Adequate Working Space Research Articles

Effect of converted buildings on the management of records and archives in the Eastern Cape Provincial Archives of South Africa

Archival buildings play a pivotal role in the management of records and archives. This paper highlights the findings of a case study that investigated the effect of converted buildings on the management of records and archives in the Eastern Cape Provincial Archives in the Eastern Cape province in South Africa. The study population consisted of all archives and records personnel in the Eastern Cape Provincial Archives. The sample comprised 13 purposively selected participants. The participants had the requisite knowledge and experience pertaining to the management of records and archives in their respective records and archives in the provincial archives offices. These included the director, assistant directors, archivists, and assistant archivists. Data were collected using interviews, observations, and document analysis. Collected data were analysed using emerging themes based on the objectives of the study. The findings of the study revealed that all archival offices and repositories of the Eastern Cape Provincial Archives are housed in converted buildings. There was a clear lack of adequate and suitable office and working space, and repositories for effective management of records and archives. This has serious implications for adequate processing, storage, access to, and preservation of, records and archival materials. It was recommended that more resources should be allocated for the management of records and archives by revamping the existing facilities while resources are provided for planning and building of requisite infrastructure for records and archives management for the Eastern Cape province.

"Sagittal Crest": Definition, Stepwise Dissection, and Clinical Implications From a Transorbital Perspective.

The recent development of the superior eyelid endoscopic transorbital approach (SETOA) offered a new route for the management of cavernous sinus and middle cranial fossa tumors. As a result, a constant anatomic landmark of the surgical pathway after drilling the medial edge of the greater sphenoid wing (GSW) is represented by a triangular-shaped bone ridge appearing as a "crest." To perform an anatomic study to define this surgical landmark, named the "sagittal crest" (SC) as seen from the transorbital endoscopic view. Four adult cadaveric specimens (8 sides) were dissected performing an endoscopic transorbital approach to the middle fossa and the SC was removed to perform interdural opening of the cavernous sinus. Computed tomography scans were made before and after removal of the SC to perform quantitative analysis and building a 3-dimensional model of the bone resection of the GSW via the SETOA. The SC is a bone ridge triangle shaping dorsally the superior orbital fissure resulting as the residual fragment after drilling the lateral aspect of the greater sphenoid wing. Predissection and postdissection computed tomography scans allowed to objectively assess SC features and dimensions (mean 1.08 ± 0.2 cm). The SC is a constant anatomic landmark constituted of the residual medial portion of the GSW. Complete resection of this key landmark provides adequate working space and appears to be mandatory during SETOA to guide the subsequent interdural dissection of the lateral wall of cavernous sinus.

Free flap reconstruction after endoscopic and robotic neck dissection using retroauricular approach

<h2>Unstructured Abstract</h2> The desire to reduce esthetic and psychological consequences following oncologic head and neck procedures has promoted the development of remote approaches to the neck. Within the last 10 y, the retroauricular approach has emerged as a feasible way to perform neck dissection and free-flap reconstruction. This was a retrospective analysis of a single-center experience and technical description. We included our early experience with the first eight cases performed by our group. No flap failures or other major complications were observed in this sample. In all of the cases, following robotic or endoscopic selective neck dissection, microvascular anastomosis was performed via a retroauricular approach with a self-retaining retractor to maintain an adequate working space and microscope assistance. Based on literature reports and our experience, robotic-assisted or endoscopic neck dissection via the retroauricular approach has a clear esthetic benefit and seems feasible and safe even when microvascular anastomosis is necessary for free-flap reconstruction in selected cases. <h3>Introduction</h3> Remote approaches to the neck following head and neck surgery have evolved and aim to reduce the aesthetic and psychological effects of surgery. In the last ten years, the retroauricular approach emerged as a feasible way to perform neck dissection and free-flap reconstruction. <h3>Methods</h3> Retrospective analysis of the experience and technical description in a single academic center. <h3>Results</h3> We included our early experience with the first 8 cases performed by our group. There were no flap failures or other major complications in this group. In all cases, following robotic or endoscopic selective neck dissection, microvascular anastomosis was performed via retro auricular approach. <h3>Conclusion</h3> Based on our experience and others described in the literature, the robotic-assisted or endoscopic neck dissection via the retroauricular approach has a clear aesthetic benefit. This technique is feasible and safe in select cases when microvascular anastomosis is performed for free-flap reconstruction.

