Posterior Dissection Research Articles

Spontaneous Isolated Posterior Inferior Cerebellar Artery Dissection: Rare but Underdiagnosed Cause of Ischemic Stroke

Spontaneous isolated posterior inferior cerebellar artery dissection (PICAD) is a very rare cause of ischemic stroke. Clinical and radiologic features of ischemic type of isolated spontaneous PICAD are not well established. We consecutively enrolled patients who had spontaneous isolated PICAD confirmed by digital subtraction cerebral angiography. Clinical manifestation, magnetic resonance imaging (MRI), and angiography were analyzed. Seven patients were diagnosed as ischemic type of spontaneous isolated PICAD. Patients experienced an occipital headache, followed by vertigo, postural imbalance, or Wallenberg syndrome. Six showed medullar, unilateral, or bilateral cerebellar infarctions on diffusion-weighted imaging (DWI). One presented with transient cerebellar ischemia and negative on DWI. T1-weighted imaging showed high signal intensity in posterior inferior cerebellar artery in only 1 patient. Susceptibility-weighted imaging (SWI) revealed hypointense signal with blooming effect in posterior inferior cerebellar artery in 5 patients. The modified Rankin Scale score at 3months was 0 or 1 in all patients. Clinical manifestations in ischemic type of spontaneous isolated PICAD were similar to those of intracranial vertebral artery dissection. Clinical course was relatively stable and benign. SWI was more helpful to suspect abnormality of posterior inferior cerebellar artery than conventional MRI or magnetic resonance angiography in our small series. Cerebral angiography is recommended in patients with clinically suspected spontaneous isolated PICAD for definite diagnosis.

Surgical management of presacral bleeding.

Presacral venous bleeding is an uncommon but potentially life threatening complication of rectal surgery. During the posterior rectal dissection, it is recommended to proceed into the plane between the fascia propria of the rectum and the presacral fascia. Incorrect mobilisation of the rectum outside the Waldeyer's fascia can tear out the lower presacral venous plexus or the sacral basivertebral veins, causing what may prove to be uncontrollable bleeding. A systematic search of the MEDLINE(®) and Embase™ databases was performed to obtain primary data published in the period between 1 January 1960 and 31 July 2013. Each article describing variables such as incidence of presacral venous bleeding, surgical approach, number of cases treated and success rate was included in the analysis. A number of creative solutions have been described that attempt to provide good tamponade of the presacral haemorrhage, eliminating the need for second operation. However, few cases are reported in the literature. As conventional haemostatic measures often fail to control this type of haemorrhage, several alternative methods to control bleeding definitively have been described. We propose a practical comprehensive classification of the available techniques for the management of presacral bleeding.

Variations in the transverse cervical artery (543.6)

The transverse cervical artery is typically seen in both the superficial back and posterior cervical triangle dissections in a human cadaver gross anatomy course. The two most commonly used references, the atlases of Grant and Netter, cite it as being a branch of the thyrocervical trunk. Also, these sources name the dorsal scapular artery as either a branch of the transverse cervical artery or a direct branch of the subclavian artery. Additionally, the suprascapular artery is typically seen as a branch of the thyrocervical trunk, but in some cases may be a branch of the transverse cervical artery. Ten cadavers were examined for source and length of the transverse cervical artery from source to the branching off of the dorsal scapular artery, and for other arteries that branched from it. In two cadavers it was a direct branch of the subclavian artery, and the suprascapular artery was a direct branch of the transverse cervical artery in two other cadavers. In this group of dissections, the transverse cervical artery was most often a branch of the thyrocervical trunk, with an average length of 5.875 cm from source to the branching off of the dorsal scapular artery.

