Intraoperative Considerations Research Articles

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

Scoping Review. To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

Challenges and pitfalls in the perioperative management of mediastinal mass syndrome: an up-to-date review.

The perioperative management of patients undergoing mediastinal mass operations presents a persistent challenge across multiple clinical specialties. General anesthesia administration further increases the risk of perioperative cardiorespiratory decompensation. The interdisciplinary team plays a crucial role in ensuring a safe perioperative period. However, due to the rarity and variability of mediastinal mass syndromes, specific management protocols are lacking. This review aims to outline the multitude of challenges and pitfalls encountered during perioperative management in patients with the mediastinal mass syndrome. We describe diagnostic evaluation, preoperative optimization, intraoperative considerations, and postoperative care strategies, emphasizing the paramount significance of a multidisciplinary approach and personalized treatment plans. Preoperative multidisciplinary discussions, meticulous anesthetic management, and well-established protocols for emergency situations are pivotal to ensuring patient safety. Healthcare providers involved in the care of patients with mediastinal mass syndrome must grasp these challenges and pitfalls, enabling them to deliver safe and effective perioperative management.

Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations

ObjectiveTo review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DesignStepwise demonstration of techniques with narrated video footage. SettingApproximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria.1 Hysterectomy with or without oophorectomy can be offered to patients who have met the World Professional Association for Transgender Health (WPATH) criteria.2 InterventionsImportant perioperative counseling points for transgender patients include: establishing terminology for relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children3,4 and discussing the use of hormone therapy post-oophorectomy to reduce the loss of bone density;5,6 and reviewing intraoperative and postoperative expectations.When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk for ovarian remnant syndrome and the need for additional surgery, such as due to persistent menstruation. The performance of a two-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications, which is preferable for patients whose pelvic organs cause gender dysphoria.7,8 ConclusionSpecial considerations outlined in this video and the WPATH guidelines should be reviewed by gynecologic surgeons to minimize transgender patients’ experiences of gender dysphoria before, during, and after surgery.

Preserved posterior cruciate ligament contributed to knee sagittal stability, but not to rollback and deep knee flexion in cruciate-retaining total knee arthroplasty with a cruciate-substituting insert

PurposeNo previous report has compared the differences in postoperative functional outcomes between posterior cruciate ligament (PCL)-retaining (CR-) and PCL-sacrificing (CS-) total knee arthroplasty (TKA) with detailed intraoperative consideration of joint gap and balance. The purpose of this study was to evaluate the in vivo function of preserved PCL in TKA by comparing postoperative functional outcomes between CR- and CS-TKA with a cruciate-substituting insert (CS-insert), considering intraoperative influence factors, such as the posterior tibial slope, posterior condylar offset, joint gap, joint balance, and joint laxity. MethodsA total of 55 knees in 38 patients (27 knees from 18 patients in the CR group, and 28 knees from 20 patients in the CS group) were analyzed. Fluoroscopic evaluation under anesthesia in sagittal laxity, rollback amount, and the maximum flexion angles were compared between the groups. ResultsThere were no significant differences in intraoperative or postoperative all measurement values between the two groups, but the sagittal laxity was significantly smaller in the CR group [5.4% ± 4.5% (2.4 ± 2.1 mm)] than in the CS group [9.0 ± 3.8% (4.0 ± 1.7 mm)] (P ​< 0.01). There were no significant differences in the amount of rollback and postoperative maximum knee flexion angle between the groups. ConclusionsPreserved PCL in TKA with a CS-insert contributed to knee sagittal stability, but not to rollback and deep knee flexion.

Guidelines in Practice: Prevention of Perioperative Pressure Injury.

Immobility and lack of sensation during perioperative procedures increase the risk of patients developing pressure injuries (PIs). Such injuries can cause pain and result in serious infections, thereby leading to increased health care costs. The recently developed AORN "Guideline for prevention of perioperative pressure injury" provides perioperative nurses and leaders with applicable recommendations for preventing these injuries. In addition to a brief overview of a health care facility's interdisciplinary perioperative PI prevention program, this article discusses a variety of concepts related to PI prevention, including prophylactic materials, intraoperative considerations, hand-over communication, pediatric patient concerns, policies and procedures, quality management, and education. It also provides a pediatric patient-specific scenario that illustrates the implementation of the described recommendations. Perioperative nurses and leaders should review the guideline in its entirety and apply the recommendations to prevent PIs as appropriate for their facility and patient population.

