High-frequency jet ventilation with a proximal injector in a case of surgery of the tracheal carina]

A 44-year-old man underwent surgery requiring medial sternotomy of resection of a tracheal carcina tumor. High frequency jet ventilation was used during tumor resection and reconstruction of the carina in order to shorten the time of surgery and to provide a nearly immobile and unobstructed surgical field. The only noteworthy complication was a tendency to respiratory acidosis that resolved without sequelae in the operating room once the trachea was closed. The anesthetic challenges presented by the various techniques used throughout history for such an interesting and complex type of surgery are briefly summarized. We also discuss the role of high frequency jet ventilation on surgery involving the major airways.     

Laparoscopic resection of a benign liver tumor in a child

Laparoscopy for the resection of liver masses in children has remained undeveloped despite the wide acceptance of laparoscopy in the field of pediatric surgery. The authors report a case of nonanatomical laparoscopic hepatic resection of a large mesenchymal hamartoma in a 2-year-old boy. The procedure was performed using an innovative approach with a combination of different technologies that allowed for a safe and precise resection. This case demonstrates the feasibility of a nonanatomical laparoscopic hepatic resection, even for very large tumors. Both technical expertise and use of novel technologies are necessary to ensure a precise and controlled resection.     

Long-term survival after a repetitive surgical approach in a patient with acinar cell carcinoma of the pancreas and recurrent liver metastases: Report of a case

Acinar cell carcinoma is a relatively rare malignant neoplasm, which represents 1%–2% of all pancreatic exocrine tumors. Its prognosis is thought to be poor, especially when it metastasizes to the liver. This report concerns a case of a long-term survivor of metastatic acinar cell carcinoma who was successfully treated with repetitive surgery. A 62-year-old man underwent a distal pancreatectomy for a pancreatic tumor, which was histologically diagnosed as an acinar cell carcinoma. The tumor recurred in the liver three times within 41 months. At the first recurrence, four hepatic lesions appeared 7 months after the initial pancreatectomy and were managed with an extended left hepatic lobectomy and partial liver resection. Thereafter, a solitary nodule in Segment 6 was identified 21 months after the second surgery and was treated with a partial liver resection. A solitary lesion in Segment 8/5 appeared 11 months after the third surgery and was also managed by a partial liver resection. The patient has remained disease-free for 22 months since the last surgery and has survived 65 months since the initial diagnosis. Although no consensus has been reached on surgery for metastatic acinar cell carcinoma, the current case has important implications for establishing an appropriate treatment strategy.     

Surgical Treatment of a Superior Sulcus Tumor in a Patient with Idiopathic Thrombocytopenic Purpura: Report of a Case

We herein report a resection of a superior sulcus tumor in a patient with idiopathic thrombocytopenic purpura. A resection of the left upper lobe of the lung, left subclavian artery, and left first to third ribs, as well as a reconstruction of the left subclavian artery, were performed. Postoperative hemorrhaging was controlled due to preoperative high-dose intravenous immunoglobulin therapy and a platelet transfusion both during and following surgery. The resected tumor was diagnosed to be a pulmonary pleomorphic carcinoma, which was pathologically determined to be T3N0M0-Stage 2B. The patient remained in good condition for 20 months following the surgery; however, he eventually died due to bone metastases.     

Laparoscopic Liver Resection in Patients with a History of Upper Abdominal Surgery

Background  

The liver is the organ where tumors most frequently metastasize. Hepatic recurrence after resection of hepatocellular carcinoma also occasionally occurs. With the increasing use of laparoscopic surgery for hepatic tumors, there may be a high probability that laparoscopic liver resection can be performed in patients with a surgical history. The purpose of this study was to assess the feasibility and clinical outcomes of laparoscopic liver resection in patients a history of upper abdominal surgery.     