MP37-17 INTRAOPERATIVE REGISTERED TRANSRECTAL ULTRASOUND GUIDANCE FOR ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: A 20 PATIENT STUDY

You have accessJournal of UrologyTechnology & Instruments: Robotics - Benign & Malignant Disease1 Apr 2014MP37-17 INTRAOPERATIVE REGISTERED TRANSRECTAL ULTRASOUND GUIDANCE FOR ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: A 20 PATIENT STUDY Omid Mohareri, Joseph Ischia, Peter Black, Larry Goldenberg, Julio Lobo, Caitlin Schneider, and Septimiu Salcudean Omid MohareriOmid Mohareri More articles by this author , Joseph IschiaJoseph Ischia More articles by this author , Peter BlackPeter Black More articles by this author , Larry GoldenbergLarry Goldenberg More articles by this author , Julio LoboJulio Lobo More articles by this author , Caitlin SchneiderCaitlin Schneider More articles by this author , and Septimiu SalcudeanSeptimiu Salcudean More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1254AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES This work demonstrates, for the first time, the clinical application of a robotic transrectal ultrasound (TRUS) system calibrated to the da Vinci surgical system, for real-time monitoring of the prostate and periprostatic anatomy from the surgeon’s console during robot-assisted laparoscopic radical prostatectomy (RALRP). METHODS Twenty patients (60.27±4.6 years of age; 33.16±11.78 cc prostate volume) with organ-confined prostate cancer undergoing RALRP at our institution agreed to participate in this CREB-approved (clinical research ethics board) study. Before docking the da Vinci system, our robotic TRUS system was attached to the foot of the operating table and a TRUS transducer was placed and adjusted to provide optimal transverse and sagittal images of the prostate and its surrounding structures. Furthermore, once the anterior surface of the prostate was visible to the surgeon, a registration technique was performed between the TRUS transducer and the da Vinci instrument, to enable the TRUS imaging plane to automatically track the tip of the da Vinci instrument. The mean duration of calibration procedure was 137.1 ± 29.59 sec. After the registration, movements of the instrument tip was constantly visible in the ultrasound image, showing the location of the tools relative to the target anatomy. RESULTS During each procedure, the TRUS robot was used to remotely control the rotation angle and insertion depth of the TRUS transducer and real-time TRUS images were relayed to the surgeon at the console using the TilePro feature of the da Vinci. No major complications occurred and the TRUS remained in place until the end of procedures. The TRUS imaging was found useful in the following stages: identifying urethra while passing the dorsal venous complex suture, defining the prostate-bladder interface during posterior and anterior bladder neck dissection, identifying the lateral edges of the seminal vesicles and their location with respect to the rectal wall, and identifying the prostate boundary at the apex. Automatic tool tracking was activated during all critical stages of the surgery to facilitate real-time TRUS navigation using the same instruments being used during the procedure. CONCLUSIONS We conclude that real-time TRUS imaging can be deployed and used easily during surgery, can be registered to the da Vinci surgical system instruments with high accuracy in a short time for remote control from the surgeon console, and it can provide the console surgeon with valuable anatomic information, aiming to improve procedure outcomes. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e398-e399 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Omid Mohareri More articles by this author Joseph Ischia More articles by this author Peter Black More articles by this author Larry Goldenberg More articles by this author Julio Lobo More articles by this author Caitlin Schneider More articles by this author Septimiu Salcudean More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Standardized Laparoscopic Sphincter-preserving Total Mesorectal Excision for Rectal Cancer

This study was designed to evaluate the impact of a standardized laparoscopic total mesorectal excision (TME) on the long-term oncologic outcome of unselected patients with rectal cancer (RC). Unselected consecutive patients with histologically proven RC underwent a standardized laparoscopic TME with medial to lateral approach encompassing 9 sequential steps: (1) ligation of inferior mesenteric vessels, (2) mobilization of the left colon and sigmoid colon (medial to lateral), (3) posterior dissection of the rectum, (4) lateral mobilization of the sigmoid, left colon, and splenic flexure, (5) left and right side dissection of the rectum, (6) anterior dissection of the rectum, (7) transection of the rectum, (8) delivery of the specimen, and (9) colorectal anastomosis. From 2005 to June 2012, laparoscopic sphincter-preserving TME was attempted in 217 patients with a 6.5% conversion rate. There were 91 women and 126 men, aged 58.3 years (range, 22 to 84 y), with body mass index of 26.10 (range, 20 to 45), operative time was 150.4 minutes (range, 60 to 330 min), and 24.7 (range, 4 to 98) lymph nodes were harvested. Length of stay was 7.56 days (range, 3 to 32 d). Complication rate was 17.05%. The mean follow-up time of all patients was 36.12 months (range, 1 to 89 mo). Local recurrence rate was 3.6% and distant recurrence rate was 8.7%. The 5-year disease-free survival rates were 81.5%. A standardized laparoscopic sphincter-preserving TME resulted in a favorable short-term outcome in unselected patients with RC.