Increased bladder injury rate during emergency and repeat cesarean section

Bladder injury is one of the complications of cesarean section (CS). It is reported that the overall incidence of bladder injury is 0.22-0.44% of CS. It is, however, unclear what factors influence this rate. The aim of this study was to determine if there is a difference in bladder injury rate between scheduled and emergency CS, as well as in primary and repeat CS at a large metropolitan hospital that serves a population at high risk for obstetric complications. In addition, the use of urology consultation following bladder injury and whether demographic factors and labor characteristics affect the rate of bladder injury were investigated. A total of 8,488 records were reviewed (4,292 primary CS and 4,196 repeat CS) from January 1, 2013 to December 31, 2020. The incidence of bladder injury was calculated and the rate of intraoperative urology/urogynecology consultation was recorded. Then the association between bladder injury and intraoperative urology/urogynecology consultation and between bladder injury and maternal age, body mass index (BMI), and gestational age were compared. There was a significant increase in risk of bladder injury in repeat CS versus primary CS (p=0.01). There was also a significant increase in risk of bladder injury in emergency CS versus scheduled CS (p=0.04). Intraoperative urogynecology/urology consultations were significantly higher in the bladder injury versus no bladder injury groups (p<0.0001). Both emergency CS and repeat CS are predictors of bladder injury with odd ratios of 5.7 and 7.4, respectively. These results add to the existing evidence that bladder injury is a rare complication in CS that may occur more often in women undergoing repeat or emergency CS than primary or scheduled CS. Given that the risk increases with repeat or emergency CS, patients should be made aware of such risks and surgeons should make careful intraoperative considerations with close postoperative follow-ups.

Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success.

Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI. A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACTTM system. Patient selection criteria, success rates, and complications were compared between the studies. Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0-1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73-93% vs 70-90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up. Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.

Recommendation for Presbyopia-Correcting Intraocular Lenses: A Delphi Consensus Statement by the ESASO Study Group

To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs). A modified Delphi method to reach a consensus among experts. A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement. Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%). Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection.

Intraoperative Considerations and Management of Simultaneous Heart Kidney Transplantation

Patients with heart failure are prone to developing non-cardiovascular comorbidities throughout the course of their disease. In particular, renal impairment is widespread in this patient population. The number of heart-kidney transplants has increased significantly over the past 2 decades. Currently, there is no consensus on therapies for patients who may need dual-organ transplants. The optimal timing of dual-organ transplantation is still debated. The options for the timing of dual-organ transplants are simultaneous, staged, or delayed. In this manuscript, the authors review their institutional experience with the intraoperative management of simultaneous heart-kidney transplants (SHKT) and discuss their outcomes, including cardiac primary graft dysfunction (PGD) and renal delayed graft function (DGF). A total of 31 patients were included in the SHKT study group. Data analysis revealed that no patients required newly initiated mechanical circulatory support (MCS) post-operatively, and 11 of 31 patients were placed on renal replacement therapy within 7 days postoperatively. Patients who did have post-operative MCS were intra-aortic balloon pumps that were present before the transplant and then removed on postoperative day 1. No patient required additional MCS after the transplant. The increasing number of patients having heart and kidney transplants demonstrates a need for developing a perioperative management protocol. The results of our experience validate our intraoperative management. None of the patients developed moderate or severe cardiac PGD, and 35% had renal DGF. With further studies, the eventual development of guidelines for patient selection and management for SHKT also may be possible.

Management of cataract in dry eye disease: Preferred practice pattern guidelines.

Cataract surgery is one of the most commonly performed ophthalmic surgeries in the world. Dry eye disease (DED) is found to coexist in most patients with cataracts due to the overlapping age groups of both these conditions. Preoperative evaluation for DED is important to improve outcomes. A pre-existing DED affecting the tear film is likely to affect biometry. Moreover, special intraoperative considerations are needed in eyes with DED to reduce complications and improve postoperative outcomes. Dry eye disease (DED) is known to occur following an uneventful cataract surgery or a pre-existing DED is likely to worsen following cataract surgery as well. In these situations, despite a good visual outcome, patient dissatisfaction is common owing to the distressing DED symptoms. This review aims to summarize the preoperative, intraoperative, and postoperative considerations when performing cataract surgery in the presence of a coexisting DED.

Genital gender-affirming surgery for transgender women.

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.

A prospective randomized control trial comparing intracorporeal sutures and tackers for mesh fixation in laparoscopic ventral hernias repair: intraoperative considerations

A prospective randomized control trial comparing intracorporeal sutures and tackers for mesh fixation in laparoscopic ventral hernias repair: intraoperative considerations

UpToDate®

UpToDate| December 2022 UpToDate® ASA Monitor December 2022, Vol. 86, 35. https://doi.org/10.1097/01.ASM.0000904280.11202.ba Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation UpToDate®. ASA Monitor 2022; 86:35 doi: https://doi.org/10.1097/01.ASM.0000904280.11202.ba Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: antirheumatic drugs, disease-modifying, combination drug therapy, diabetic neuropathies, guidelines, heart failure, right-sided, pain, perioperative care, pulmonary hypertension UpToDate® and ASA Monitor are collaborating to present select content abstracts on “What's New in Anesthesiology.” UpToDate is an evidence-based, clinical support resource used worldwide by healthcare practitioners to make decisions at the point of care. For complete, current “What's New” content, or to become a subscriber for full content access, go to www.uptodate.com. “What's New” abstract information is free for all medical professionals. Pulmonary hypertension with right heart failure is a risk factor for perioperative morbidity and mortality. In a recently published consensus statement, the International Society for Heart and Lung Transplantation recommended a multidisciplinary approach to preoperative assessment to ensure that the indication and benefits of surgery are reasonable and that the patient's condition is optimal for surgery.1 Intraoperative considerations include use of invasive monitoring for higher-risk cases, use of slowly titrated epidural or spinal neuraxial anesthesia as appropriate, and induction of general anesthesia... You do not currently have access to this content.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline.

