Posterior Port Research Articles

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

The Anterolateral Approach in Robotic Lung Cancer Surgery

The anterolateral approach in robotic lung cancer surgery was developed for the purpose of more efficient port placement by removing the posterior port, decreasing the total number of ports, and securing enough distance between the robotic arms. When this approach is used, 4 ports are made in the anterolateral area of the patient, and the robot can be docked from an anterolateral direction. By using this port placement, the assistant surgeon's role can be minimized, and solo surgery is possible using the robotic procedure. An anterolateral approach can be considered as a useful port placement method in robotic lung cancer surgery.

Minimally Invasive Lateral Endoscopic Multiport Approach to the Infratemporal Fossa: A Cadaveric Study.

Expanded endoscopic endonasal approaches to the infratemporal fossa (ITF) are increasingly performed owing to improved visualization and less morbidity compared with classic open approaches. Only a few studies in the literature investigated lateral endoscopic access to the ITF. The aim of this study was to examine the ITF with the minimally invasive endoscopically assisted Gillies approach with a trial of its expansion through a double port technique. The ITF was examined in 10 sides of 5 cadaveric heads using a lateral endoscopic assisted approach. A double portal technique was developed to allow bimanual dissection. Specific long angled skull base instruments were used for dissection under stereotactic guidance. The endoscopic assisted Gillies approach permitted minimally invasive access to the complete anteroposterior extension of the ITF with sufficient mobility of surgical instruments. A new anatomic classification for the ITF from a lateral endoscopic perspective was introduced. The addition of the second port allowed bimanual dissection. This cadaveric study shows the feasibility of an endoscopically assisted lateral approach to the ITF. The addition of a posterior port expands the approach through increasing the working area and enabling a bimanual dissection technique. Performed alone or combined with an anterior endoscopic transnasal approach, this technique offers minimally invasive access to the ITF. The development of specifically designed instruments would further improve this promising approach.

Robotic Lobectomy: Left Lower Lobectomy by Surgery

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation.

Port Placement and Docking for Robotic Surgery: The University of Southern California Approach.

To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS.

Robotic First Rib Resection

Thoracic outlet syndrome is a complex disease, presenting with multiple symptoms arising from a possible combination of subclavian vein, subclavian artery, or brachial plexus compression. Multiple techniques have been used for first rib resection, some of which are no longer used. Current common techniques use a supraclavicular, transaxillary, or infraclavicular approach, each of which has its limitations. Minimally invasive transthoracic approaches have been slow to gain popularity owing to limitations in current video-assisted thoracoscopic surgery instrumentation and technology. We describe a minimally invasive and successful transthoracic approach utilizing the da Vinci robotic system with excellent results and minimal morbidity. The described approach incorporates first rib resection and division of the scalene muscles with removal of the rib in a nonpiecemeal fashion, with clear visualization of the entire rib and the need for minimal dissection around the subclavian vessels and brachial plexus.