V10-11 ROBOTIC CYSTECTOMY WITH ANTERIOR PELVIC EXENTERATION: A SIMPLIFIED STEP-BY-STEP APPROACH

You have accessJournal of UrologyBladder Oncology/Robotics1 Apr 2014V10-11 ROBOTIC CYSTECTOMY WITH ANTERIOR PELVIC EXENTERATION: A SIMPLIFIED STEP-BY-STEP APPROACH Idir Ouzaid, Jayram Krishnan, Vishnu Ganeshan, Riccardo Autorino, Nima Almassi, Iryna Makovey, Robert Stein, Jihad Kaouk, and Georges-Pascal Haber Idir OuzaidIdir Ouzaid More articles by this author , Jayram KrishnanJayram Krishnan More articles by this author , Vishnu GaneshanVishnu Ganeshan More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Nima AlmassiNima Almassi More articles by this author , Iryna MakoveyIryna Makovey More articles by this author , Robert SteinRobert Stein More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , and Georges-Pascal HaberGeorges-Pascal Haber More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2460AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic cystectomy with anterior pelvic exenteration (RCAPE) is feasible and is a minimally invasive approach for managing bladder cancer in females requiring cystectomy. We describe a simplified, standardized technique that removes many technical limitations while adhering to all oncologic principles. METHODS Ports are placed in the standard cystectomy fashion as previously described in the “W” configuration with a 12 mm assistant port on the right side of the patient. The patient is placed in the steep Trendelenberg position and the robot is docked. The ureters are dissected followed by posterior dissection with assistance of a malleable retractor in the vagina. Lateral dissection is performed to develop the pedicles and vaginal walls which are then secured using the Caiman© Tissue Sealing Device (Aesculap, Center Valley PA). Finally, the dorsal venous complex and urethra are divided. We routinely perform intracorporeal ileal conduit urinary diversion according to our described technique. RESULTS Between August 2011 and October 2013 we have performed 25 RCAPE using this standardized technique. Operative time including pelvic exenteration, vaginal closure, bilateral extended pelvic node dissection and intracorporeal ileal conduit urinary diversion was an average of 355 minutes and estimated blood loss was an average of 347 mL. One patient required a blood transfusion and length of hospital stay was an average of 6 days. Finally, complications were assessed according to the Memorial-Sloan Kettering Grading System and 3 patients had minor (grades 1-2) complications and 2 patients experienced major (grades 3-5) complications. CONCLUSIONS Robotic cystectomy with anterior pelvic exenteration can be performed using our simplified technique safely with minimal difficulty. Our technique is reproducible with excellent oncologic outcomes and allows for rapid progression to intracorporeal urinary diversion if desired. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e909-e910 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Idir Ouzaid More articles by this author Jayram Krishnan More articles by this author Vishnu Ganeshan More articles by this author Riccardo Autorino More articles by this author Nima Almassi More articles by this author Iryna Makovey More articles by this author Robert Stein More articles by this author Jihad Kaouk More articles by this author Georges-Pascal Haber More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V6-08 NEUROVASCULAR BUNDLE PRESERVATION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY: A VARIATION OF THE ANTEROGRADE TECHNIQUE.

