Surgery Journal最新文献

Background  The present study assesses the educational value of laparoscopic cholecystectomy videos on YouTube regarding the correct application of the critical view of safety (CVS), and evaluates… surgical trainees' perceptions of the CVS criteria in a simulated, operative decision-making exercise. Methods  YouTube was systematically searched for laparoscopic cholecystectomy videos, explicitly reporting a satisfactory CVS. The top 30 most popular videos, by number of views, were identified and scored on the 6-point scale by three experienced consultants. After watching a training module on CVS rationale and criteria, 10 trainees, blinded to the consultants' assessment, were instructed to view the videos, score each criterion and answer the binary question "Would you divide the cystic structures?" by "yes" or "no." Results  An inadequate CVS was found in 30% of the included videos. No statistical association was noted between number of views, likes, or dislikes with successful CVS rates. Inter-observer agreement between consultants and trainees ranged from minimal to moderate ( k  = 0.07-0.60). Discrepancy between trainees' CVS scores and their simulated decision to proceed to division of the cystic structures was found in 15% of assessments, with intra-observer agreement ranging from minimal to excellent ( k  = 0.27-1.0). For the CVS requirements, inter-observer agreement was minimal for the dissection of the cystic plate ( k  = 0.26) and triangle clearance ( k  = 0.39) and moderate for the identification of two and only two structures ( k  = 0.42). Conclusion  The CVS is central to the culture of safety in laparoscopic cholecystectomy. Surgical videos are a useful training tool as simulated, operative decision-making exercises. However, public video platforms should be used judiciously, since their content is not peer-reviewed or quality-controlled.

Background  Amebic liver abscess (ALA) contributes significantly to morbidity and mortality in patients of the developing world. Even though medical management is the primary modality of treatment, 15% of the cases are refractory and require intervention for drainage. Pigtail catheterization is inefficient and results in a long duration of hospital stay. So, we conducted a prospective observational study to determine the efficacy and safety of drainage of large ALA using a wide bore 24 French (Fr) drain compared with a conventionally used 10 Fr pigtail catheter. Materials and Methods  A single center prospective observational study was conducted over a period of 5 years and data of 122 patients was collected. After starting empirical medical therapy, patients underwent drainage of ALA with either a 10 French pigtail or a 24 Fr drain. The primary outcome variables were resolution of clinical symptoms such as fever and pain in abdomen, length of hospital stay, and resolution of abscess on imaging at day 3. Secondary outcome was complications related to the procedures. Results  Data of 122 patients was collected. Males constituted a vast majority (96%) of the study population and the fifth decade was the most common age group involved. Alcoholics had a higher chance of developing a large ALA. Sixty-eight patients underwent drainage of the ALA using a 24 Fr drain which resulted in faster resolution of symptoms (2.4 vs. 5.1 days, p -value 0.033), a shorter duration of catheter in situ (6.4 vs. 13.2, p -value 0.011), and a faster drainage of ALA (residual volume at day 3; 177 vs. 212 mL, p -value 0.021). Twenty-eight patients had a biliary communication of which 26 required therapeutic endoscopic retrograde cholangiopancreatography. Conclusion  In patients with a large ALA, placement of a wide bore 24 Fr catheter hastens recovery of the patients when compared with drainage with a standard 10 Fr pigtail catheter. Placement of a biliary stent serves as a useful adjunct for their management and it may obliviate the need for a major biliary diversion surgery.

Hydatid disease is rare; nevertheless, several areas of the world are endemic. Lebanon is one of the endemic countries. This disease requires careful management, as its diagnosis is tough, and its complications are severe and can lead to sudden death. These complications include fistulas, infection, and rupture. Rupture of a hydatid cyst can mimic acute abdomen and show an array of nonspecific symptoms. It could be mistaken for hemorrhagic shock, trauma, or injury to an intra-abdominal organ. The diagnosis of ruptured hydatid cyst should be kept in mind in cattle-raising countries. We report the case of a polytrauma patient who was suspected to have severe intra-abdominal bleeding and hemorrhagic shock, but imaging and laparotomy showed the rupture of a liver hydatid cyst that drove the patient into anaphylactic shock. This article reviews similar cases in the literature and discusses the diagnostic tools, appropriate management, and expected complications.

Introduction  Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Their primary treatment is surgical. Case Report  Here we report a case of a 36-year-old male patient who was being evaluated for weakness, anemia, and melena. Upper GI endoscopy showed a mass projecting into the lumen and an abdominal computed tomography (CT) confirmed a well-defined mass close to the lesser curvature on the posterior wall. An endoscopic ultrasound-guided fine needle aspiration suggested a diagnosis of GIST. After optimization, the patient was taken up for a laparoscopic transgastric resection of the GIST. The resected specimen measured 9.5 × 8.5 × 7.5 cm. Postoperatively, the patient recovered well and was discharged by the fifth postoperative day. Discussion  While traditionally, open surgery has been advocated for GISTs, for fear of spillage and peritoneal seeding, the role of minimal access surgery has been growing in recent years. The use of a transgastric approach avoids the potential complication of luminal stenosis following a wedge resection of a tumor close to the cardia. Because lymphadenectomies are rarely required and local invasion is uncommon, a wide local resection is usually curative. Thus, a laparoscopic approach can be considered as the first line in uncomplicated GISTs, irrespective of tumor size.