156 LAPAROSCOPIC UTERINE EMBRYO TRANSFER IN THE CAT

In the first successful transfer of cat embryos (Theriogenology 11, 51–62), the uterus was accessed by midventral laparotomy. That surgical approach was the most widely used method for transferring cat embryos for more than two decades. Then, 10 to 15 years ago pregnancies were reported after early cleavage stage embryos were transferred to the oviduct of recipients using a laparoscopic technique. Even though laparoscopic oviducal embryo transfer has produced higher survival/pregnancy rates than were obtained previously there are valid reasons for establishing a minimally invasive, technically simple method for depositing morulae and blastocysts into the uterus of recipients. Thus, the purpose of the present project was to develop a technique for laparoscopic uterine embryo transfer in the cat. Recipients (n = 4) were gonadotropin-treated females (Theriogenology 81, 126–37) from which prevoulatory oocytes (n = 27–42/retrieval) had been recovered 7 or 8 days previously. The procedure for accessing the reproductive tract has been described (Theriogenology 71, 864–71). Briefly, after abdominal insufflation via a Veress needle, two 5-mm ports were inserted in the midline – one ~2.5 cm anterior to the umbilicus and the other between the two most posterior teats. An endoscope/camera and a Babcock forceps were placed in the anterior and posterior ports, respectively. After the left uterine horn was stabilised with the Veress needle, the Babcock forceps were gently applied at ~2–3 cm from the anterior tip. In the first two attempts, a 16 g × 5 cm thin-walled stainless steel (s.s.) trocar/cannula was inserted transabdominally such that it aligned with the anterior portion of the left uterine horn when elevated with the forceps. Then, either a 14-cm, 3.5 Fr tom cat catheter with a s.s. sharp-tipped stylette or a 20/22 g × 6 cm indwelling catheter was passed through the s.s. cannula and inserted into the uterine horn. In each case, the length of the s.s. cannula restricted depth of insertion of the catheter into the horn. Polyethylene tubing (PE10) containing the embryos was threaded through the catheter and embryos were expelled with a 1-mL threaded-plunger syringe. The failure to establish pregnancies after transfer of five or six Day 7 or Day 8 IVF-derived “fresh” embryos into the first two recipients was attributed to technical difficulties. So, for the third and fourth procedures, we shortened the s.s. trocar/cannula to 2.5 cm and, for insertion into the horn, a 20/22 g × 6 cm indwelling catheter was used. With the third procedure, in which cryopreserved d 8 IVF blastocysts were transferred into a Day 7 recipient, the failure was possibility due sub-optimal in vitro development of embryos after thawing on d 7. For the fourth transfer, 6 “fresh” Day 8 IVF blastocysts – 2 expanding and 4 in the early stages of emerging from the zona pellucida – were auto-transferred into a 3-year-old recipient. A singleton pregnancy was diagnosed by ultrasonography on Day 28 and a live, healthy male kitten (119 g) was born on Day 67. In summary, we demonstrated the feasibility of transferring in vitro-derived cat embryos into the uterus of recipients by the minimally invasive technique of laparoscopy.

Dual-Port 2D and 3D Endoscopy: Expanding the Limits of the Endonasal Approaches to Midline Skull Base Lesions with Lateral Extension.

Objective To investigate a novel dual-port endonasal and subtemporal endoscopic approach targeting midline lesions with lateral extension beyond the intracavernous carotid artery anteriorly and the Dorello canal posteriorly. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic endonasal approach from the sella to middle clivus. The endonasal port was combined with an anterior or posterior endoscopic extradural subtemporal approach. The anterior subtemporal port was placed directly above the middle third of the zygomatic arch, and the posterior port was placed at its posterior root. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The anterior subtemporal port complemented the endonasal port with direct access to the Meckel cave, lateral sphenoid sinus, superior orbital fissure, and lateral and posterosuperior compartments of the cavernous sinus; the posterior subtemporal port enhanced access to the petrous apex. Endoscopic dissection and instrument maneuverability were feasible and performed without difficulty in both the anterior and posterior subtemporal ports. Conclusion The anterior and posterior subtemporal ports enhanced exposure and control of the region lateral to the carotid artery and Dorello canal. Dual-port neuroendoscopy is still minimally invasive yet dramatically increases surgical maneuverability while enhancing visualization and control of anatomical structures.

Burden of complications from needle penetration of plastic ports in children

BackgroundComplications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations. MethodsWe performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution. ResultsThere were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2±21.3months (range 0.3 to 63.4months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15). ConclusionsThere is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.

Biportal complete video-assisted thoracoscopic lobectomy and systematic lymphadenectomy.

The video-assisted thoracoscopic approach (VATS) for lobectomy of non-small-cell lung cancer (NSCLC) has not been standardized. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out via only two incisions. This video demonstrates a case undergoing biportal complete VATS (biportal cVATS) right upper lobectomy and systematic lymphadenectomy. Here we describe our technique of biportal approach by using a combination of conventional and endoscopic instruments. As our experience gained, we consider the knacks of biportal cVATS lobectomy imply two radical changes of perspectives from the traditional triportal technique. One fundamental step is how to achieve satisfactory exposure in the case of single utility incision for multiple instruments to insert. Another technical tip that should be taken into account is how to introduce staplers conveniently without the third posterior port. Optimization of the whole procedures is critical for accomplishing anatomic hilar vascular, bronchial, and lymphatic dissection via two ports. In conclusion, biportal cVATS lobectomy for lung cancer is a safe and reliable procedure that can achieves good postoperative results without oncological compromise.

