HighlightsA rare case of laparoscopic Roux-en-Y gastric bypass on a patient with situs inversus totalis (SIT).SIT is a rare congenital condition, but surgeons in general do encounter those patients throughout their career.SIT should not solely be an indication for an open approach as minimally invasive surgery is safe and should still be considered the standard of care.Gastric bypass can be safely performed in SIT without the need for major adjustment to the surgeon’s position, trocar placement or instruments used.
HighlightsA rare case of spontaneous perforation of common hepatic duct due to stones impaction.Because of its rarity, spontaneous biliary perforation requires high index of suspicion.Impacted stones in the biliary tree need to be extracted to avoid complications.ERCP and stent placement should be only used as temporizing measures to manage the acute obstructive phase.Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones.
Introduction Pillar pain is a frequent postoperative complication of carpal tunnel release (CTR). The precise definition of pillar pain is lacking, but most authors describe it as diffuse aching pain and tenderness in the thenar and hypothenar area. The etiology of pillar pain is unclear. However, the most prevalent theory is the neurogenic theory, which attributes the pain to the damage of small nerve branches of palmar cutaneous branches of median nerve after surgical incision, with resulting entrapment of the nerves in the scar tissue at the incision site. We postulated that a main source of pillar pain is sensory neuromas along the incision site. In this article, we describe a simple modification of the standard CTR technique with intent to decrease neuroma formation and thus minimizing pillar pain. Materials and Methods This is a retrospective study comparing the incidence and duration of pillar pain between patients who underwent standard CTR (SCTR, n = 53) versus the minimizing pillar pain CTR technique (n = 55). Based on duration of pillar pain, the groups were placed into 3 subgroups (<3, 3–6, and >6 months). Presence and duration of pillar pain in each group were recorded along with return to work (RTW), complications, and patient satisfaction. Results The SCTR group had a total of 17 patients with pillar pain (32.1%), 5 of which resolved within 3 months, 7 within 3 to 6 months, and 5 in more than 6 months. The group that underwent the minimizing pillar pain technique had a total of 4 patients with pillar pain (7.2%). Three resolved within 3 months, 1 resolved within 3 to 6 months, and there were no patients with pillar pain lasting more than 6 months. Average RTW time for minimization of pillar pain CTR (MPPCTR) was 34.9 days. Average RTW time for SCTR was 54.8 days. Satisfaction was higher among patients who underwent surgery with MPPCTR. Conclusions Based on these results, we concluded that MPPCTR compared with SCTR had equal complication rate, however, significantly lower incidence and duration of pillar pain, higher rate of satisfaction, and earlier RTW.
Background: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. Methods: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. Results: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. Conclusion: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.
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