The reverse latissimus dorsi flap for congenital diaphragmatic hernia repair

The reverse latissimus dorsi muscle flap was successfully used for the repair of recurrent congenital diaphragmatic hernia in three neonates. This muscle flap can be rapidly raised on a reliable blood supply, and provides sufficient vascularized tissue to replace the whole hemidiaphragm without tension. It should be considered at the first reparative operation when insufficient tissue is available for safe repair by direct suture.     

The Rumel technique. An aid for difficult diaphragmatic closures.

The inherent weakness of repairing the surgically divided respiratory diaphragm is that it is a muscle to muscle closure which can easily tear. During the thoracoabdominal exposure of the thoracolumbar vertebrae, the left hemidiaphragm is divided circumferentially. Possible due to unique conditions related to these operations the diaphragm could not initially be reapproximated primarily in about 20% of the patients. A modified Rumel technique is described as an aid for closing these difficult divided diaphragms. This simple techniques succeeds by distributing the wound tension along the entire diaphragmatic suture line and not on one suture especially while being tied.     

Lipoma of the diaphragm: a rare presentation

Lipoma of the diaphragm is an extremely rare entity. A 67-year-old asymptomatic man who had a tumor located in the posterior region of the left hemi-diaphragm is presented. The tumor was removed through a left mini-thoracotomy. The diaphragm was reconstructed primarily by using nonabsorbable suture material. The final pathologic examination revealed a mature lipoma. The patient remains without evidence of recurrence 60 months after the operation.     

Suture barb giant papillary conjunctivitis

Giant papillary conjunctivitis can be due to an allergic reaction as in soft contact lens wearers and allergic palpebral conjunctivitis, or can result from a cut exposed suture end that abrades the upper palpebral conjunctiva. The syndrome of suture barb giant papillary conjunctivitis consists of a mucoid ocular discharge with blurred vision, a foreign body sensation, upper lid edema and blepharoptosis concomitant with giant papillae of the upper palpebral conjunctiva. Removal of the offending suture(s) results in resolution of the papillae and symptoms.     

双45度俯卧位经直肠直视下前列腺改良穿刺法28例应用体会

目的 探讨前列腺癌经直肠可直视下穿刺活检的简便,准确方法.方法 28例患者采用的双45度俯卧位前列腺经直肠可直视下改良穿刺方法.借用肛肠科庤上黏膜环形缝扎器套件中的部分组件,包括环形肛管扩张器（CAD33）及镜芯、肛镜缝扎器（PSA33）.结果 28例患者均穿刺成功,并取得活检标本.无严重并发症发生.结论 双45度俯卧位经直肠直视下前列腺改良穿刺活检的方法简便,定位准确值得推广.     

Diaphragmatic eventration with paroxysmal supraventricular tachycardia; report of a case

A 68-year-old man visited our hospital complaining of chest discomfort and palpitation and was hospitalized under the diagnosis of diaphragmatic eventration. The chest X-ray showed an elevated left hemidiaphragm including air bubbles. The chest computed tomography (CT) and magnetic resonance imaging (MRI) showed a very high position of the left hemidiaphragm and displacement of the abdominal organs into the left thoracic cavity. The Holter electrocardiogram showed paroxysmal supraventricular tachycardia. The procedure was performed under video-assisted thoracoscopic surgery with a minithoracotomy (7 cm) in the 8th intercostal space. The left diaphragm appeared loose and reduced in thickness, the diaphragm was incised and longitudinal plication 12cm in diameter was accomplished with a series of U-stitches with Teflon-felt. Furthermore, the suture line was reinforced by prolene mesh. Postoperative course was uneventful, and the chest symptom and arrhythmia were resolved immediately.     