You have accessJournal of UrologyNovel Imaging/Prostate Oncology/Robotics1 Apr 2014V6-08 NEUROVASCULAR BUNDLE PRESERVATION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY: A VARIATION OF THE ANTEROGRADE TECHNIQUE. Alfredo Velasco, Ruben Olivares, Cristobal Roman, Lucas Spencer, Camilo Leon, Ivan Pinto, Felipe Balbontin, Manuel Diaz, Cristian Wohler, Jose Miguel Cabello, Pablo Marchetti, Renato Cabello, Sergio Moreno, Gonzalo Azocar, Javier Aviles, and Alvaro Kompatzki Alfredo VelascoAlfredo Velasco More articles by this author , Ruben OlivaresRuben Olivares More articles by this author , Cristobal RomanCristobal Roman More articles by this author , Lucas SpencerLucas Spencer More articles by this author , Camilo LeonCamilo Leon More articles by this author , Ivan PintoIvan Pinto More articles by this author , Felipe BalbontinFelipe Balbontin More articles by this author , Manuel DiazManuel Diaz More articles by this author , Cristian WohlerCristian Wohler More articles by this author , Jose Miguel CabelloJose Miguel Cabello More articles by this author , Pablo MarchettiPablo Marchetti More articles by this author , Renato CabelloRenato Cabello More articles by this author , Sergio MorenoSergio Moreno More articles by this author , Gonzalo AzocarGonzalo Azocar More articles by this author , Javier AvilesJavier Aviles More articles by this author , and Alvaro KompatzkiAlvaro Kompatzki More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1871AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Robot-Assisted Radical Prostatectomy (RARP) has commonly dissected the neurovascular bundle by anterograde approach, either inside the fascia or outside. In the Open Radical Prostatectomy (ORP), the nerve-sparring technique commonly uses the retrograde dissection. In the RARP the retrograde approach is no used, because of the risk of rectum injury, due to scope limitations in the angle of view. In the RARP the Seminal Vesicle (SV) dissection is also by anterograde approach, same as in the ORP. However when SV dissection is performed by posterior approach and it is dissected until the apex is reached, it is possible to perform a retrograde preservation with 30-grades scope view, without risk of rectum injury. This technique has never been described. METHODS A single Robot-assisted Radical Prostatectomy with the technique description, and neurovascular preservation is presented, using the Da Vinci SI Surgical System. Technique for posterior approach of the SV and retrograde dissection of the neurovascular bundle with 30-grade angle scope is explained. RESULTS No damage or injury to the neurovascular bundle was performed, allowing complete neural integrity and functionality. CONCLUSIONS The RARP requires a proper training, which consolidates over time, as the number of cases increases. Urologists are more familiar with retrograde nerve preservation, because of their access on the open surgery. The posterior dissection of the SV completely frees the prostate from rectum, preserving the innervation without risk of damaging the rectum. We believe that this variation allows a better conservation and more appropriate handling by the surgeon, as it is more trained in this surgical approach. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e680 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Alfredo Velasco More articles by this author Ruben Olivares More articles by this author Cristobal Roman More articles by this author Lucas Spencer More articles by this author Camilo Leon More articles by this author Ivan Pinto More articles by this author Felipe Balbontin More articles by this author Manuel Diaz More articles by this author Cristian Wohler More articles by this author Jose Miguel Cabello More articles by this author Pablo Marchetti More articles by this author Renato Cabello More articles by this author Sergio Moreno More articles by this author Gonzalo Azocar More articles by this author Javier Aviles More articles by this author Alvaro Kompatzki More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Posterior subscapular dissection: An improved approach to the brachial plexus for human anatomy students

Students of human anatomy are required to understand the brachial plexus, from the proximal roots extending from spinal nerves C5 through T1, to the distal-most branches that innervate the shoulder and upper limb. However, in human cadaver dissection labs, students are often instructed to dissect the brachial plexus using an antero-axillary approach that incompletely exposes the brachial plexus. This approach readily exposes the distal segments of the brachial plexus but exposure of proximal and posterior segments require extensive dissection of neck and shoulder structures. Therefore, the proximal and posterior segments of the brachial plexus, including the roots, trunks, divisions, posterior cord and proximally branching peripheral nerves often remain unobserved during study of the cadaveric shoulder and brachial plexus. Here we introduce a subscapular approach that exposes the entire brachial plexus, with minimal amount of dissection or destruction of surrounding structures. Lateral retraction of the scapula reveals the entire length of the brachial plexus in the subscapular space, exposing the brachial plexus roots and other proximal segments. Combining the subscapular approach with the traditional antero-axillary approach allows students to observe the cadaveric brachial plexus in its entirety. Exposure of the brachial dissection in the subscapular space requires little time and is easily incorporated into a preexisting anatomy lab curriculum without scheduling additional time for dissection.

