Surgery Journal最新文献

Radical hysterectomy is a standard operation for invasive cervical cancers. However, if the invasion to the parametrium is more advanced than estimation in the operation, it is difficult to perform usual radical hysterectomy. Superradical hysterectomy was developed by Prof. Ryukichi Mibayashi of Kyoto University and was published in 1941, and has been performed for the limited cases by a part of Japanese gynecologic surgeons. Superradical hysterectomy is a procedure in which the soft tissues in the pelvis are removed en bloc by sequential processing of the internal iliac vessels, which leads to a complete dissection of the lymphatic tissue in the pelvis to the pelvic wall.

Psoas abscess is a rare condition that can present with vague clinical features. Its insidious onset can lead to a delay in diagnosis, resulting in high rates of complications and mortality. Here we describe a unique case of a patient presenting with enterocutaneous fistula and pneumoretroperitoneum due to ruptured psoas abscess.

Abdominal radical trachelectomy is a fertility-sparing surgery for early invasive cervical cancer. The surgical steps involved in abdominal radical trachelectomy are similar to those for radical hysterectomy prior to removal of the uterus. The difference is that in trachelectomy, the uterine corpus and infundibulopelvic ligament are conserved and the cervical remnant is connected to the vaginal wall. Surgeons should pay close attention to avoiding postsurgical complications such as infection and ileus, which might interfere with subsequent fertility treatments.

Abdominal radical hysterectomy is the standard operation for stage IB-IIB cervical cancer in the world, which was established by Professor Hidekazu Okabayashi in 1921. In this article, the basic principle and step-by-step procedure of Okabayashi radical hysterectomy are presented, especially for young doctors to understand clearly the important points of this surgery and to realize its radicality and safety for better survival and quality of life of patients with cervical cancer.

Hysterectomy for placenta percreta with bladder invasion is a difficult operation because of the high possibility of massive bleeding; therefore, surgery should be performed in a facility equipped with a sufficient number of trained staff. The degree of bladder invasion should be assessed correctly before the operation, and it is necessary to carefully consider how to address intraoperative complications and massive bleeding in the preoperative conference. The following should be prepared preoperatively: autologous blood and stored blood; ureteral catheter and insertion materials; materials to separate and tape the internal iliac artery and ureter; balloon for insertion into the common iliac artery or aorta and aortic clamps; and materials for compression suturing, such as B-Lynch suture. Sufficient informed patient consent is also required. During surgery, which may cause massive and sometimes life-threatening bleeding, the general rule is to begin at a safe site without adhesions and then treat the adhesion site. According to this rule, bladder dissection should be performed last in cases of placenta percreta with bladder invasion. As a surgical technique using this principle, we introduce retrograde hysterectomy approaching from the posterior vaginal wall.

Radical hysterectomy is a standard operation for patients with early-stage cervical cancer. Over the recent decades, laparoscopic radical hysterectomy has been considered an alternative treatment. In 2018, the results of the laparoscopic approach to cervical cancer trial suggested that women with early-stage cervical cancer who underwent minimally invasive surgery for radical hysterectomy had poorer prognosis than those who underwent open surgery. This finding was unexpected, and direct evidence supporting poor prognosis related to minimally invasive radical hysterectomy was not available because the trial was not designed to evaluate the cause of the inferior outcomes. Tumor spillage caused by surgeon-related factors, including squeezing of the uterine cervix and tumor exposure to circulating CO ₂ gas, is considered to be associated with the poor prognosis of patients who underwent minimally invasive radical hysterectomy. We believe that protective maneuver to avoid tumor spillage is the key to improve oncologic outcomes of cervical cancer. Here, we present a procedure of total laparoscopic nerve-sparing radical hysterectomy for early-stage cervical cancer in which techniques, such as the "no-look no-touch technique," were used to prevent tumor spillage.