胃幽门窦癌浸润胰头联合胰十二指肠切除43例临床分析

目的探讨胃幽门窦癌浸润胰头时的手术方法。方法回顾性分析1984年6月至2004年6月收治的采用胰十二指肠切除术(PD)治疗的胃癌侵及胰头43例临床资料。结果无手术死亡。19例根治手术中联合胰十二指肠切除术15例,胰头局部切除4例;姑息切除17例;探查及胃空肠吻合7例。术后并发症发生率:PD术后为33%(5/15),胰头部分切除为25%(1/4),姑息切除为18%(3/17),探查活检为14%(1/7)。组间差异无显著性意义(P>0·05)。随访:中位生存时间PD为26个月(12~156个月),胰头部分切除为23个月(14~73个月),姑息切除为8个月(3~37个月),探查及胃空肠吻合为3个月(1·5~9·0个月)。联合PD和胰头部分切除的生存期明显长于姑息切除和探查及胃空肠吻合组(P<0·01)。结论胃幽门窦癌联合PD或胰头局部切除能够提高病人的生存期,手术指征选择恰当和肿瘤的彻底根治是取得良好临床效果的关键。     

Successful laparoscopic resection of a sacrococcygeal teratoma in an adult: report of a case

Sacrococcygeal teratoma is a relatively rare congenital retroperitoneal tumor in adults. The standard treatment is a complete tumor resection. This report describes the successful laparoscopic resection of a sacrococcygeal teratoma. The patient was a 27-year-old woman with a well-demarcated cystic mass, 6 cm in diameter, in the retroperitoneum overlying the anterior surface of the sacrum. The mass was resected laparoscopically. A histopathological examination showed a mature teratoma. The magnifying function of the laparoscope allowed an en bloc resection in the narrow pelvic cavity, without damaging the tumor. The aesthetic outcome was excellent. The patient remains relapse-free at 1 year 6 months after surgery.     

Laparoscopic resection of a proximal splenic artery aneurysm

The usual treatment for splenic artery aneurysm is resection under laparotomy. In recent years, the laparoscopic approach has consisted of ligation without resection. More recently,laparoscopic resection was reported by the Cleveland Clinic. In this paper, we describe the technique used in the laparoscopic resection of our first case of laparoscopic resection of splenic artery aneurysm (SAA). The patient was a young woman with a 12-mm SAA discovered on systematic abdominal ultrasound. The laparoscopic procedure was done successfully, and the aneurysm was resected using an ultrasonic dissector. The postoperative course was uneventful, and the patient was discharged on the 3rd postoperative day. Pathological examination revealed the atherosclerotic origin of the aneurysm. The patient is doing well 12 months after surgery, with normal splanchnic Doppler ultrasound. This procedure offers a one-step definitive cure via a minimally invasive surgical procedure.     

Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients

OBJECTIVE: The surgical strategies and outcomes for 70 patients operated on for tuberculum sellae meningioma were analyzed retrospectively. The analysis was based on factors that probably determined the difficulties encountered during surgery, assisted in predicting the extent of resectability, and helped in predicting the surgical outcome. METHODS: Seventy patients with tuberculum sellae meningiomas were operated on in the neurosurgery department at King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Bombay, India, between 1991 and May 2001. The patients were analyzed retrospectively on the basis of clinical and radiological factors that appeared to affect the outcome. Each factor was given points, and for each tumor, the points were added to obtain a score. On the basis of the score, the tumors were then divided into three grades. The grades determined the difficulties that could be anticipated during surgery. The majority of patients were operated on by use of unifrontal craniotomy on the side of worse vision by standard dissection techniques. RESULTS: Total tumor resection was achieved in 59 patients, and subtotal tumor resection with less than 7% of tumor left behind was achieved in 11 patients. All patients with subtotal resection had higher-grade tumors. Preoperative visual status had a bearing on the visual outcome after surgery. Four patients were misdiagnosed as having a pituitary tumor. Two patients died in the immediate postoperative period. The average follow-up was 46 months (range, 6 mo to 9 yr). There was symptomatic recurrence in one patient in whom a subtotal resection had been performed. CONCLUSION: The extent and duration of visual symptoms, encasement of the anterior cerebral artery complex, and size of the tumor were the more important factors that affected the surgery. The grading system gave a reasonable assessment concerning the possible surgical problems.     