The Pink Pad: A Method of Post-Free Distraction During Hip Arthroscopy

Distraction is essential during hip arthroscopy to allow for adequate working space during central and peripheral compartment procedures. Pudendal posts are frequently used with traction boots to achieve distraction, but use of these posts is believed to be associated with the iatrogenic pudendal area and perineal nerve injuries seen with hip arthroscopy. Current post-free distraction tables are costly and cumbersome. The pink pad positioning device allows for post-free distraction through the creation of friction between the patient, the pad, and the bed. This device can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty, as there is less restriction of the patient’s range of motion without a post present. The purpose of this Technical Note is to describe a method of post-free distraction using the pink pad positioning device.

Evaluating the feasibility and effectiveness of extremely low-pressure pneumoperitoneum for robotic-assisted cholecystectomy

Standard-pressure pneumoperitoneum (12 to 15 mmHg) has been used to create an adequate working space during the laparoscopic surgery, but it has adverse effects such as postoperative pain, especially in the shoulder. Attempts are being made to reduce the postoperative pain by keeping low-pressure insufflation (7 to 10 mmHg). With advances in operative technology, the robotic-assisted cholecystectomy using da Vinci Xi could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (4 mmHg) by the videoscope pushing the abdominal wall upward. This study aimed to compare the postoperative outcomes using standard- and extremely low-pressure pneumoperitoneum in patients undergoing laparoscopic or robotic-assisted cholecystectomy. A retrospective study was designed to compare the postoperative outcomes of 53 extremely low-pressure robotic-assisted cholecystectomy (ELRC), 116 standard-pressure robotic-assisted cholecystectomy (SRC) and 105 standard-pressure laparoscopic cholecystectomy (SLC). The surgery took longer in robotic-assisted cholecystectomy than laparoscopic cholecystectomy (p < 0.001). Postoperative pain score was significantly less in ELRC group as compared to SRC or SLC group at 6, 12, and 24 hours (p = 0.004, p = 0.005, and p = 0.009, respectively). However, there was no significant difference between groups in the number of demands for analgesic. The incidence of shoulder pain was significantly lower in ELRC group (p < 0.001). The rate of postoperative complication and length of stay were no difference between groups. The use of the ELRC is associated with a significantly lower postoperative pain and shoulder pain. This study also shows that extremely low-pressure technique is feasible without increasing postoperative complications.

Extended endonasal approaches for pituitary adenomas.

Pituitary adenomas with significant extension beyond the sellar boundary, large size, asymmetrical shape and subarachnoid space invasion, although rare, represent a therapeutic challenge. The invasiveness of the tumor itself often limits the potential for complete tumor resection and increases the likelihood of intraoperative or postoperative complications, regardless of the approach. The extended endoscopic endonasal approach has been proposed as a valid alternative to the transcranial route for the treatment of certain pituitary adenomas not suitable to the standard transsphenoidal approach. Thanks to the wide and close up view provided by the endoscope via the appropriate expanded bone removal at the skull base, this technique offers, in an adequate working space, a safe exposure of the tumor and surrounding anatomical structures, at the supra-, para-, and retro-sellar areas. It stands clear that the primary goal of this approach remains the maximum allowed resection with preservation of neurological and endocrine functions. Herein, we debate the extended endoscopic endonasal technique for the treatment of pituitary adenomas, with the aim of underlying its indications, pitfalls, advantages, and limitations.

Relationship of superior sagittal sinus with sagittal midline: A surgical application.