Traumatic diaphragmatic hernia repaired by video-assisted thoracic surgery; report of two cases

Two cases of traumatic diaphragmatic hernia treated by video-assisted thoracic surgery (VATS) were experienced. Both a 67-year-old female (left side) and a 44-year-old female (right side) was admitted to our hospital in a traffic accident. These patients were diagnosed as diaphragmatic hernia by chest magnetic resonance imaging (MRI). We tried VATS to this trauma, but the combined mini-thoracotomy for 7 cm in length was necessary to replace sliding organs for both cases. The rupture of diaphragm was repaired by direct suture of 2-0 viclyl. VATS will be recommended in the hernia of the diaphragm.     

A surgical case of adult Bochdalek hernia assisted by thoracoscopic surgery

A case of adult Bochdalek hernia in a naturally healthy 49-year-old woman is described. She was seen at our hospital because of cough lasting for about one month. The chest X-ray film revealed a gastrointestinal gas image in the left thoracic cavity. In addition, the CT scan and upper gastrointestinal series showed prolapse of the stomach, small intestine and a part of transverse colon. Operation was performed through a mini-thoracotomy using a thoracoscope assistedly. No hernia sac was observed and the diaphragmatic defect was 6 x 5 cm in size. After the organs was restored, the defect was closed with continuous over-and-over suture and the diaphragm was enhanced by PROLEN MESH.     

Avoiding potential complications in left atrial reduction: partial heart autotransplantation

Left atrial reduction is a surgical procedure designed in order to eliminate the chronic atrial fibrillation caused by mitral valve disease. However, this surgical technique is not high-risk free. Since a mount of tissue is excised from the left atrium, misalignment of the left atrium can be present. Bleeding of the posterior suture line in this chamber, as well as injury of the circumflex coronary artery may be fatal complications of this technique. Partial heart autotransplantation offers a good solution allowing an excellent visual operative field. The circumflex coronary artery is under direct vision while performing the anastomosis of the left atrium, and the suture line becomes safer and easier.     

How to evaluate the outflow tract of LVAD after minimally invasive implantation by 3D CT-scan

During a minimally invasive implantation technique, the outflow graft of left ventricular assist device (LVAD) is tunnelled blindly through the pericardium or left pleura, with an inability to assess for twisting or malposition. Three-dimensional computed tomography scan (CT-scan) has a role in qualitative evaluation of the different outflow tract configurations. The different surgical minimally invasive approaches include: (a) mini-sternotomy and left mini-thoracotomy, (b) right mini-thoracotomy and left mini-thoracotomy, (c) subclavian artery access and left mini-thoracotomy. The outflow graft could be anastomosed to the left axillary artery or the ascending aorta. CT-scan reconstruction using syngo InSpace4D (Siemens, Muenchen, Germany) was used to provide fast segmentation and high-resolution images. The 3D reconstructions permit an evaluation of different anastomosis configurations and to assess the route of outflow graft.     

电视胸腔镜（或辅助小切口）手术治疗食管良性肿瘤56例临床体会

目的总结电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）治疗食管良性肿瘤的临床经验。方法1995年3月-2008年1月,对56例食管良性肿瘤施行电视胸腔镜（或辅助小切口）手术。在纤维胃镜辅助下,手术采用一个1.5cm左右胸腔镜进镜口加2个2cm左右操作孔或辅助腋下5cm左右小切口完成食管良性肿瘤摘除。结果54例顺利完成VATS（其中8例辅助小切口）食管良性肿瘤摘除术,术后病理证实为食管平滑肌瘤47例,间质瘤7例。1例因平滑肌瘤巨大,食管肌层破坏严重且术中冰冻切片病理检查报告肿瘤生长活跃,1例因术中冰冻切片病理报告低度恶性平滑肌瘤,均中转开胸行食管部分切除、食管胃端侧吻合术。无手术期及围手术期死亡,无术后严重并发症发生。49例随访2-128个月,平均58.6月,无明显进食梗噎等症状出现或复发。结论VATS（或辅助小切口）食管良性肿瘤摘除术具有安全、彻底、有效、可行等特点,可作为食管良性肿瘤摘除术的首选治疗方法。     