Diaphragmatic Hernia Masquerading as a Pulmonary Metastasis

Iatrogenic injury accounts for the second most common cause of acquired diaphragmatic hernias after penetrating trauma. An increased incidence of these hernias has been observed with the widespread use of laparoscopic surgery. We present the case of a 65-year-old woman who initially underwent sigmoid resection for an adenocarcinoma and a subsequent liver resection for metastasis. She was noted to have a left lower lobe pulmonary nodule on surveillance computed tomography, for which she underwent a mini-thoracotomy for a planned resection. At the time of surgery, the pulmonary nodule was discovered to be a diaphragmatic hernia, most probably of iatrogenic origin. We discuss the difficulty in diagnosis given her history and the location of such a lesion.     

Carotid body tumours: report of six cases and a review of management

We have treated six patients with carotid body tumours in the period from 1972 to 1988. All patients had a neck mass on presentation. In addition one patient complained of tinnitus and another was noted to have Horner's syndrome. The diagnosis was confirmed by ultrasound and angiography in all cases. Five patients subsequently underwent successful surgical resection. At the time of surgery one of the tumours was found to be locally invasive. One elderly patient was deemed unfit for surgery and was managed non-surgically with a satisfactory outcome. A review of the literature reveals that surgery is still the preferred mode of treatment although preoperative embolization may be a useful adjunct. Although the incidence of peroperative stroke has gradually been reduced from that found in earlier series, injury to the cranial nerves remains high and is the main hazard of surgical management. The improved results of surgical resection in more recent reports support the view that these tumours should be treated in units with expertise in vascular surgery of the neck.     

Video-assisted thoracoscopic resection of a mediastinal cyst: Report of a case

Video-assisted endoscopic surgery has recently been expanding its potential, which is shown by our report herein describing the case of a 23-year-old woman for whom successful thoracoscopic resection of a mediastinal cystic lesion was carried out. The patient's postoperative course was uneventful with minimal pain and a prompt recovery. Histological examination confirmed that the lesion was a benign cystic teratoma. We believe that video-assisted thoracoscopic surgery will become the standard procedure for most mediastinal cystic lesions in the future.     

Robotic versus laparoscopic liver resection: a comparative study from a single center

Purpose

The significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center.

Methods

From July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study.

Results

The robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group.

Conclusions

Robotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.     

Use of a distal arteriovenous fistula in a complex vascular reconstruction after resection of an osteosarcoma in a high-risk child

Osteosarcoma is the most common osseous malignancy of childhood. Vascular reconstruction during resection is uncommon. However, when required, thrombosis is a major cause of failed limb salvage surgery. A 19-year-old patient required complex vascular reconstruction in conjunction with lower extremity osteosarcoma resection. Preoperatively, his case was complicated by an ipsilateral popliteal deep vein thrombosis presenting during neoadjuvant chemotherapy. At the time of resection, to increase vascular graft flow, a distal arteriovenous fistula was created between the posterior tibial artery and the greater saphenous vein. This case illustrates a patient with a complex extirpation procedure requiring concomitant vascular reconstruction. This technique should be considered when limb salvage with vascular resection is being attempted in a high-risk patient.     

Surgical excision of giant venous angioma of the face under extracorporeal circulation: apropos of a case by a multidisciplinary team]

Because of the risk of haemorrhage related to their resection, deep angiomas of the face are often considered to be inaccessible to treatment. The use of cardiopulmonary bypass with profound hypothermia allows the surgeon to operate in a bloodless field, enabling almost oncological resection of the tumour. The authors report a case of venous angioma of the submaxillary region treated in this way after failure of limited surgery and embolisation. Complete resection of the lesion was achieved and the defect was repaired with a pectoralis major flap and a latissimus dorsi flap. The authors stress the value of a multidisciplinary approach: a cardiac surgeon for CPB, an ENT surgeon for resection and a plastic surgeon for reconstruction.     