Transanal rectal mucosectomy and partial internal anal sphincterectomy for Hirschsprung's disease

PurposeHirschsprung-associated enterocolitis (HAEC) is a serious complication of Hirschsprung’s disease (HD), with generalized sepsis and high mortality rate. Although the surgical correction of HD is mostly successful, challenges remain in the management of children with repeated episodes of enterocolitis. The authors describe a novel modification of transanal rectal mucosectomy and partial internal anal sphincterectomy (TRM-PIAS) for HD. MethodsOne hundred twenty-seven HD children aged from 8days to 16years who successfully underwent TRM-PIAS were reviewed. TRM-PIAS was carried out circumferentially along the anorectal line. Anterior dissection was conducted between the rectal submuscosal layer and the rectal muscular sleeve. The posterior dissection was performed along the plane between internal and external anal sphincters. Normal colon was pulled through and anastomosed to anal mucosa. Aganglionic segment, rectal mucosa, part of internal anal sphincter and posterior rectal muscular cuff were removed. Twenty-five age-matched children without defecation dysfunction were used as the control group in the study of anal resting pressure. ResultsPatients were followed up for 6–12years (median: 8.2years). The median age at last follow-up was 12.2years (7.2–20.1years). The incidence of enterocolitis decreased from 33.9% (43/127) preoperatively to 1.6% (2/127) postoperatively (P<0.01). The incidence of constipation decreased from 100% (127/127) preoperatively to 2.4% (3/127) postoperatively (P<0.01). Soiling rate on postoperative 1month was 32.3%. It gradually decreased to 1.6% 6months later. Anorectal manometries showed that mean anal resting pressure was significantly reduced from 37.9±12.5mm Hg preoperatively to 20.2±6.4mm Hg on postoperative 1month and 24.8±9.9mm Hg on postoperative 6months, which were similar to age-matched normal controls (27.9±9.6mm Hg, P>0.05). ConclusionsTRM-PIAS is effective in treatment of HD. It is associated with low postoperative HD-associated enterocolitis.

Dextrocardia with situs solitus and inversion apex-basis axis in lesser anteater (Tamandua tetradactyla): case report

Dextrocardia is a rare cardiac anomaly where the heart is situated on the right antimeres of the thorax. This study had the objective of describing a case of dextrocardia with situs solitus and apex-basis axis inversion in a lesser anteater (Tamandua tetradactyla) between five evaluated animals, all from the area of Mine Bauxite - Paragominas - Para. The arterial system was filled with contrasted latex and the animals were fixed with 10% formaldehyde and a posterior dissection was done. The heart of an animal was found in right antimere with inversion of the base-apex axis. The right atrium was more developed then the left and the pulmonary veins arrived directly in the left ventricle. The main vases of the base were identified with some topographic alterations resulting in: aorta dorsal to the cava caudal vein, pulmonary artery dorsal and cranial to aorta, pulmonary veins ventral to the pulmonary artery, cava caudal vein in ventral plain and cava cranial vein in dorsal plan in relation to the other vessels. Internally there were four cardiac chambers, with absence of septal communication.

Arthroscopic Sternoclavicular Joint Resection Arthroplasty: A Technical Note and Illustrated Case Report

Open resection arthroplasty of the sternoclavicular (SC) joint has historically provided good long-term results in patients with symptomatic osteoarthritis of the SC joint. However, the procedure is rarely performed because of the risk of injury to vital mediastinal structures and concern regarding postoperative joint instability. Arthroscopic decompression of the SC joint has therefore emerged as a potential treatment option because of many recognized advantages including minimal tissue dissection, maintenance of joint stability, avoidance of posterior SC joint dissection, expeditious recovery, and improved cosmesis. There are, however, safety concerns given the proximity of neurovascular structures. In this article we demonstrate a technique for arthroscopic SC joint resection arthroplasty in a 26-year-old active man with bilateral, painful, idiopathic degenerative SC joint osteoarthritis. This case also highlights the pearls and pitfalls of arthroscopic resection arthroplasty for the SC joint. There were no perioperative complications. Four months postoperatively, the patient had returned to full activities, including weightlifting, without pain or evidence of SC joint instability. One year postoperatively, the patient showed substantial improvements in the American Shoulder and Elbow Surgeons score; Single Assessment Numeric Evaluation score; Quick Disabilities of the Arm, Shoulder and Hand score; and Short Form 12 Physical Component Summary score over preoperative baseline values.

