Inferior Edge Research Articles

Robotic extended distal pancreatectomy with splenectomy for pancreatic adenocarcinoma

Presenter: Sharona Ross MD | AdventHealth Tampa Background: This video describes our technique of an extended distal pancreatectomy for locally advanced post neoadjuvant chemoradiation. Methods: This video is of a 72-year-old woman who presented with epigastric pain and was found to have a pancreatic body mass. Preoperative workup included triple phase CT scan and EUS/FNA showing abutment < 180 degrees of SMV/SMA and encasement of the splenic artery and vein. Patient progressed after 6 months of neoadjuvant chemotherapy and 30 sessions of radiation therapy. Results: The operation began by taking down the gastrohepatic ligament followed by the gastrocolic omentum. The short gastric vessels were taken down and the stomach retracted. An intraoperative ultrasound was utilized to identify the location of the tumor mass and the pancreas was dissected along its inferior edge. The colonic mesentery area along the inferior edge of the pancreas and the common hepatic artery was excised and sent to pathology which returned negative for malignancy. The neck of the pancreas was dissected, and the pancreas was divided with a robotic hook cautery. The left side of the SMV and portal vein was dissected. All the tissue surrounding the celiac trunk, the splenic artery and common hepatic artery were dissected. Next, we arrived at the splenic artery and vein which was divided with two clips on either side. The specimen was removed off the SMV, SMA, portal vein and the celiac trunk. Lastly the pancreas was dissected, medial to lateral, and all the attachments to the spleen were taken down. Conclusion: Operative duration was 3.5 hours with 50 ml of estimated blood loss. Final pathology showed microscopic focus of viable ductal carcinoma of the pancreas in the pancreatic body, associated with extensive fibrosis with zero nodes positive for malignancy. Patient had an uneventful postoperative stay and was discharged on postoperative day 4. This video shows that the robotic approach is safe and efficacious for resection of locally advanced pancreatic carcinoma following neoadjuvant therapy.

The New Concept of making the Excellent Result in Mastopexy

Background: Breast ptosis is one of the more common issues seen in cosmetic surgeons’ offices, particularly those performing a significant amount of aesthetic breast surgery. Patients with ptosis generally desire the same result – youthful and “perky” breasts. However, due to wide variations in breast volume and tissue quality, ultimate results vary with each patient, and as a result, preoperative management of expectations is critical. There are many surgical options that can be customized to patients’ needs, but these generally address repositioning of the glandular tissue and nipple areolar complex and management of skin excess. Scar patterns include circumareolar, circumvertical (including J or L scar variations), and inverted-T patterns. If author’s new concept can eliminate the remaining skin excess that occur from approximately preoperative markings of traditional mastopexy and can decrease the scar pattern (J or L scar variations and inverted-T patterns), they are interesting to bring an alternative to reduce complications and more satisfactory results. Objective: Author study the new concept of surgical techniques of mastopexy in severe ptotic breasts. The new concept is the changing steps of procedure that performs repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex before, follow by design and excise the excess skin flaps. Surgical result, main complications and patient satisfaction are evaluated. Methods: The study has performed in 11 patients who have severe ptotic breasts with author’s techniques of mastopexy since July 2017 to march 2018. The techniques including repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex, skin flaps are designed and excised accurately. Postoperative care makes as standard protocols. Results: Of 11 patients who underwent mastopexy with author’s techniques, all patients have symmetric, only short vertical scar and beautifully shaped breasts and 2 patients have superficial necrosis of skin which at junction of inferior edge of areola and vertical incision, both sides and right side respectively. Three breasts which have superficial skin necrosis, manage include death tissue was removed, dress wet wound every day and make delay primary wound closure in some areas. Nipple sensation is usually normal. Some patients have decrease sensation and fully recover within three months. Conclusion: Author’s surgical techniques change steps of standard mastopexy, as new concept for severe ptotic breast. Repositioning and reshaping of glandular tissue and repositioning of nipple areolar complex firstly, these will help surgeon design and excise the excess skin flaps more accurately. But surgeons do not over excise skin flap to prevent skin necrosis especially junction area. Accordingly, author’s technique can decrease frequent complications of mastopexy including asymmetry, improper of flap excision and undesired J or L, inverted T scar.