Background: Interhemispheric approach is widely used to surgical management of midline tumors and vascular lesion in and around the third ventricle. Complete exposure of the superior sagittal sinus to obtain adequate working space of midline lesion is difficult, because of the risk to inadvertent injury to the sinus and bridging veins, which may cause several neurological deficits. Understanding the SSS neuroanatomy and its relationships with external surgical landmarks avoid such complications. The objective of this study is to accurately describe the position of SSS and its displacement in relation with sagittal midline by magnetic resonance imaging.Methods: A retrospective cross-sectional, observational study was performed. Magnetic resonance image of 76 adult patients with no pathological imaging was analyzed. The position of the halfway between nasion and bregma, bregma, halfway between bregma and lambda, and lambda was performed. The width and the displacement of the superior sagittal sinus accordingly to the sagittal midline were assessed in those landmarks.Results: The mean width of superior sagittal sinus at halfway between nasion and bregma, bregma, halfway between bregma and lambda, and lambda was 5.62 ± 2.5, 6.5 ± 2.8, 7.4 ± 3.2, and 8.5 ± 2.1 mm, respectively, without gender discrepancy. The mean displacement according to the midline at those landmarks showed a statistically significant difference to the right side among sexes.Conclusion: In this study, we demonstrate that sagittal midline may approximate external location of the superior sagittal sinus. Our data showed that in the majority of the cases, the superior sagittal sinus is displaced to the right side of sagittal midline as far as 16.3 mm. The data we obtained provide useful information that suggest that neurosurgeons should use safety margin to perform burr holes and drillings at the sagittal midline.

Evone® Flow-Controlled Ventilation During Upper Airway Surgery: A Clinical Feasibility Study and Safety Assessment.

Introduction: During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance. This can be achieved by small-lumen ventilation such as High Frequency Jet Ventilation (HFJV). However, this technique has major drawbacks, such as air-trapping and desaturation in patients with poor pulmonary reserve. Recently, an innovative ventilating system with flow-controlled ventilation (FCV) and a small-lumen endotracheal tube, the Evone® (Ventinova, Eindhoven, The Netherlands), was introduced, claiming to counter the drawbacks of HFJV.Objectives: To evaluate feasibility and safety of the Evone® FCV system in difficult upper airway surgery and to critically appraise this novel ventilation method.Patients and methods: Evone® is a FCV-device using a small-bore cuffed tube (Tritube®). This ventilator actively sucks air out of the lungs, rather than relying on the passive backflow of air like in HFJV. Data related to the medical history, surgery, and anesthesia of all consecutive patients undergoing upper airway surgery with Evone® FCV ventilation were included in a tertiary center retrospective observational study.Results: Fifteen Patients, with a median age of 54 years, were included. Surgical procedures and indications included laser-assisted endoscopic treatment of idiopathic subglottic stenosis (n = 3), tracheal stenosis (n = 1), and posterior glottic stenosis (n = 2), biopsy and/or Transoral Laser Microsurgery for laryngeal (pre)malignancy (n = 7) and resection of benign lesions with posterior (supra)glottic location (n = 2). Mean ventilation duration was 52.0 min (range 30–115 min, SD 19.6 min), mean surgery duration was 31.7 min (range 15–65 min, SD 13.2 min), mean minimal SaO2 was 96.3% (range 89–100%, SD 4.0%) and mean peak pCO2 was 41.4 mmHg (range 31–50 mmHg, SD = 5.5 mmHg). No anesthesia- or surgery-related complications, adverse events or intra-operative difficulties were reported during or after any of the 15 procedures. In all cases, compared to HFJV, Evone® FCV ventilation allowed a superior visualization and working space during the surgical procedure.Conclusion: The Evone® FCV ventilation system provides excellent conditions in patients undergoing upper airway surgery, as it combines excellent accessibility and visibility of the operation site with safe and stable ventilation.

Laparoscopic adrenalectomy.