Korrekturen der Nasenspitze: Techniken, Zugänge und Inzisionen

Much experience is needed for the correction of nasal tip deformities; in many cases, a good rhinoplasty result depends on the successful modification of the tip. It is advisable to follow a specific algorithm, starting with exploration of the nasal anatomy and the operative goal, followed by the choice of technique, approach, and incisions. In addition to excision and incision techniques on the tip cartilage and the use of tip grafts, within the last decade suture techniques that allow so-called nondestructive tip modifications became popular. These suture techniques are preferred in minor and moderate deformities, whereas in major deformities the other techniques should be the first choice. Each of these techniques can be used alone or can be combined with each other. For all techniques, closed as well as open approaches can be used; however, with the open approach, all techniques can be performed with more precision under direct vision. The surgeon’s personal experience is also important in realizing the most convenient and effective techniques, approaches, and incisions.     

Left ventricular aneurysm resection with port-access surgery: a new mini-invasive surgical approach

BACKGROUND: In recent years port-access and endovascular extra-corporeal circulation techniques have allowed valvular and coronary operations to be performed by mini-thoracotomy. Experience with the technique suggested application to resection of ventricular aneurysms, which are usually approached through a median sternotomy with the use of traditional cardiopulmonary bypass. METHODS: We performed a left port-access mini-thoracotomy, with 6 to 8 cm skin incisions, in 7 patients undergoing endoventricular pericardial patch repair for anterior left ventricular aneurysm. Cardiopulmonary bypass was effected using the Heartport system. The mean interval between myocardial infarction and operation was 60.4 +/- 57.7 months. Three patients developed sustained ventricular tachicardia. Mean preoperative ejection fraction was 34% +/- 11%. Associated procedures were coronary bypass grafting in 2 patients and cryosurgery in 3 patients. RESULTS: All patients survived to discharge and are alive and well after an average 14.5 months. They are all in NYHA class I-II. Postoperative echocardiograms revealed an average ejection fraction of 48.0% +/- 7.5% (p = 0.006 compared with preoperative value). The 3 patients who had cryosurgery did not demonstrate any recurrence of arrhythmias. CONCLUSIONS: Left ventricular aneurysm can be successfully treated through port-access mini-thoracotomy with endovascular cardiopulmonary bypass, avoiding median sternotomy. This mini-invasive approach allows effective ventricular remodeling. Revascularization and antiarrhythmia surgery can also be done at the same time. In case of severely reduced ventricular function this approach permits fibrillatory arrest without aortic cross-clamping. The results are also good in terms of hospitalization time and long-term survival.     

Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself.Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.     

Thoracolaparoscopic repair of traumatic diaphragmatic rupture

Diaphragmatic rupture may occur after blunt or penetration trauma caused by the application of a powerful external force. Diaphragmatic rupture usually is repaired via laporotomy and/or thoracotomy, depending on the associated organ injury. The case of a 49-year-old man with traumatic rupture of the left hemidiaphragm is presented. Preoperatively, diaphragmatic rupture with herniation of the stomach into the left thoracic cavity was confirmed by computed tomography scan of the thorax. Under thoracoscopic guidance, the stomach, spleen, and omentum were repositioned in the abdominal cavity, and the rupture site (10 cm) was closed by nonabsorbable suture. A subsequent laparoscopy was performed to assess the efficacy of the repair and the absence of any abdominal organ injury. The patient was discharged from hospital without any respiratory or abdominal symptoms. Our report confirms that in the case of a patient with penetration injuries to the lower chest and upper abdomen, a combined thoracoscopic and laparoscopic approach may offer both diagnostic and therapeutic benefits with reduced surgical trauma. We conclude that thoracoscopic repair of traumatic diaphragmatic rupture can be used safely when no abdominal organ injuries are found.     