APPLICATION OF ISCHEMIC COMPRESSION TECHNIQUE AND MYOFASCIAL RELEASE TECHNIQUE IN LUMBAL SPONDYLOSIS PATIENTS IN RATULANGI MAKASSAR MEDICAL CENTER

Lumbar spondylosis is a condition of lower back pain caused by disc degeneration and facet joint which is characterized by osteophyte growth in the vertebral body precisely at the inferior and superior corpus edges, causing problems of pain, spasm, and impaired lumbar flexibility. The purpose of this study was to determine the difference in effect between the Ichemic compression technique (ICT) and Myofascial Release Technique (MRT) on the improvement of Lumbar Flexibility in patients with lumbar spondylosis, which was carried out at the Physiotherapy Clinic of TK II Pelamonia Hospital Makassar. The number of research subjects obtained as many as 20 people who meet the research criteria Then randomized into 2 groups: the treatment group I with ICT as many as 10 people and the treatment group II as many as 10 people with MRT. The research results show that the administration of Ichemic Compression Technique can increase lumbar flexibility with a mean difference 1,250. Whereas MRT administration can increase lumbar flexibility with a mean difference of 1,950. Wilcoxon test results of the treatment group I on the flexibility component obtained p value = 0.004 (p &lt;0.05) while the treatment group II on the lumbar flexibility component obtained p value = 0.004 (p &lt;0.05) which means that the provision of ICT with MRT can produce significant effect on increasing lumbar flexibility in patients with lumbar spondylosis. Mann Whitney test results on the lumbar flexibility component for treatment groups I and II p value = 0.035 (p &lt;0.05). If seen from the mean values above, it can be concluded that the administration of Myofascial Release Technique (MRT) can result in a greater increase in lumbar flexibility compared to the Intermitten compression technique. Keywords: Ichemic compression technique., Lumbar flexibility, Myofascial Release Technique, Lumbar Spondylosis

Histologic Investigation of the Female Vesicourethral Junction and Adjacent Tissues for Nerve-sparing Radical Cystectomy

ObjectiveTo understand the structures around the vesicourethral junction and to improve functional outcomes after nerve-sparing radical cystectomy with orthotopic urinary diversion for female patients, we histologically elucidated the fibromuscular construction and nerve distribution around the vesicourethral junction. MethodsPelvic specimens containing all the pelvic viscera were obtained from 33 donated female cadavers. Macroslices that included the urethra, the anterior wall of the vagina, and the inferomedial edge of the levator ani muscle were made and performed elastica Masson and immunohistochemical staining. The intraoperative findings were collected in 3 female patients undergoing nerve-sparing radical cystectomy. ResultsIn 18 out of the 33 cadavers, smooth muscle mass occupied a space between the urethra and the inferomedial edge of the levator ani muscle and covered the inferior margin of the bladder detrusor. We termed this mass the hiatal smooth muscle. The detrusor nerves entered the bladder, and the cavernous and sphincter nerves ran between the hiatal smooth muscle and vesicourethral junction. The boundary between hiatal smooth muscle and urethral smooth muscle was easily distinguished intraoperatively during dissection of the vesicourethral junction. ConclusionWe found that more than half of elderly women have hiatal smooth muscle between the urethra and inferior edge of the levator ani. Autonomic nerve fibers innervating the urethral sphincter, run between the hiatal smooth muscle and vesicourethral junction in female cadavers with hiatal smooth muscle. When performing female radical cystectomy before neobladder reconstruction, nerve sparing can be reliably performed using the hiatal smooth muscle as a landmark.

Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome.