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

8979 Laparoscopic Lysis of Adhesions: Adhesiolysis, Enterolysis, and Salpingo-Ovariolysis in a Patient with Infertility

Study Objective To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Design Step-by-step video demonstration of the technique. Setting A university tertiary care hospital. Patients or Participants A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Interventions Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. Measurements and Main Results We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. Conclusion It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis. To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Step-by-step video demonstration of the technique. A university tertiary care hospital. A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Laser Assisted Appendectomy

<h3>Study Objective</h3> Appendiceal endometriosis is commonly encountered by gynecologists during laparoscopy for endometriosis or chronic pelvic pain. This video reviews appendiceal endometriosis, highlights important anatomical landmarks for appendectomy and demonstrates a novel technique for laparoscopic appendectomy using a CO2 Laser at the time of surgical management of endometriosis. <h3>Design</h3> This video uses still images, video footage and narration to review appendiceal endometriosis and laser-assisted appendectomy. The laser appendectomy approach is reviewed in four steps, addressing preoperative and intraoperative considerations. <h3>Setting</h3> Patient positioned in Trendelenburg position with left lateral tilt. <h3>Patients or Participants</h3> Patients undergoing gynecologic laser laparoscopic surgery for endometriosis or chronic pelvic pain. <h3>Interventions</h3> Laser assisted laparoscopic appendectomy. <h3>Measurements and Main Results</h3> When performing a laparoscopy for endometriosis or chronic pelvic pain assess the appendix for signs of endometriosis. The four key steps when planning a laser appendectomy are (1) patient preparation, (2) isolate the appendix, (3) secure blood supply, and (4) remove appendix. <h3>Conclusion</h3> Appendiceal endometriosis is common and pre-operative diagnosis is challenging. Appendectomy should be considered at the time of gynecologic surgery for endometriosis or chronic pelvic pain. This video can be used as a reference for gynecologists when performing appendectomy at the time of hysterectomy or laparoscopy for endometriosis or chronic pelvic pain.

8569 Approach to a Giant Pedunculated Fibroid

<h3>Study Objective</h3> This video reviews the surgical approach to a large pedunculated fibroid including preoperative assessment and intraoperative considerations for performing a laparoscopic myomectomy with contained tissue extraction. <h3>Design</h3> Surgical technique demonstration. <h3>Setting</h3> The patient was seen in an academic medical center. In the outpatient setting, she was consulted by a minimally invasive gynecologic surgeon with expertise in fibroid management. The surgery was performed in the outpatient surgery center. <h3>Patients or Participants</h3> A 37-year-old nulliparous female with a fibroid uterus. Based on preoperative imaging, the predominant fibroid was a posterior, pedunculated fibroid with an estimated weight of 1300 grams. The patient agreed to the use of photos and videos for educational purposes via an informed consent process. <h3>Interventions</h3> Preoperatively, the patient received leuprolide acetate injection in effort to decrease the size and vascularity of the large, broad-stalked, pedunculated fibroid. Eight weeks later she underwent laparoscopic myomectomy with a minilaparotomy for contained tissue extraction. Prior to the start of the surgery, she received misoprostol and tranexamic acid to aid in hemostasis. The video demonstrates the intraoperative use of vasopressin in addition to the surgical approach to the primary myomectomy. Use of the minilaparotomy for surgical assistance, open myomectomy of an additional fibroid, and contained morcellation is portrayed in the video. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This video reviews the surgical approach to a large, pedunculated fibroid via laparoscopic myomectomy with minilaparotomy. The surgery was without complication and the patient was discharged on the same day. Key learning points that lead to a successful case included: preoperative optimization when you expect to encounter high risk of blood loss, retention of a rim of serosa overlying a broad pedicle when performing myomectomy of an exophytic fibroid, and use of minilaparotomy to aid progression of case, not only for tissue extraction.

A review of venous reconstruction options for the mediastinum.

Major vessels of the mediastinum such as the superior vena cava (SVC) and bilateral innominate veins can occasionally become involved with aggressive tumors or the mediastinum, including non-small cell lung cancer and thymoma. This may result in partial or complete obstruction. With presentation of these tumors symptoms can often be debilitating and would otherwise be treated with palliative therapy. A select population of patients are candidates for tumor resection. The ability to perform an adequate resection will depend on the ability to create a durable reconstruction of the SVC and bilateral innominate veins. Pre-operative and intra-operative considerations will allow for a safe surgery with few complications to the patient. Furthermore, depending on the extent of resection, there are a variety of techniques for reconstruction. These can range from a primary repair of a partial venous wall resection to a complex replacement of both the SVC and one or both innominate veins. Multiple options exist for the use of these conduits, such as polytetrafluoroethylene, homograft, autologous vein, and bovine or porcine pericardium. Depending on the type of conduit used, the post-operative outcomes will differ. In order to perform this operation safely, proper knowledge and experience is required. We review a variety of strategies used to manage these rare but complex scenarios.