In the last three decades, endoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal diseases. Gagner et al., first reported in 1992, the lateral trans-abdominal laparoscopic approach to adrenalectomy. Afterwards, several retrospective and comparative studies addressed the advantages of minimally invasive adrenalectomy specifically consistent in less postoperative pain, improved patients' satisfaction, shorter hospital stay and recovery time when compared to open adrenalectomy. The lateral transabdominal approach to the adrenals is currently one of the most widely used, since it allows an optimal comprehensive view of the adrenal region and surrounding structures, and provides and adequate working space. On the other hand, from a technical point of view, essential requirements for a successful laparoscopic adrenalectomy are an appropriate knowledge of retroperitoneal anatomy, a gentle tissue manipulation and a precise haemostasis technique in order to identify appropriately the structures of interest and avoid the troublesome 'oozing' that could complicate the surgical procedure.

Comparative Analysis of Hemodynamic Changes and Shoulder Tip Pain Under Standard Pressure Versus Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy.

ABSTRACTBackgroundLaparoscopic cholecystectomy is the gold standard procedure for cholelithiasis. Pneumoperitoneum is created using carbon dioxide (CO2) which is usually maintained at a range of 12-14 mm Hg. An emerging trend has been the use of low-pressure pneumoperitoneum in the range of 7-10 mm Hg in an attempt to lower the impact of pneumoperitoneum on the human physiology while providing adequate working space. Our study proposes to compare the effects of low-pressure pneumoperitoneum with the use of standard pressure of pneumoperitoneum.Aims and objectiveTo compare and analyze various factors like blood pressure, heart rate, end-tidal CO2 and postoperative shoulder tip pain in cases undergoing laparoscopic cholecystectomy using standard pressure versus low pressure.Materials and methodsThis is a prospective randomized study carried out at Santosh Medical College and Hospitals, Ghaziabad from September 2017 to December 2018. This study included 60 patients of cholelithiasis which were divided into two groups of 30 patients each. Group I was offered laparoscopic cholecystectomy under standard pressure pneumoperitoneum and group II underwent laparoscopic cholecystectomy using low-pressure pneumoperitoneum. Patients in each group were evaluated for various intraoperative physiological changes and postoperative shoulder tip pain.Observations and resultsCholelithiasis is commonly seen in middle-aged females. There is no significant difference in duration of surgery between the two groups. However, various factors like systolic blood pressure, heart rate, end-tidal CO2 were significantly better in the low-pressure group. Postoperative shoulder tip pain (measured by VAS scoring system) was significantly less in the low-pressure group during the first 24 hours.ConclusionLaparoscopic cholecystectomy under low-pressure pneumoperitoneum causes minimal physiological changes and less postoperative shoulder tip pain.How to cite this articleGoel A, Gupta S, et al. Comparative Analysis of Hemodynamic Changes and Shoulder Tip Pain Under Standard Pressure Versus Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy. Euroasian J Hepatogastroenterol 2019;9(1): 5-8.

Low Pressure versus Standard Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy

Background: the laparoscopic cholecystectomy (LC), one of the utmost commonly assumed operations in general surgery. Adequate working space inside the abdominal cavity is required. Carbon dioxide (CO2) is used with a definite pressure to establish this working space. Aim: our study was to compare the hemodynamic symptoms, post-operative shoulder-tip pain and the frequency of nausea and vomiting between standard and low-pressure CO2 pneumoperitoneum (PP) in patients undergoing LC. Patients and Methods: a prospective randomized study was done on 50 patients aged 18 to 75 years in Bab ElShaaria hospital, Al-Azhar University with symptomatic gallstones. Patients were allocated into two groups: standard pressure (Group A: 12-14 mmHg) and low-pressure (Group B: 8-10 mmHg). Hemodynamics were assessed pre insufflation and 15 min post insufflation and desufflation. The frequency of nausea and vomiting were assessed at 0, 8, 16, 24-hour post-operative. Post-operative shoulder- tip was assessed 1, 6, 12, 24-hour post-operative. Statistical analysis was postulated using SPSS V.25. Results: a noticeable difference between the two groups was observed with respect to the mean systolic blood pressure (p=0.003) and the mean heart rate (p=0.001). Furthermore, a significant difference as regard post-operative shouldertip pain, which was higher in the standard pressure group (p< 0.05). There were no major differences between the two groups concerning the frequency of nausea and vomiting. Conclusion: low-pressure PP can be used instead of standard pressure considering its low side effects without any effect on the working space and quality of the surgical procedure.