Cesarean scar defect often causes postmenstrual abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and infertility, which are collectively known as cesarean scar syndrome (CSS). Several studies have reported that hysteroscopic surgery can restore fertility in women with CSS. The study aimed to identify factors that influence subsequent pregnancy following hysteroscopic surgery. Therefore, we studied 38 women with secondary infertility due to CSS who underwent hysteroscopic surgery at Shiga University of Medical Hospital between July 2014 and July 2019. Our hysteroscopic procedure included inferior edge resection and superficial cauterization of the cesarean scar defect under laparoscopic guidance. Patients were followed up for 3 to 40 months after surgery. Surgery was successful in all cases and no complications were observed. Twenty-seven patients (71%) became pregnant (pregnant group), while 11 (29%) did not (non-pregnant group). Baseline characteristics of age, body mass index, gravidity, parity, previous cesarean section, presence of endometriosis, retroflex uterus, and preoperative residual myometrial thickness were not significantly different between the groups. However, the median residual myometrium thickness was significantly higher after surgery than before surgery in the pregnant group (1.9 [1.1-3.6] vs 4.9 [3.4-6.6] mm, P<0.0001), whereas this difference was not significant in the non-pregnant group. Of those who became pregnant, 85% conceived within 2 years of surgery. Although three pregnancies resulted in abortion and one is ongoing at the time of writing, 23 pregnancies resulted in healthy babies at 35-38 gestational weeks by scheduled cesarean sections with no obstetrical complications due to hysteroscopic surgery. The average birth weight was 3,076 g. Our findings support that hysteroscopic surgery is a safe and effective treatment for secondary infertility due to CSS. The thickness of the residual myometrium may be a key factor that influences subsequent pregnancy in women with CSS.

Using Cherenkov Imaging to Verify Anterior Field Match Lines between Supraclavicular and Tangent Whole Breast Irradiation Fields

In radiation therapy, stage 2A Breast Cancer or later (which include the treatment of the axillary nodes) involves use of two irradiation fields: the entirety of the breast (tangent fields) and the supraclavicular (SCLV) fields for the irradiation of the nodes. These fields meet at the isocenter, which is placed at the superior edge of the tangent field and at the inferior edge of the supraclavicular field, forming what is known as the field junction. Even small movements from patient breathing or slight inherent setup uncertainties can manifest as dose-related hot or cold spots at the field junction. Insufficient coverage (cold spots) at the field match can lead to recurrence, and over treating (hot spots) in treatment offer increased risk to healthy tissues if the region of high dose were to migrate out of the PTV. A controlled field match study was conducted using identical square fields on a white ABS board, and changes in match area were quantified with respect to increased separation/overlap between fields. An anthropomorphic phantom was irradiated using a plan adapted from a patient treated in the clinic, and the techniques developed were then applied to a patient. This patient was imaged using a time-gated intensified CMOS camera (C-Dose Research, DoseOptics LLC, Lebanon, NH) in this IRB-approved, non-clinical trial passive imaging study. All fields were deconvolved using the PSF, fit from the ESF. By applying a threshold to multiplied Cherenkov images, the region of field match can be isolated automatically, using an automated bounding feature extraction in a computer algorithm. The integral from the extracted profiles from these regions were compared over 10 mm of separation to 10 mm of overlap in each of two phantom cases (ABS phantom R2 = 0.99, Anthropomorphic phantom R2 = 0.86). Profiles from patient imaging sessions were then evaluated similarly and evaluated for consistency. This developing technique employs automated match finding, and was shown to be very sensitive to change and could prove instrumental in assessing separation/overlap in the region of field match.

Intrafraction cone beam computed tomography verification of breath hold during liver stereotactic radiation therapy.

IntroductionIntrafraction imaging is an Elekta feature that enables cone beam computed tomography (CBCT) acquisition simultaneously with treatment arc delivery. It has facilitated the introduction of breath‐hold (BH) gated stereotactic body radiation therapy (SBRT) by enabling visualisation of tumour and organs at risk during treatment. The aims of this study were to assess BH reproducibility and use intrafraction CBCT (IF‐CBCT) to quantify any variation in diaphragm position (diaphragmatic feathering) during the multiple BHs performed during each arc.MethodsIF‐CBCTs for consecutive liver SBRT patients where BH was achieved using the Elekta Active Breathing Control (ABC) system were retrospectively evaluated. Average intrafraction couch shifts for deep‐inspiration BH (DIBH) or end‐expiration BH (EEBH) were recorded as an indication of reproducibility. Diaphragmatic feathering was quantified by measuring the difference between the most superior and inferior visible edges of the diaphragm on IF‐CBCTs.ResultsA total of 212 images from 30 patients were reviewed. Twenty‐two (73.3%) patients were treated in EEBH. The mean intrafraction shift was similar between DIBH and EEBH groups with the largest mean shift of 0.22cm occurring in the superior–inferior direction. Mean diaphragmatic feathering was similar between the DIBH and EEBH groups, 0.09cm (0‐0.44cm) and 0.14cm (0–1.89cm) respectively. A higher percentage of EEBH patients demonstrated no diaphragmatic feathering throughout treatment compared with DIBH patients (31.8% vs 25%).ConclusionThe results of this study indicate that BH is reproducible in both DIBH and EEBH for liver SBRT treatment using the ABC system. Appropriate patient selection and BH coaching prior to CT simulation are critical to its success.

