfort, even if not yet an alternative to synthetic mesh.     

An Instrument to Facilitate Construction of Miniature Vascular Suture Lines

A microvascular suture technique has been devised employing an instrument tipped with a silicone “thimble” into which the needle is driven. Rotating the shaft of the instrument completes the needle's excursion and steadies it for regripping with the needleholder.     

Innovative Laboratory Techniques to Facilitate Processing of Large Mohs Cases

Background Processing multiple tissue sections in large Mohs cases is time consuming and labor intensive.
Objective To present innovative laboratory techniques to facilitate processing of large Mohs cases.
Methods A method for processing a large dermatofibrosarcoma protuberans Mohs case is outlined.
Results Modifications in tissue processing and equipment employed in a large Mohs case are presented.
Conclusion Innovative modifications to the standard Mohs laboratory technique can facilitate processing of large Mohs cases, resulting in high-quality, rapid frozen sections while optimizing efficiency.     

Predictors of Failure of Medical Management in Uncomplicated Type B Aortic Dissection

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Treatment of Neurocritical Care Emergencies in Pregnancy

Neurologic emergencies are a major cause of morbidity and mortality in pregnant women. In part because the patient population is young, the nihilistic approach that often accompanies neurologically devastating disorders in other contexts is largely absent. A number of studies have demonstrated improved patient outcomes in the setting of aggressive care delivered by neurointensivists in a specialty-specific environment. It stands to reason that young, pregnant women who suffer from neurologically devastating disorders and who have a wide range of prognosis may also benefit from such specialized care. Close collaboration between obstetricians and neurointensivists is critical in this context. A number of unique considerations in diagnosis and management present dilemmas in the context of pregnancy, such as radiation dose from diagnostic neuroimaging, choice of pharmacotherapy for seizures, anticoagulation, and the method of delivery in the context of cerebral mass lesions and elevated intracranial pressure. Patients and their physicians are often faced with the additional challenge of balancing the relative risks and benefits of the impact of a management approach on both mother and fetus. In general, this balance tends to favor the interests of the mother, but the impact on the fetus becomes more relevant over the course of the pregnancy, especially in the third trimester. A low threshold for admission to an intensive care unit (ideally one that specializes in neurointensive care) should be used for pregnant patients. Because of the limited information regarding long-term outcomes in this population, rigid prognosis formation and early care limitations should be deferred in the immediate period. After the patient is stabilized and a plan has been charted for the remainder of the pregnancy, every effort should be made to engage patients in aggressive, urgent neurologic rehabilitation.     

A Simple Instrument to Facilitate Dissection in the Mediastinum from the Neck

The use of a vaginal speculum to gain access to the mediastinum through the neck is described. This enables manipulative procedures to be carried out which include biopsy and also the placement of an electrode in the region of the sino-atrial node where a cardiac pacemaker is being used.     

Mechanical Support and Medical Therapy Reverse Heart Failure in Infants and Children

Most infants and children implanted with ventricular assist devices (VADs) go on to cardiac transplantation. Recovery of dilated cardiomyopathies with the combination left ventricular decompression with a VAD and treatment with maximal medical therapy has been possible in some adults, and may be more feasible in infants and children. We used pulsatile and continuous flow VADs and the total artificial heart (TAH) as bridges to transplantation or to recovery. Candidates for native heart recovery were treated with maximal medical therapy for congestive heart failure and short‐term dobutamine prior to weaning off device support. Since 1997, 28 infants and children, ages 1 month to 16 years, were implanted for durations of 3–107 days (mean 27). Eighteen received left VADs (LVAD), seven biventricular assist devices (BiVADs), and three TAHs. Device‐related mortality was 7/28 (25%), leaving 21/28 (75%) surviving to transplantation or weaning from device support and 20/28 (71%) discharged from the hospital and currently surviving for 2 months to 9 years. Ten of 11 transplant recipients (90%) have survived 2 to 9 years. All 10 with recovered hearts are alive and well for 2 months to 5 years. Eight of 12 (67%) LVAD patients with dilated hearts recovered. None of the recovery patients were over 6 years old. Infants and children who have failed inotropic therapy may be treated with an LVAD and medical therapy for congestive heart failure anticipating native heart recovery. A variety of devices have been tried. All small LVADs yielded comparable results. Larger and older children also have a chance of recovery, but our experience with them is too small except to note that they do well with larger devices and transplantation.     

Results After Implementing a Program of Intensive Care to Facilitate Organ Donation

A program of intensive care to facilitate organ donation (ICOD) represents one of the ways to increase donation rate following brain death (BD).

Use of Magnetic Anchoring and Guidance Systems to Facilitate Single Trocar Laparoscopy

A magnetic anchoring and guidance system uses instruments that can be inserted through a laparoscopic port site into the abdomen and then controlled through coupling with an externally held magnet. Use of these tools can improve the ergonomics of laparoscopic surgery, allowing positioning of intra-abdominal instruments that do not require a separate transabdominal trocar. Further developments of this technology have occurred in multiple surgical fields, broadening their utility and improving the instrumentation.