Thoracoscopic esophagectomy

The current roles of thoracoscopic esophagectomy in the treatment of cancer in Japan are described. Lymphadenectomy of the same quality as open surgery should be performed thoracoscopically to obtain good oncological outcomes. The indications for thoracoscopic esophagectomy are 1) no extensive pleural adhesions; 2) pulmonary function sufficient for single-lung ventilation; and 3) tumor not invading other organs. Hand-assisted or mini-thoracotomy facilitates the dissection of lymph nodes, especially on the left side of the trachea. However, for any type of procedure, a good en-face view is essential for safe and accurate lymphadenectomy. The magnifying effect of video, with the camera in close proximity, is important to maintain a proper dissecting plane. Although sufficient experience is necessary to master the learning curve, lymphadenectomy of the same quality as open surgery can be performed with mini-thoracotomy in a feasible time period. Thoracoscopic esophagectomy contributes to reducing postoperative pain and constrictive pulmonary dysfunction. It may be too soon to assert that the thoracoscopic approach can provide oncological outcomes comparable to those after open surgery because long-term follow up is not yet sufficient. Thoracoscopic esophagectomy, however, has the potential to improve the postoperative quality of life of patients with esophageal cancer.     

经直肠直视下穿刺法在前列腺穿刺活检中的应用

目的探讨经直肠直视下前列腺穿刺活检方法的可行性。方法采用改良的俯卧位前列腺直视下穿刺方法行经直肠前列腺穿刺活检56例。利用庤上黏膜环形缝扎器（PPH）套件中的部分组件,即环形肛管扩张器及镜芯、肛镜缝扎器以协助显露直肠段前列腺。结果经直肠直视下前列腺穿刺活检方法可直视穿刺,穿刺深度和方向易控制。针刺布局规范,患者体位舒适,耐受适应好。无严重并发症发生。穿刺效果良好。结论经直肠直视下俯卧位前列腺穿刺活检方法简便,穿刺准确,值得推广。     

Alternative technique for laparoscopic port-site closure

Abstract 0-polyglactin suture into the abdomen via a puncture through the rectus fascia parallel to the fascia defect under visual guidance. Second, we perform a similar puncture with the tonsil forceps on the opposite side of the fascia defect under direct vision to grasp the suture. This cost-effective maneuver is safe and eliminates the need for ancillary port-site closure devices.     

胸部小切口心脏不停跳心内直视手术

目的介绍胸部小切口心脏不停跳心内直视手术。方法自１９９５年３月至１９９７年６月,经腋下及腋前外小切口在常温体外循环、心脏不停跳下进行心内直视手术３４例,其中房间隔缺损１６例、室间隔缺损１４例、二尖瓣关闭不全２例、右冠状动脉右室瘘及三尖瓣下移畸形各１例。结果全组平均体外循环时间２２５４分钟,术后恢复良好,无栓塞、心律失常及脑部并发症。术后住院时间８０±２２天。随访２～２６个月,均能参加正常活动,无残余分流和杂音。结论胸部小切口心脏不停跳心内直视手术创伤小、恢复快、简便、安全、美容效果好     

Biventricular pacing for end-stage heart failure: early experience in surgical vs. transvenous left ventricular lead placement

Transvenous coronary sinus lead placement is currently the standard approach for left ventricular pacing. The aim of this study is to assess whether a mini-thoracotomy approach would be feasible and safe when used for cases in which transvenous procedures were ineffective or judged unlikely to succeed. Biventricular pacing was performed in 138 consecutive patients with 47 patients undergoing a mini-thoracotomy procedure. NYHA status, quality of life, electrical and echocardiographic data were assessed in the two groups over a follow-up period of 17.6+/-4.2 weeks. There was no significant difference in the preoperative characteristics in both groups other than a greater prevalence of renal failure and previous cardiac surgery among the surgical patients. The mean procedure time was significantly longer in the transvenous group. No significant differences were noted in the immediate or long-term pacing parameters. Two mortalities were observed in the surgical group >2 weeks following the procedure. During the follow-up period, we noted a comparable improvement in the echocardiographic parameters, QRS duration and NYHA status with both approaches. Our results suggest that even when performed on high-risk patients, epicardial lead placement through a mini-thoracotomy is beneficial and feasible as a 'rescue' procedure after a failed transvenous approach.