Single-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic Instruments.

Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed "double-flap" esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel laparoscopic instruments. Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra-abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110minutes each, and anastomosis took 75 and 46minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.

Demonstration of Isthmocele Surgical Repair

To describe the surgical treatment of a uterine isthmocele. Demonstration of the laparoscopic technique with narrated video footage. Cesarean section rate has been increasing despite the World Health Organization's recommendation of a maximum 15%, with some countries reaching rates as high as 50%. The choice of delivery method is a complex topic based on physical and psychologic health, social and cultural context, and quality of maternity care. With the increasing number of cesarean sections, a new entity was recognized, the isthmocele [1]. A uterine isthmocele is a dilatation of the uterine cesarean scar and functions as a reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2]. The most frequent complaint relates to intermittent postmenstrual bleeding (30%). Isthmocele can be a cause of infertility and pelvic pain [3]. Interstitial pregnancy is a known complication with a mortality rate up to 2.5%. The diagnosis can be made by transvaginal ultrasound and/or magnetic resonance imaging but also by hysteroscopy or hysterosalpingography. Treatment can be done by controlling the symptoms with oral combined contraceptive (decreasing metrorrhagia) or with surgical correction improving symptoms and/or fertility [4-7]. Isthmocele correction seems to improve secondary infertility in patients in whom a fertility workup did not find other cause [8,9]. Surgical approach can be done by vaginal route with hysteroscopy; abdominal route with laparoscopy, robotic or laparotomy; or through a combine procedure with both routes. Hysterectomy is the definitive treatment, but for those who want to preserve fertility, isthmocele correction can be offered. For laparoscopic surgery, several ways have been described to detect the isthmocele such as Foley catheter, hysteroscopy, methylene blue, and Hegar probe. When we do laparoscopy, we prefer concomitant use of hysteroscopy. There is a trending opinion that patients with a smaller isthmocele could be treated hysteroscopically (2.5 mm according to Jeremy etal [10] and 3.0 mm described by Marotta etal [11]). The goal of hysteroscopy correction is to remove the inflammatory infiltration in the endocervix, cutting the superior and inferior edges of the defect enabling normal blood evacuation of the uterus. By contrast, those with a larger isthmocele (with <2.5-3.0-mm residual myometrium) and a risk of perforation during hysteroscopy could be better treated by laparoscopy. This is especially important in patients interested in pregnancy because of the risk of uterine perforation [12]. There is still no strong evidence that hysteroscopic correction leads to an increased number of uterine ruptures compared with laparoscopy, but myometrium thickness seems to be greater after laparoscopic correction. Myometrium thickness is an independent risk factor for uterine rupture [13], and therefore, laparoscopic correction is preferred over hysteroscopic in women with a pregnancy desire. Finally, after surgical correction of an isthmocele, we recommend a 6-month interval before attempting pregnancy. Laparoscopic treatment is important in women who are symptomatic, have thin endometrium, and desire a pregnancy. Key strategies are (1) dissection of the vesicouterine pouch laterally to avoid entering the bladder wall; (2) transillumination with hysteroscopy; (3) cut with cold scissors avoiding thermal damage of remaining myometrium; and (4) suture with figure 8 in multiple layers. No evidence of using a specific suture is available. Surgical treatment of a uterine isthmocele is a good option in women who are symptomatic and infertile. Laparoscopic treatment guided by hysteroscopy is a good option if residual myometrium is <3 mm.

A New Orthotic Device for Maintaining Neck Flexion Following Tracheal and Cricotracheal Resection.

View Video S1 Laryngoscope, 131:1805–1809, 2021

Inferior Meatus Mucosal Flap for Septal Reconstruction and Resurfacing After Nasoseptal Flap Harvest.

View Video S1

Anatomy of Rouviere's Sulcus and Its Association with Complication of Laparoscopic Cholecystectomy.