Endoscopic 2-Port Technique for Infratemporal Fossa Tumors: Using Prelacrimal Medial Maxillectomy and Caldwell-Luc Approach

The endoscopic endonasal approach to the infratemporal fossa (ITF) has gained popularity. However, the inferior turbinate and/or lacrimal duct are often removed when performing endoscopic medial maxillectomy for ITF approach, and there is potential risk for empty nose syndrome or epiphora. Although the endoscopic prelacrimal recess approach was introduced to avoid these complications, there were some limitations associated with surgical freedom. We report a 2-port endoscopic technique using both prelacrimal recess and antral window as a means to preserve the inferior turbinate and lacrimal duct, while facilitating instrument availability during ITF tumor resection. We retrospectively reviewed 3 patients between September 2016 and May 2018 who were treated with a modified 2-port technique for ITF tumors. There was 1 case of trigeminal schwannoma originating in the mandibular nerve, 1 recurrent meningioma, and 1 paraganglioma. The 2-port technique was not initially planned in these 3 cases, but it was decided to use the technique during surgery because tumors were extensively attached to surrounding muscles and had profuse bleeding. After tumor resection, sinonasal anatomy including inferior turbinate and lacrimal duct was well preserved. We propose a hybrid endoscopic surgical procedure for ITF tumors using both endoscopic prelacrimal recess approach and transantral window. This technique provides surgeons an adequate working space via a bimanual technique through 2 different ports, while preserving normal sinonasal structures.

COMPARISON OF ISOBARIC AND INSUFFLATED LAPAROSCOPY-ASSISTED OVARIOHYSTERECTOMY IN THE COMMON RABBIT (ORYCTOLAGUS CUNICULUS)

Surgical sterilization of female rabbits can be associated with a significant risk of postoperative morbidity. Laparoscopic ovariectomy has been reported previously to address this issue. The aim of the current study is to assess whether an isobaric (ISO) technique, utilizing an abdominal lifting technique, rather than insufflation (INS) technique, which involves pressurizing the abdomen, is feasible in this species. Four rabbit cadavers were used to subjectively compare the viability of the 2 techniques. Seven rabbit cadavers were used to assess the effects of ISO and insufflated pneumoperitoneum on the dimensions of the abdomen and the volume of the thorax at atmospheric and positive inspiratory pressures using CT imaging. There was a significantly higher (P = 0.006) difference between baseline and pneumoperitoneum thoracic volume in the ISO specimens versus the INS specimens. There was no significant difference in abdominal height in either technique and both afforded adequate working space. The implementation of ISO laparoscopy-assisted ovariohysterectomy was subjectively no more technically difficult than INS laparoscopy-assisted ovariohysterectomy in the rabbit. Based on this investigation, ISO laparoscopy is feasible and requires less specialized equipment compared with insufflated laparoscopy, making it more available in a general practice setting and for routine surgery. Use of ISO laparoscopy could potentially decrease ventilatory compromise compared with insufflated laparoscopy in rabbits.

A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study.

While guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery. Multicenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO2 gas needed to perform the surgical procedure. Ninety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8mmHg. In 17 patients, IAP was raised up to 12mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO2 volume at which surgery was performed was 3.2L. A multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure. ClinicalTrials.gov (Trial Identifier: NCT03000465).

Pediatric Meningoencephaloceles Endoscopic Endonasal Repair: Our Experience.