Abdominal wall hernias rarely cause obstruction of the urinary tract. We present the case of a patient undergoing regular smooth dilatations for urethral stricture since 8 years who developed right inguinoscrotal swelling and narrowing of urinary stream since 2 years of age. There was a growing difficulty in dilatation due to path distortion of urethra by the hernia. He had a history of open suprapubic cystostomy (SPC) 8 years ago. The patient refused surgery till he landed with an inability to pass dilators and difficulty in passing urine. He was taken up for right inguinal exploration with internal optic urethrotomy (IOU). Intraoperatively, he was found to have right inguinal hernia with incisional hernia at the site of SPC which was repaired and a cystoscopy revealed urethral deviation with anterior urethral stricture for which IOU was done. Postoperatively, the patient's urethral tract straightened and his urinary complaints resolved. A complex hernia can cause urethral deviation and obstruction due to pressure effects of its contents and should be repaired at an early stage.

Gracilis free muscle transfer is considered the gold standard technique for facial reanimation in cases of facial palsy. However, it is limited by its long operative and recovery times, the need for a second surgical site, and its outcomes that can sometimes show midfacial bulk and oral commissure malposition. Facial reanimation with lengthening temporalis myoplasty (LTM)-Labbé technique- carries the advantage of having a shorter surgical time, a faster recovery, and being a less invasive surgery. Almost all patients included in studies of LTM were evaluated by subjective methods, and very little quantifiable data was available. A 64-year-old woman presented with long-standing incomplete right facial palsy secondary to acoustic neuroma surgery. Since she was overweight (body mass index [BMI]: 43.9) and had several cardiovascular comorbidities (hypertension, dyslipidemia), she was not a good candidate for gracilis free muscle transfer. She was submitted to facial reanimation with LTM. Fourteen months after surgery, she presented excellent facial symmetry, both at rest and in contraction, while smiling. She was evaluated with the Facegram-3D, a technology that we have developed for dynamic evaluation of facial muscle contraction. The analysis showed symmetry at rest and contraction, according to Terzis and Noah. Regarding vertical and horizontal displacement, the postoperative movement was synchronized and with less fluctuations when compared with the preoperative period. Notably, the anatomical pair's trajectories were smoother. Similar velocity profiles were found between anatomical pairs, with less abrupt changes in velocity values, further supporting improved movement control. Comparing the symmetry index, which takes a theoretical maximum of 1.0 for perfect 3D symmetry, its value was 0.56 for the commissures and 0.5 for the midpoints in the preoperative period, having improved to 0.91 and 0.82, respectively, 3 months postoperatively. Good aesthetic and functional results were achieved using the Labbè technique. LTM is a good option in cases of long-standing facial paralysis, if the patient desires a single-stage procedure with almost immediate dynamic function. Moreover, this technique assumes extreme importance in facial reanimation of patients of advanced age, overweight, or those who have several comorbidities.

Importance  Preoperative imaging provides an advantageous balance by helping patients to effectively communicate their aesthetic desires while allowing surgeons to establish realistic expectations of surgical outcomes. Objective  To determine the role of preoperative imaging and the importance of online-based photo galleries in influencing a patient's decision to pursue cosmetic facial plastic surgery. Design, Setting, and Participants  A retrospective study was conducted on 100 patients who underwent preoperative imaging prior to undergoing aesthetic facial plastic surgery from July 2019 to May 2020. An in-office physician-led clinical consultation followed by a preoperative imaging session was performed on each patient prior to surgical intervention. A 6-question survey was provided once to all patients between their 3- and 12-month postoperative time periods. Main Outcomes and Measures  The importance of preoperative imaging and the influence of physician website and social media photo galleries regarding surgical decision-making was evaluated. Results  A total of 100 participants (female [90; 90%]) and mean age 52.6 (range, 18-77) years were included. Nearly 60% of patients underwent facial rejuvenation procedures. All reported that preoperative in-office physician consultation in combination with the use of preoperative imaging were helpful in facilitating a commitment to surgical intervention. Sixty-nine (69%) patients endorsed the use of both the frontal and lateral imaging views, while 30 (30%) deemed a single angle to be superior. Seventy (70%) participants utilized online-based "before & after" photo galleries in the form of physician websites and/or social media platforms to assist in their decision to undergo surgical intervention. Conclusions and Relevance  The combination of in-office physician consultation, preoperative imaging, and availability of website and/or social media photo galleries plays a key role in a patient's decision to pursue cosmetic surgery. Thus, implementation of all facets should become an integral part of any facial plastic surgeon's aesthetic practice.

Purpose  Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases  We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion  Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.