Methods This is a prospective observational study involving patients of age ≥16 years who underwent laparoscopic cholecystectomy for uncomplicated gall stone at BPKIHS between May and July 2019. Result 230 cases were analyzed, and RS was present in 90.4%. Open sulcus type was the commonest (54%), followed by scar type (22.9%), closed sulcus type (12.5%), and slit type (10.6%), respectively. In 59.1% of cases, it was oblique to the anterior, inferior, and external edge of the liver, while in the remaining cases, it was transverse. The mean ± SD values for operative time and duration of hospital stay in the RS visible and the RS not visible groups were 29.16 ± 8.736 and 42.9 ± 23.646 minutes, and 1.26 ± 0.440 and 1.90 ± 0.910 days, respectively (p value ≤0.001). One minor complication occurred in each group: RS initially visible group and RS visible on the adhesion release group, while 3 minor complications occurred in the RS not visible group. Only one major complication occurred in the RS not visible group. Conclusion Identification of RS by operating surgeons is a predictor of safe laparoscopic cholecystectomy.

Defining the proximity of the axillary nerve from defined anatomic landmarks: an in vivo magnetic resonance imaging study

The location of the axillary nerve in the shoulder makes it vulnerable to traumatic or iatrogenic injury. Cadaveric studies have reported the location of the axillary nerve but are limited because of tissue compression, dehydration, and decay. Three-Tesla (T) magnetic resonance imaging (MRI) allows high anatomic resolution of neural structures. The aim of our study was to better define the location of the axillary nerve from defined bony surgical landmarks invivo, using MRI scan. Using MRI, we defined a number of anatomic points and measured the distance from these to the perineural fat surrounding the axillary nerve using simultaneous tracker lines on both images. Two observers were used. A total of 187 consecutive 3-T MRI shoulder scans were included. Mean age was 57.9 years (range 18-86). The axillary nerve was located at a mean of 14.1 mm inferior from the bony glenoid at the anterior border, 11.9 mm from the midpoint, and 12.0 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P < .001), and between the anterior and posterior borders (P < .001). The axillary nerve was located at a mean of 12.6 mm medial to the humeral shaft at the anterior border, 9.9 mm at the midpoint, and 8.6 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P = .008) and between the anterior and posterior borders (P = .002). The mean distance of the axillary nerve from the anterolateral edge of the acromion was 53.3 mm (95% confidence interval [CI] 52.3, 54.2; range 33.9-76.3). The mean distance of the axillary nerve from the inferior edge of the capsule was 2.7 mm (95% CI 2.9, 3.1; range 0.3-9.9). There was a positive correlation between humeral head diameter and axillary nerve distance from the inferior glenoid (R2 = 0.061, P < .001). There was a positive correlation between humeral head diameter and distance from the anterolateral edge of the acromion (R2 = 0.140, P < .001). Our study has defined the proximity of the axillary nerve from defined anatomic landmarks. The proximity of the axillary nerve to the inferior glenoid and medial humeral shaft changes as the axillary nerve passes from anterior to posterior. The distance of the axillary nerve from the anterolateral edge of the acromion remains relatively constant. Both sets of distances may be affected by humeral head size. The study has relevance to the shoulder surgeon when considering "safe zones" during arthroscopic or open surgery.

Septorhinoplasty by disarticulation

Septorhinoplasty by disarticulation is an esthetic and functional solution for naturally occuring nasal pyramid dysmorphia, releasing the anatomic traces of growth-related stresses. Disarticulating the septolateral cartilage from its bony framework via a closed approach to the septal pocket is associated to Rethi's external approach in order to disarticulate the fibrocartilaginous nasal dorsum, while conserving its integrity, under the bony dorsum. The bony pyramid is then disarticulated down to the nasion, after resecting any bone hump, by 2 paramedian and 2 low lateral osteotomies in the basal groove. The lateral sides of the bony pyramid are then fractured at their posterior edges by percutaneous pinching to close the open roof and realign them along the midline. The septolateral cartilage, reduced as necessary at the inferior and anterior edges, is thereafter repositioned on the premaxillary bone. Traction on its anterior edge restores rectilinear frontal and lateral tension in the fibrocartilaginous dorsum, fully conserved from its attachment to the nasion. This technique corrects any septal deformity and restores frontal and lateral dorsum straightness.