保存的治療中に続発した両側性後下小脳動脈解離による小脳梗塞の1 例

保存的治療中に続発した両側性後下小脳動脈解離による小脳梗塞の1 例

Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap

Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap Background: Septal perforations are usually difficult to treat. Surgery is indicated if the perforation is symptomatic. Our aim is to evaluate endoscopic closure of nasal septal perforation using pedicled inferior turbinate flap. Patients and Methods: Endoscopic closure of nasal septum perforations were performed in 31 patients using unilateral pedicled inferior turbinate flap. Results: Twenty-three patients (74%) had complete closure of their perforations. Six other patients (19.5%) had incomplete closure with a small residual perforation< 1cm in diameter posteriorly. Two patients (6.5%), who had previous submucosal diathermy of the inferior turbinate, had flap necrosis with complete failure of the repair. There was a significant inverse relationship between the diameter of the perforation and the success of the repair. Conclusions: Endoscopic repair of nasal septal perforations, up to 2 cm in diameter, using a modified pedicled inferior turbinate flap, is a feasible technique that offers acceptable success rates due to the remarkable vascularity and thickness of the flap. The use of endoscopes allowed more precise a traumatic elevation of the flap posteriorly. The present technique differs from other previously described flap procedures in that it extends the posterior dissection to include a part of the mucosa of the inferior meatus in order to allow more free un-constrained rotation of the flap, and decrease the thickness of the pedicle so that we may not need to divide it in a second stage. This step would have been more difficult and less precise without the use of the endoscope. Previously operated turbinates are not suitable for this technique. Also the procedure may not be suitable if the perforation is very anterior or larger than 2 cm in diameter.

Complete bilateral arcuate foramina and atlantoaxial subluxation

Letter to the Editor A cadaveric specimen undergoing a posterior cervical dissection was noted to have complete bilateral ossification of the posterior atlanto-occipital membrane over the vertebral artery groove and a type-1 atlantoaxial subluxation—atlas rotation on the odontoid process with no anterior displacement (Fig. 1). This ossification anomaly, known as Kimmerle’s variant, ponticulus posticus, arcuale foramen, and/or arcuate foramen, is found with partial and complete ossification in 6– 18 % and 4–8 % (3.3–6.7 % unilateral, 0.7–1.3 % bilateral) of the population, respectively, with a debated higher reported prevalence in females [2, 4, 7, 9]. This anomaly often remains asymptomatic; however, compression of the neurovascular structureswithintheforaminacaninducepressurephenomena of the periarterial sympathetic plexus, especially when rotating the head, and induce vertebro-basilar insufficiency and/or clinical symptoms resembling Barre–Lieou syndrome, presenting with shoulder-arm and neck pain, cervical migraine, hearing loss, vertigo, and/or loss of consciousness [2, 5, 7]. Theaverageageatclinicalpresentationhasbeendebatedin the literature, and has been reported to be greatest between 11 and 20 years and 21–30 years, while another study indicated that presentation is most common during the third and fourth decades of life [5, 8]. Though it is possible that ossification progresses over time, arcuate foramina have been reported in children as young as 2 years of age with one study reporting four cases of partial and three cases of complete arcuate foramina in children younger than 10 years of age [1, 6]. Awarenessofthisdysmorphicfeatureisbothmedicallyand surgically relevant, as intraoperative injury to the vertebral artery can result in disastrous neurological complications and deficits. Knowledge of any variations in the course of the vertebral artery or in the morphology of the posterior vertebral arch is of critical importance when performing instrumentation involving C1 or surgery of craniocervical junction [7]. Preoperative CTangiography has been recommended in order to preclude to the possibility of misidentifying an arcuate foramen as a broad lamina or widened posterior arch, and risking injury to the vertebral artery [3, 12]. Several studies, with positive findings, have examined surgical excision of the arcuateforamenwithdecompressionofthevertebralarteryfor