BackgroundPediatric patients presenting with a nasal mass is uncommon and a high index of suspicion for it to be a meningoencephalocele is essential. Majority of these are congenital and require early intervention owing to the risk of meningitis. Surgery in these cases is very challenging because of the risk of anesthesia and limited space.ObjectiveThis study aimed to describe our technique and experience in managing pediatric meningoencephaloceles.MethodsA retrospective study of 19 pediatric patients (age ranging from 40-day-old infants to 11.5-year-old children) was conducted at our tertiary care center from January 2012 to February 2017. Patients presenting with an intranasal meningoencephalocele were treated by endoscopic approach, using otological microinstruments. After detailed imaging and clinical evaluation, a tailored repair, using fat/fascia/cartilage, a multilayer closure, was carried out in all cases.ResultsAll patients had a successful repair and recovery, except for one death following an episode of convulsion. There was a minor circumferential narrowing of the nasal vestibule and synechia formation in 2 of our cases.ConclusionTransnasal endoscopic repair of meningoencephalocele is minimally invasive. It avoids permanent anosmia and is cosmetic. A combination of miniaturized instruments and a 4-mm 0° nasal endoscope gives excellent visual field and an adequate working space. Owing to the larger defects in congenital meningoencephaloceles, a multilayer repair provides excellent outcomes.

A modified endoscopic submucosal dissection for a superficial hypopharyngeal cancer: a case report and technical discussion

BackgroundAdequate working space and a clear view for the dissected lesion are crucial for endoscopic submucosal dissection (ESD). Pharyngeal ESD requires that an otorhinolaryngologist creates working space by lifting the larynx with a curved laryngoscope. However, many countries do not have this kind of curved laryngoscope, and the devices could interfere with endoscope because of the narrow space of the pharynx. To overcome these issues, we used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and pharyngeal ESD could be done by gastroenterologists.Case presentationA 64-year-old male patient was admitted to our hospital because of chronic persistent swallowing dysfunction for 2 years. Oesophagogastroduodenoscopy showed a superficial hypopharyngeal cancer in the right pyriform sinus. We used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and dental floss tied to a haemoclip was applied to create counter traction during ESD. The lesion was pathologically confirmed as superficial squamous cell carcinoma and resected completely.ConclusionsThis is the first report of modified ESD for a superficial hypopharyngeal cancer. The modified ESD enables early pharyngeal superficial cancer to be removed completely under endoscope by gastroenterologist.

Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study

Background: With the establishment of laparoscopic cholecystectomy as gold standard for management of cholelithiasis, the current stress is on increasing patient safety. Hence, this study was undertaken to compare the effect of low pressure pneumoperitoneum (LPP &lt;10mm Hg) versus high pressure pneumoperitoneum (HPP &gt;14mm Hg) in a prospective randomized manner on intraoperative safety, assessing the working space and safety by seeing contact of parietal peritoneum to underlying viscera during secondary port insertion.Methods: 120 patients undergoing laparoscopic cholecystectomy were randomized into the LPP (&lt;10mm Hg) group (n=60) and the HPP (&gt;14mm Hg) group (n=60) prospectively. Available working space assessed directly, safety by contact of parietal peritoneum to underlying viscera during secondary port insertion and operative difficulty assessed by visualization, dissection and grasping, total duration of surgery; intra-operative gas consumption, and bile spillage were assessed.Results: There was no significant difference in terms of available working space, operative duration, consumption of carbon dioxide, surgeon’s operative difficulty and intraoperative bile spillage. Out of 180 secondary ports inserted, there was evident contact of 20 (11.1%) secondary ports in high pressure groups and 14 (7.7%) secondary ports in low pressure group, which is suggestive of adequate exposure and working space available for surgery at both pressures.Conclusions: Low-pressure cholecystectomy did not compromise intraoperative safety and should be the standard of care in day care surgery.