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0mm (0-10.4mm). The mean distance between both observers was 4.2 ± 3.2mm (0-10.3mm). The mean distance to the sural nerve was 1.4 ± 2mm (0-5.8mm). The mean distance to the peroneal tendons was 7.3 ± 3.1mm (1.2-12.4mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

Ultrasound and Magnetic Resonance Imaging of Agenesis of the Corpus Callosum in Fetuses

We hypothesized that: (1) fetal frontal horn (FH) morphology and their proximity to the cavum septi pellucidi (CSP) can assist in suspecting complete agenesis of the corpus callosum (cACC) and partial agenesis of the corpus callosum (pACC) earlier than known indirect ultrasound (US) findings; (2) FHs assist in differentiating a true CSP from a pseudocavum; and (3) magnetic resonance imaging (MRI) is useful in learning FH morphology and pseudocavum etiology. Thirty-two patients with cACC and 9 with pACC were identified on an Institutional Review Board-approved retrospective review. Of the 41 cases, 40 had prenatal US, and 21 had prenatal MRI; 17 had follow-up neonatal US, and 14 had follow-up neonatal MRI. Variables evaluated retrospectively were the presence of a CSP or a pseudocavum, ventricle size and shape, and FH shape (comma, trident, parallel, golf club, enlarged, or fused). Displacement between the inferior edge of the FH and the midline or cavum/pseudocavum was measured. Fetal FHs had an abnormal shape in 77% ≤20 weeks' gestation, 86% ≤24 weeks, and 90% >24 weeks. Frontal horns were laterally displaced greater than 2 mm in 85% ≤20 weeks, 91% ≤24 weeks, and 95% >24 weeks. The CSP was absent in 100% of cACC cases and 78% of pACC cases, and a pseudocavum was present in 88% of cACC cases and 78% of pACC cases across gestation. Magnetic resonance imaging confirmed US pseudocavums to be focal interhemispheric fluid or an elevated/dilated third ventricle. Frontal horns assist in assessing ACC ≤24 weeks and throughout gestation. Pseudocavums, often simulating CSPs, are common in ACC. Frontal horn lateral displacement and abnormal morphology, recognized by MRI correlations, are helpful in differentiating a pseudocavum from a true CSP. A normal CSP should not be cleared on screening US unless normally shaped FHs are seen directly adjacent to it.

Practical Guide for Identification of Internal Carotid Artery During Endoscopic Nasopharyngectomy.

View Supplementary Video 1 Laryngoscope, 2020

Mandibular slope: a reproducible and simple measure of horizontal gaze.

This study is a single-center retrospective radiographic review. The objective of this study is to evaluate a novel measurement parameter, mandibular slope (MS), as a measure of horizontal gaze. Assessment of sagittal spinal alignment is essential in the evaluation of spinal deformity patients. Ability to achieve a horizontal gaze, a parameter of sagittal alignment, is needed for the performance of daily activities. Standard measures of horizontal gaze, including the gold-standard chin-brow to vertical angle (CBVA) and the surrogate measures McGregor's line (McGS) and Chamberlain's line (CS), require high-quality imaging, precise head positioning, and reliance on difficult to view visual landmarks. A novel measurement parameter, MS, utilizing the caudal margin of the mandible on standard lateral spine radiographs is proposed. 90 radiographs from spine deformity patients with or without spinal implants from a single center were evaluated. Three spine surgery fellows independently measured CBVA, McGS, CS, and MS at two timepoints at least one week apart to assess accuracy and reliability. MS was measured as the angle created by the inferior edge of the mandibular body and the horizontal. Formulas for calculating CBVA based on the above parameters were derived and compared to the actual CBVA. Mean age was 49.7years, 76 females and 14 males. CBVA correlated with CS, McGS, and MS, r = 0.85, 0.81, and 0.80, respectively (p < 0.001). Standard error between real CBVA and calculated CBVA using CS (0.4 ± 4.79) and McGS (0.4 ± 3.9) was higher than that calculated using MS (-0.2 ± 4.3). ICC demonstrated the highest inter-observer reliability with MS (0.999). MS had the highest intra-observer reliabilities 0.975, 0.981, and 0.988 (p < 0.001); CS and McGS also demonstrated high intra-observer reliability. MS is a promising measure of horizontal gaze that correlates highly with CBVA, has excellent intra- and inter-observer reliability with CBVA, and is easily measured using standard lateral spine radiographs.