Partial Anomalous Pulmonary Venous Return to Azygos Vein With Absent Segmental Bronchus

Fig 2. Apulmonary venous blood flowing directly into the right side of the heart or into the systemic veins, which creates a left-to-right shunt. The clinical importance of this anomaly is based on its association with a sinus venosus atrial septal defect in 90% of patients [1]. However, when partial anomalous pulmonary venous return is into the azygos vein, the association with pulmonary anomaly has more importance. A 51-year-old woman presented with persistent cough and recurrent right upper lobe pulmonary infections. Chest computed tomography demonstrated a mass in the posterior segment of the right upper lobe with postobstructive characteristics (Fig 1A) and suggested right upper lobe pulmonary venous drainage into the azygos vein (Fig 1B; arrow). Bronchoscopy was performed, which demonstrated an absence of the posterior segment from the right upper lobe bronchus. Transthoracic echocardiography was performed to exclude the presence of associated atrial septal defect, and results were normal. Because of the recurrent infections, thoracoscopic right upper lobectomy was recommended and performed. Posterior dissection to encircle the right upper lobe bronchus confirmed absence of the posterior segment bronchus. Anterior dissection demonstrated a single 1-mm pulmonary vein from the anterior segment draining into the superior pulmonary vein, with a large anomalous pulmonary vein draining superiorly into the azygos vein (Fig 2; AV 1⁄4 azygos vein; PA 1⁄4 pulmonary artery; SPV 1⁄4 superior pulmonary vein; SVC 1⁄4 superior

Teaching video-assisted thoracic surgery (VATS) lobectomy.

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

Reduction techniques in the management of atlantoaxial subluxation.

Background:The traditional approach to atlantoaxial subluxation which is irreducible after traction is transoral decompression and reduction or odontoid excision and posterior fixation. Transoral approach is associated with comorbidities. However using a posterior approach a combination of atlantoaxial joint space release and a variety of manipulation procedures, optimal or near optimal reduction can be achieved. We analysed our results in this study based on above procedure.Materials and Methods:66 cases treated over a 5 year period were evaluated retrospectively. Three cases treated by occipito cervical fusion were not included in the study. The remaining 63 cases were classified into three types. All except two cases were subjected to primary posterior C1-C2 joint space dissection and release followed by on table manipulation which was tailored to treat the type of atlantoaxial subluxation. Optimal or near optimal reduction was possible in all cases. An anterior transoral decompression was needed only in two cases where a bony growth (callus) between the C1 anterior arch and the odontoid precluded reduction by posterior manipulation. All cases then underwent posterior fusion and fixation procedures. Patients were neurologically and radiologically evaluated at regular followups to assess fusion and stability for a minimum period of 6 months.Results:Of the 63 cases who underwent posterior manipulation, 49 cases achieved optimum reduction and the remaining 14 cases showed near optimal reduction. Two cases expired in the postoperative period. None of the remaining cases showed neurological worsening after the procedure. Evaluation at 6 months after surgery revealed good stability and fusion in all except three cases.Conclusion:Atlantoaxial joint release and manipulation can be used to achieve reduction in most cases of atlantoaxial subluxation, obivating the need of transoral odontoid excision.