Ultrasound guided supraclavicular nerve blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia

Ultrasound guided supraclavicular nerve blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia

Video‐Assisted Thoracic Surgery (VATS) Lobectomy: Focus on Technique

BACKGROUND A clear definition of video-assisted thoracic surgery (VATS) lobectomy is lacking in the current peer-reviewed literature. Reported cases vary from four to six incisions in number, 4.0 to 10.0 cm in length, and with and without rib spreading; in addition, they include direct visualization through a utility incision. Described is a complete standardized three-incision thoracoscopic technique that maximizes the benefits of minimally invasive surgery without compromising oncologic principles. METHODS Patients with clinically suspected stage I non-small-cell lung cancer (NSCLC) were selected for VATS lobectomy on the basis of thoracic computed tomography. VATS lobectomies were performed using a standardized three-incision technique: a 2-cm camera port, a 2-cm posterior port, and a 4 cm utility incision without rib spreading. Hilar structures were individually ligated, fissures were completed, and lymph node dissection was performed entirely under thoracoscopic visualization. RESULTS From May 2002 to December 2009, VATS lobectomy was performed successfully in more than 600 patients at our institution. There were no operative deaths, and the median length of stay was 4 days. CONCLUSIONS Standardized VATS lobectomy is feasible, expeditious, and safe. This standardized three-incision technique utilizing a 4-cm utility incision without rib spreading may allow valid comparisons of conventional procedures in clinical trials.

Mapeamento do trajeto extraforaminal da raiz L4 no espaço intertransversário L4-L5 através do acesso paramediano à coluna vertebral

As hérnias discais extremolaterais correspondem a 10% das hérnias discais sintomáticas, mais comumente localizadas nos níveis L3-L4 e L4-L5. Por muitos anos, a abordagem cirúrgica das hérnias lombares foraminais e extraforaminais foi feita através de via de acesso posterior mediana com hemilaminectomia e facetectomia total ou parcial. Inúmeras foram as variações propostas para essa técnica a fim de se evitar a facetectomia e suas repercussões biomecânicas, que ocasionavam com certa freqüência o surgimento de dor lombar baixa devido à instabilidade vertebral criada. A abordagem cirúrgica dessa patologia pela via paramediana, entre os músculos multífido e longuíssimo (via de Wiltse), tem a vantagem de poupar o paciente de perdas ósseas e permitir uma visão mais oblíqua do neuro-foramen. Essa abordagem permite, com mínima mobilização da raiz de L4, acesso ao disco L4-L5 e eventuais herniações extra-foraminais do mesmo. Nosso objetivo é apresentar um estudo do trajeto extra-foraminal da raiz de L4 no espaço intertransversário L4-L5. Para isso, foram realizadas dissecções em 10 cadáveres (20 lados) e obtidas as medidas baseadas em 6 parâmetros anatômicos. A análise dos dados nos permite concluir que as hérnias discais extremo-laterais no nível L4-L5 podem ser acessadas com relativa segurança através da via paramediana.

Comparison of two repositioning devices used during radiation therapy for Hodgkin's disease