Laparoscopic colorectal resection: a safe option for elderly patients

BACKGROUND: Open colorectal surgery in the elderly has been associated with higher morbidity and mortality rates. The favorable short-term outcomes of laparosocopic colorectal resection might reduce the morbidity in elderly patients. This study compares results of elderly patients (aged 70 and above) who underwent laparoscopic colorectal resection with those having open surgery. STUDY DESIGN: Consecutive patients aged 70 and above who had elective colorectal resection from June 2000 to December 2001 were included. Data concerning demographics, diseases, details of operations, and postoperative events were collected prospectively. Comparisons between results of laparoscopic surgery and open surgery were made. RESULTS: Sixty-five patients had laparoscopic colectomy and 89 had open surgery during the study period. Median ages were 77 years and 75 years in the open and laparoscopic groups, respectively. Presence of premorbid medical conditions, American Society of Anesthesiology score, and incidence of previous surgery were similar in the two groups. Median operative time was longer (180 minutes versus 135 minutes, p < 0.001), but blood loss was less (100 mL versus 200 mL, p = 0.001) in the laparoscopic group. Conversion to open surgery occurred in eight patients. One patient died in the laparoscopic group and five died in the open group. Laparoscopic resection was associated with earlier return of bowel function (3 days versus 4 days, p = 0.004), earlier resumption of solid diet (3 days versus 5 days, p < 0.001), shorter hospital stay (7 days versus 9 days, p = 0.001), and less cardiopulmonary morbidity (7.7% versus 22.4%, p = 0.033) when compared with open colorectal resection. CONCLUSIONS: Laparoscopic colorectal resection is a safe option for elderly patients and is associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. It is also associated with less cardiopulmonary morbidity, which is an important complication after colorectal surgery in the elderly.     

A selective therapeutic approach to gastric cancer in a large public hospital

: Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain. : The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease. : Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and sup-portive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy. : Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.     

Thoracoscopic lung resection: use of a new endoscopic linear stapler.

Recent advances in rigid endoscopic imaging capabilities, light sources, and instrumentation have dramatically expanded the potential role of laparoscopic and thoracoscopic surgery. The recent introduction of an endoscopic linear stapling device has made possible thoracoscopic pulmonary resection. A 28-year-old woman with a history of recurrent pneumothorax, diffuse interstitial fibrosis, and left apical microblebs underwent thoracoscopic lung resection using this new stapling device. A 3 x 5 cm segment of involved lung tissue was removed. Postoperatively, the patient manifested no evidence of air leak and was discharged 48 h after surgery.     

Endo-robotic resection of the submandibular gland in a cadaver model

BACKGROUND: By means of a prospective, nonrandomized investigation, we evaluated the feasibility of performing endo-robotic resection of the submandibular gland in a cadaver model and compared the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. METHODS: Procedural times were recorded in a consecutive series of 11 endoscopic submandibular gland resections using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) and a modified endoscopic surgical approach previously developed in a porcine model. The presence of neurovascular injury was assessed postoperatively, and the specimens were examined histologically. RESULTS: Eleven endo-robotic submandibular gland resections were successfully performed in six cadavers (no conversions to open resection were necessary). The median duration of the procedures was 48 minutes (range, 33-82 minutes). Creation of the operative pocket took an average (+/-SD) of 12.2 +/- 5.3 minutes, assembly of the robot required 9.3 +/- 4.1 minutes, and the mean time for submandibular gland resection was 29.4 +/- 8.9 minutes. The time required for robotic assembly was offset by the reduced operative time necessary compared with conventional endoscopic resection. Histologic examination confirmed the presence of normal glandular architecture, without evidence of excessive mechanical or thermal injury. There were no cases of apparent neurovascular injury. CONCLUSIONS: Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.