Retrorectal cystic hamartoma: this cyst has a “tail” to tell

A 50-year-old man presented with a 6-week history of lumbosacral back pain and altered bowel habit without hematochezia. Abdominopelvic computed tomography (CT) revealed a 5-cm rectal mass with obliteration of the fat plane between the mass and the tip of the coccyx that was interpreted as representing a neoplasm(● Fig.1a). Followinganormal digital rectal exam, colonoscopy revealed a subtle posterior mid-rectal wall indentation, suspected to represent either an intramural process or extrinsic compression. The overlying mucosa appeared normal (● Fig.1b). A curvilinear endoscopic ultrasound examination excluded a subepithelial lesion, instead revealing a 3.4× 3.3cm multiloculated cystic mass extrinsic but adjacent to the rectal wall with no evidence of lymphadenopathy. This lesion was located distal and posterior to the inferior border of the prostate gland and comprised approximately 15 loculi. Each locule was thin-walled in the absence of septations. Many of the loculi contained intracystic echogenic material (● Video1). Surgical resection of the retrorectal cystic mass mandated posterior dissection of the coccyx laterally. Surgical pathology confirmed a multiloculated presacral cystic mass measuring 6.0× 4.3×3.2cm (● Fig.1c). The cystic loculi were lined by squamous epithelium, transitional type epithelium, and columnar epithelium with focal goblet cells and no evidence of malignancy (● Fig.1d). The findings were diagnostic of cystic hamartoma (tailgut cyst). Until adverse event data for lower gastrointestinal endoscopic ultrasound (EUS) become available, the current recommendation is to avoid fine-needle aspiration (FNA) of perirectal cysts due to concerns regarding abscess formation even with prophylactic antibiotic use, as highlighted in one patient who subsequently required percutaneous drainage [1]. Complete intact surgical excision is advised to avoid the potential risk of needle-tract seeding, infection, and fistula formation [2].

Meckel’s cave access: anatomic study comparing the endoscopic transantral and endonasal approaches

Recent advances in endonasal endoscopy have facilitated the surgical access to the lateral skull base including areas such as Meckel's cave. This approach has been well documented, however, few studies have outlined transantral specific access to Meckel's. A transantral approach provides a direct pathway to this region obviating the need for extensive endonasal and transsphenoidal resection. Our aim in this study is to compare the anatomical perspectives obtained in endonasal and transantral approaches. We prepared 14 cadaveric specimens with intravascular injections of colored latex. Eight cadavers underwent endoscopic endonasal transpterygoid approaches to Meckel's cave. Six additional specimens underwent an endoscopic transantral approach to the same region. Photographic evidence was obtained for review. 30 CT scans were analyzed to measure comparative distances to Meckel's cave for both approaches. The endoscopic approaches provided a direct access to the anterior and inferior portions of Meckel's cave. However, the transantral approach required shorter instrumentation, and did not require clearing of the endonasal corridor. This approach gave an anterior view of Meckel's cave making posterior dissection more difficult. A transantral approach to Meckel's cave provides access similar to the endonasal approach with minimal invasiveness. Some of the morbidity associated with extensive endonasal resection could possibly be avoided. Better understanding of the complex skull base anatomy, from different perspectives, helps to improve current endoscopic skull base surgery and to develop new alternatives, consequently, leading to improvements in safety and efficacy.

Trainee performance at robotic console and benchmark operative times

It is an ongoing challenge to maintain surgical efficiency while integrating trainee participation. We hypothesize that a program of graduated surgical responsibility for trainees does not hinder operative efficiency. This was a retrospective cohort study of trainee performance times, collected prospectively in real time, for robotic cases performed at one university hospital between September 2008 and August 2011. The primary aim was to compare overall operative times between cases performed by trainees versus attendings. Secondary aims were to compare operative times for major portions of each operation by level of training and to establish benchmark operative times for trainees. During the study period, 98 cases had recorded trainee performance times. Total robot docked time was longer for trainees than for attendings (155 vs 132 min, p = 0.011), but mean performance times for hysterectomy (70 vs 59 min, p = 0.096) and sacrocolpopexy (76 vs 79 min, p = 0.545) were similar. Within the trainees, there was no correlation between surgical time and rank for each step of the procedures. Utilizing mean performance times for all trainees, benchmark operative times were established for each step of hysterectomy in minutes: right side (21), left side (21), bladder flap (10), colpotomy (15), and cuff closure (19); similarly, for sacrocolpopexy: sacral and peritoneal dissection (12), anterior cuff dissection (10), posterior cuff dissection (8), anterior mesh attachment (15), posterior mesh attachment (18), sacral mesh attachment (12), and peritoneal closure (9). In a program of graduated surgical responsibility, robotic operative efficiency was comparable when trainees were involved as console surgeons.