Patients irradiated for Hodgkin's disease are fixed in an immobilization cradle to improve repositioning. In the early 1990s, we changed our cradle system from a "short" upper torso cradle to an extended near-total body cradle that also includes the lower torso and thighs. In this study, we assess the impact of the extended cradle on the reproducibility of patient repositioning during irradiation of Hodgkin's disease. A total of 782 port films of 56 patients treated immediately before and after the change-over were studied to assess positioning reproducibility. Patients treated prior to 1993 were positioned in the short cradle, while those treated 1993 and later were positioned in the extended cradle. All treatment were delivered via anterior and posterior fields and treatment areas above and below the diaphragm were considered separately and together. All treatment fields were simulated and the field shape was designed on anterior and posterior radiographs. Discrepancies in field placement between the simulation radiographs and subsequent port films were noted by a radiation oncologist and requests for position adjustment (both translational and rotational shifts) were noted. The number, magnitude, and direction of any physician-requested position adjustment on port films were retrospectively reviewed. For the purpose of scoring the frequency of field misplacements, when an adjustment was noted on two port films taken during the same treatment session (i.e., a left shift on both an anterior and a posterior port film), it was scored as only one event. A two-tailed chi-square test was used to compare the differences in requested shifts in the two patient groups. The study population consisted of 56 patients (31 short and 25 extended cradle) representing 92 treatment sites. A total of 782 port films representing 450 treatment setups were analyzed (292 above and 158 below the diaphragm). When all port films above the diaphragm (mostly mantle fields) are considered, position adjustments were requested in 13.4% (21 out of 157) of treatment setups with the upper torso cradle and in 5.9% (8 out of 135) of treatment setups with the extended cradle (p = 0.054). When all port films below the diaphragm (mostly paraaortic/spleen and pelvic fields) are considered, position adjustments were requested in 33.8% (27 out of 80) of treatment setups with the upper torso cradle and in 16.7 % (13 out of 78) of treatment setups with the extended cradle (p = 0.056). A reduction in the frequency of both translational and rotational adjustments were seen. When both treatment sites are combined, position adjustments were requested in 20.3% (48 out of 237) of treatment setups with the upper torso cradle and in 9.9% (21 out of 213) of treatment setups when the extended cradle was used (p = 0.0086). The extended cradle provides superior repositioning of patients undergoing radiation therapy for Hodgkin's disease. Differences observed in setup accuracy in this study underscore the importance of aggressive immobilization of patients with Hodgkin's disease. Increased accuracy of daily setup may provide an opportunity to improve the therapeutic ratio both by increased likelihood of tumor control and decreased risk of normal tissue complications.

A comparison of high-energy oblique lung irradiation techniques

The lung cancer death rate in the U.S. rose 440% between 1957–1959 and 1987–1989, from 5.4 to 29.4 per 100,000. While surgical resection of small, localized carcinomas offers the best prognosis, only 15–20% of lung cancers fall into this category. The remaining 80–85% of patients are generally candidates for radiation therapy. Typically, the tumor volume (plus a 2 cm margin) and the mediastinum will be irradiated, using parallel opposed anterior and posterior ports, until the spinal cord has reached tolerance at 45 Gy. At this point, an off-cord lateral or oblique treatment technique will be used to complete the prescribed dose to the tumor. The depth to isocenter for oblique ports may easily be 15 cm. With this depth, a high-energy x-ray beam seems to be required; however, the beam may pass through a significant portion of lung tissue, reducing the equivalent depth. Another factor to consider is the build-up region beyond the lower density lung tissue. Two different energy beams, 6 MV and 18 MV, were compared for the oblique treatment ports. Plans were run using a thorax CT slice of an anthropomorphic phantom for parallel opposed oblique fields at these two energies, each with and without CT correction. Further data were collected for comparison by thermoluminescent dosimetry measurements. This paper describes the process and results obtained.

Auditory acuity in the orientation behaviour of the bushcricket Pachysagella australis walker (Orthoptera, Tettigoniidae, Saginae)

The female tettigoniid Pachysagella australis (Saginae) orients to the call of the conspecific with an angular acuity of ±5°. This acuity is mediated by sound entering to the tympanic receptors through the auditory trachea and the slits exterior to the tympanic membranes. The phonokinetic response of females was filmed in an arena. The slit system was blocked on both anterior and posterior ports with the effect that the female spiralled towards the sound source; blocking the posterior slit alone reduced the auditory acuity as did the partial occlusion of the fore slit, but in both cases the female located the male. Complete blocking of the auditory spiracle caused the insect to spiral towards the unoperated side, whereas reducing the sound input to one side by some 8–12 dB, by plugging the auditory bulla with compacted cotton wool, did not substantially affect the orientation pattern of the insect. Ablation of the tympanic organ on one side caused the female to move in a circular pattern to the unoperated side. A hypothesis is formulated whereby the female, when actively orienting to the calling male, may use the slit port system to gain a high degree of auditory acuity to sound in front of her body axis. When off target she may use the less accurate spiracular input system. This system, with its greater sensitivity to high frequency sounds, may function as an effective anti-predator warning system.