Background  Surgical site infections (SSIs) are the infections of wound after an invasive operative approach. It remains to be a major morbidity for patients undergoing surgeries although there have been tremendous improvements in the surgical techniques. Different interventions to suppress the selective serotonin reuptake inhibitors have been proposed. Many of them have been routinely used by surgeons like minimizing shaving, hand washing, and preoperative antibiotics and these are well accepted. Drains are used in major abdominal surgeries, hernia repairs, breast surgeries reducing collections in closed areas. 1 Hematoma, serous fluid, and dead space in surgical incision wounds raise the risk of infection as they serve as the platform for microbial growth. Studies have proved that the usage of subcutaneous drains has lowered the chances of infection. Results  The patients in the case group had lower incidence of SSI compared with the control group. The patients in the case group had subcutaneous drain which drained any collection that developed in the subcutaneous space. When the incidence of SSI was compared between the emergency cases and elective cases, the emergency cases showed higher propensity for SSI and increased rate for patients who had co-morbidities like diabetes mellitus, hypertension, etc. The most common organism isolated from the SSI was found to be Escherichia coli . It was also noted that the mean number of days of hospital stay was comparatively higher for the patients who developed SSI compared with patients who did not develop SSI. Conclusion  Thus the presence of SSI adds morbidity to the patient and the patients who undergo major surgeries are likely to develop SSI postoperatively. The presence of subcutaneous closed suction drain helps in reducing the SSI to a certain extent.

Intestinal intussusception is uncommon in adults. It occurs more often in the small intestine than in the colon. In adults, when small bowel intussusception occurs, it can be due to a malignant lead point. Malignant etiology is most frequently due to diffuse metastatic disease. We present a rare case of an 18-year-old woman who was diagnosed with jejunojejunal, jejunoileal, and colocolic intussusceptions. She presented with vomiting, abdominal pain, and passage of semisolid stools for 5 days. During emergency exploratory laparotomy, multiple polyps were found in the jejunum, ileum, and sigmoid. Jejunotomy and sigmoidotomy were done to remove the respective polyps. The ileal polyp showed hemorrhagic changes; hence, an intraoperative decision was taken to proceed with resection and anastomosis. On histopathological examination, the resected ileal part showed moderately differentiated adenocarcinoma (grade 2) arising from an adenomatous polyp, while the jejunal polyp and sigmoid polyp were adenomatous polyps with low-grade dysplasia. Patient received six cycles of adjuvant chemotherapy consisting of capecitabine and oxaliplatin (CAPEOX regimen). After 2 years, she is symptom free with a normal colonoscopy. The treatment of intussusception in adults typically involves surgery, often with bowel resection as there is always a pathologic leading cause which may be malignant, like in our case.

After Prof. S. Okabayashi introduced Okabayashi Operation in 1921, several surgeons introduced numerous improvements in Japan. One of them is so-called the Tokyo Method which was improved and revised by Dr. Kyusaku Ogino (1950), Prof. Takashi Kobayashi, University of Tokyo (1961, 1970), and Prof. Shoichi Sakamoto, University of Tokyo (1981). The nerve-sparing radical hysterectomy without sacrificing radicality was introduced in 1961 ¹ and improved in 1970 by Prof. Kobayashi. ² The autonomic nerve pathway including hypogastric nerve (sympathetic nerve), pelvic splanchnic nerve (parasympathetic nerve), and pelvic nerve plexus as a junction of the two nerves and the branch of the plexus to the bladder (vesical nerve branch) are preserved except in advanced cases. He divided the process of nerve-sparing surgery into four steps for separating the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacrouterine, rectouterine/vaginal, and vesicouterine ligaments. The first step is separation of the cardinal ligament (deep uterine vessels) from the pelvic splanchnic nerve. The second step is separation of the medial side of severed cardinal ligament from the pelvic nerve plexus. The first and second steps are performed in the lateral side of the autonomic nerve system. The third step is separation of sacrouterine and rectouterine/vaginal ligaments from hypogastric nerve and pelvic nerve plexus. The third step is necessary for achieving high radicality, namely, for severing the sacrouterine and rectouterine/vaginal ligaments near the rectum without damage to the pelvic nerve plexus. The fourth step is separation of paravaginal tissues and posterior (deep) layer of the vesicouterine ligament from the vesical nerve branches of the plexus. The third and fourth steps are performed in the medial side of the autonomic nerve system.

Placenta accreta spectrum (PAS) disorder often causes a large amount of intraoperative bleeding in a short period which makes maternal circulation unstable and threatens life. As a countermeasure, two-stage surgery combined with selective uterine arterial embolization (UAE), named "stepwise treatment" was introduced in 2003. At a cesarean section (CS), only the baby is delivered and the placenta is left in situ. The transcatheter angiographic UAE is performed on the operation day, followed by the total hysterectomy on 5 to 7 days after CS. The difficulty in the operative procedures for hysterectomy and the amount of bleeding can be reduced by the added effect of the blood flow interruption by UAE and the uterine involution. Although there are not many indication cases, this is the prudent operation that should be considered for the most severe PAS case such as total placenta increta/percreta with placenta previa. In this article, the practical procedures and tips of stepwise treatment are described.