Modular Classification of Endoscopic Endonasal Transsphenoidal Approaches to Sellar Region: Anatomic Quantitative Study

Endoscopic visualization does not necessarily correspond to an adequate working space. The need for balancing invasiveness and adequacy of sellar tumor exposure has recently led to the description of multiple endoscopic endonasal transsphenoidal approaches. Comparative anatomic data on these variants are lacking. We sought to quantitatively compare endoscopic endonasal transsphenoidal approaches to the sella and parasellar region, using the concept of "surgical pyramid." Four endoscopic transsphenoidal approaches were performed in 10 injected specimens: 1) hemisphenoidotomy; 2) transrostral; 3) extended transrostral (with superior turbinectomy); and 4) extended transrostral with posterior ethmoidectomy. ApproachViewer software (part of GTx-Eyes II, University Health Network, Toronto, Canada) with a dedicated navigation system was used to quantify the surgical pyramid volume, as well as exposure of sellar and parasellar areas. Statistical analyses were performed with Friedman's tests and Nemenyi's procedure. Hemisphenoidotomy provided limited exposure of the sellar area and a small working volume. Atransrostral approach was necessary to expose the entire sella. Exposure of lateral parasellar areas required superior turbinectomy or posterior ethmoidectomy. The differences between each of the modules was statistically significant. The present study validates, from an anatomic point of view, a modular classification of endoscopic endonasal transsphenoidal approaches to the sellar region.

The "frontal peak" sign: A potential new indication of open approach in frontal sinus mucoceles with posterior table erosion. A retrospective chart review of thirty-seven patients.

To date, most frontal mucoceles are treated endoscopically, provided that there is no major neo-osteogenesis and that the frontal sinus floor is wide enough to provide an adequate working space: the presence of a sinus wall dehiscence is not considered as a contraindication to an endoscopic approach. We report on a series of 37 patients presenting with frontal sinus mucoceles with posterior table erosion. Thirty-three (89.2%) had minimal erosion and/or a limited protrusion of the mucocele within the anterior cranial fossa on CT-scan, and were successfully operated on through an endoscopic approach. Four patients (10.8%) displayed a distinct aspect of “frontal peak” on CT-scan, namely an acute angle between the edge of the bony erosion and the dura. The first 2 patients were operated on through an endoscopic approach and presented with a delayed cerebrospinal fluid leak requiring a duraplasty through an open approach: in both cases, a laceration of the dura against the sharp bony edge of the erosion was found intra-operatively. The 2 other patients were primarily operated on through an open approach to drill out this frontal peak and prevent any dural trauma. Based on this observation, we suggest that an open approach should be considered in cases of frontal mucoceles with erosion of the posterior table with the “frontal peak” sign. This article is protected by copyright. All rights reserved.

Utility of anteroposterior diameter ratio of tumor and abdomen for laparoscopic approach for radical nephrectomy in large renal masses.

Laparoscopic radical nephrectomy (LRN) is now increasingly done for tumors larger than 10 cm. Despite selection of favorable cases, LRN may not be successful due to lack of adequate working space with large tumors. We describe a new feature on Contrast Enhanced Computed Tomography (CECT) abdomen to predict feasibility of LRN for large renal masses between 10 and 15 cm. From January 2005 to December 2015, renal tumors between 10 and 15 cm were selected retrospectively for LRN. Patients with retroperitoneal lymphadenopathy, Inferior vena cava (IVC) thrombus and involvement of adjacent organs were excluded. Anteroposterior (AP) diameter ratio of renal tumor and abdomen (APROTA) was calculated by dividing the maximum AP diameter of tumor along with normal renal parenchyma, by the AP diameter of abdomen on CECT. The patients were stratified into two groups: Group A (successful LRN) and Group B (conversion to open surgery) and outcomes were compared. The reasons for conversion were also noted. Of 29 patients, 16 (55.2%) had successful LRN (Group A), while 13 (44.8%) had conversion to open surgery (group B). The median tumor size in Group A was 11.3 ± 1.8 cm and in Group B was 13.6 ± 1.26 cm. Eleven of 13 patients had conversion due to large tumor size causing failure to progress. Two conversions were due to bleeding and injury to the colon each. There was a significant difference in the APROTA in group A and B [0.43 ± 0.09 in group A and 0.64 ± 0.14 in group B (p = 0.0001)]. Patients with APROTA of more than 0.65 are unlikely to have successful outcome with LRN.