Polyadenopathy - A Multidisciplinary Approach

Abstract Introduction. Sarcoidosis is a multisystemic disease, that can basically affect any organ of the body, the lungs and the intrathoracic lymph nodes being the most affected. Despite the attempts to understand the exact pathogenic mechanism of the disease, this continues to remain uncertain. Histopathologically, the trademark of sarcoidosis is the presence of nonnecrotizing granuloma. Case presentation. We report the case of a 33-year-old man without significant past medical history, who is admitted to our clinic for bilateral supraclavicular and axillary adenopathies, progressive asthenia for the last three months and pain in the latero-thoracic region. The patient denies weight loss, odynophagia and fever. Clinically, the patient is afebrile and has supraclavicular, bilateral laterocervical and axillary adenopathies which are painless, elastic and mobile with a maximum diameter of 1.5 cm. The prehepatic diameter is 16 cm, with rounded inferior edge and the spleen in not palpable. The laboratory tests reveal moderate inflammatory syndrome, with C-reactive protein (CRP) of 1.4mg/dL (N&lt;0.5mg/dL) and the erythrocyte sedimentation rate (ESR) 65mm/h (N&lt;40mm/h). There is no lymphocytosis or neutrophilia. The ENT (Ear Nose Throat) consultation found no evidence of angina and, combined with the paraclinical investigations, excluded mononucleosis. Thus, the presumptive diagnosis was difficult because of the non-specific symptomatology and included the following: lymphoma, mononucleosis, sarcoidosis, tuberculosis and systemic vasculitis. The chest X-ray reveals enlarged pulmonary hilums, diffuse outlined-adenopathic/tumoral aspect, diffuse changes in the pulmonary interstitium and micronodular opacities of medium intensity, being diffusely outlined with the tendency of basal merging on the left side and slight asymmetrical enlargement of the superior mediastinum on the right side, para trachealadenopathic aspect. The lymph node biopsy reveals the aspect of non-necrotizing granuloma, which suggests the diagnosis of sarcoidosis. We used the dosage of angiotensin convertase, which reveals high values of 108.20U/L (N 13.3-63.9 U/L). Therefore, a pulmonary clinical evaluation was recommended. Conclusion. Case of 33-year-old man with sarcoidosis. The diagnosis was difficult, considering the non-specific symptomatology and the numerous pathologies that can be included in the differential diagnosis.

V09-09 THE RICHARD GRADY MONSPLASTY

INTRODUCTION AND OBJECTIVE: Classic bladder exstrophy in the female results in an exstrophic bladder and urethra, an anterior introitus with a bifid clitoris, and short labia minora. During closure, the lower abdominal wall is closed and the bifid clitori are brought into close apposition, but are often not completely closed to prevent injury to the clitoral bodies. The lower abdominal wall is often under tension, leading to gradual spreading of the distance between the clitoral bodies. We demonstrate a vertical z plasty closure to provide a 2-layer closure of the mons that decreases tension and improves cosmetic appearance of the female external genitalia by creating a clitoral hood. METHODS: This technique was developed as part of an international collaboration focused on the repair of bladder exstrophy and epispadias. After closure of the lower abdominal fascia, 2 lateral incisions are made just superior to the clitoral bodies. The inferior edges of these incisions are re-approximated in the midline in a subcuticular fashion with absorbable monofilament suture, thus forming the deep, posterior ledge of the skin closure. Next, the superior cut edges are re-approximated in a similar fashion, creating the superior/outer ledge of the mons. This closure is then extended and joined with the abdominal skin closure. RESULTS: This technique has been used as an adjunct in newborn primary closures and in older patients who present for cosmetic revision. The extension of the mons to create a clitoral hood eliminates the appearance of a protruding bifid clitoris. There have been no wound infections, skin breakdowns, or early clitoral separations. CONCLUSIONS: The vertical Z-plasty closure of the mons creates a more normal appearance of the external genitalia of girls with bladder exstrophy and epispadias by developing a clitoral hood, while also providing a robust, multi-layer closure that decreases tension and the risk of wound dehiscence. Source of Funding: None