A technique for cranial-spinal irradiation.

Accurate and homogenous irradiation of junctions between irradiated tissue volumes is a persistent problem in radiation oncology. The treatment of medulloblastomas and other tumours requiring irradiation of the entire central nervous system presents a particularly difficult junctional problem. Several solutions have been proposed, each with its own inherent advantages and disadvantages. The two solutions in most widespread use involve either shifting the level of abutting ports over the cervical spine, or calculating a gap between the brain and spinal fields in the same region. The purpose of this note is to present a method of joining cranial and spinal treatment volumes which provides a reproducibly uniform dose distribution across the junction at a specified depth. To ensure dose homogeneity, we prefer to irradiate the brain through parallel opposed lateral treatment ports. Joining these with a posterior port over the spinal cord presents a three-beam junctional problem with beam incidence at 90 deg. angles. Our proposed solution involves a 6 cm overlap of treatment volumes with lead spoilers inserted in the edge of the beams corresponding to the region of overlap (Fig. 1).

RADIATION‐INDUCED THYROID CARCINOMA*

Epidemiologic studies show a definite relation between thyroid carcinoma and prior radiotherapy for various diseases in childhood. Information regarding such an association for persons treated during adult life is limited and difficult to obtain because of the long period between exposure and tumor development. Nevertheless, there is some evidence that such an association also exists in irradiated adults. None of the prospective investigations has been properly controlled, and for this reason the treated children studied may represent a selected group predisposed to develop thyroid neoplasia without exposure to ionizing radiation. However, two observations provide strong circumstantial evidence that radiation treatment is, indeed, a factor in thyroid tumor induction. First, in the retrospective studies, x-ray therapy was given to the head, neck, and chest for many unrelated conditions. This suggests that the radiation exposure, rather than the disease being treated, is a primary factor in the etiology of the thyroid neoplasia. Second, the development of excessive numbers of tumors can be related to a specific radiologic technique, that is, the use of anterior and posterior ports. Thus, a dose of x rays, if administered one- half to the anterior and one-half to the posterior chest, is associated with a higher thyroidmore » tumor incidence than if given anteriorly only. All of these studies are concerned with radiation from external sources. Insufficient data are currently available to conclude that radioiodine is also oncogenic. More definitive information may be provided when the results of a current national survey of patients treated with /sup 131/I are reported. (auth)« less

Radiation therapy through cooled skin.

Skin changes are of great importance in radiotherapy and are frequently the factor limiting the dose administered. Except for superficial lesions, the skin acts only as a port of entry for the radiation beam. The skin changes, both acute radiodermatitis and the late development of atrophy and telangiectasia, are undesirable side-effects and serve only to increase the discomfort and concern of the patient. Any method that would reduce these side-effects without decreasing the effectiveness of the irradiation on the primary object of treatment would be desirable. Supervoltage units, including telecobalt-60 and telecesium-137 units, produce considerably less skin effect, dose for dose, than orthovoltage (200-kv) units. The majority of therapy departments, however, have orthovoltage apparatus and will continue for economic reasons to use it for some time. If a technic could be developed to decrease an undesirable skin reaction, the clinical value would be great, and the general usefulness of the orthovoltage units would be increased. With this in mind, equipment was assembled in April 1959 to cool the skin at the port of entry, and a clinical trial was attempted. Method and Material A hollow aluminum sandwich was made with two tubular connectors to permit the circulation of cold water. The sandwich was connected to a pump that circulated the water from a coil in the refrigerator. The temperature of the water was kept near 0° C., and an anti-freeze preparation was used to prevent the formation of ice. The surface of the aluminum sandwich had a temperature of 5° C. A duplicate device kept filled with water at room temperature was used as a control. This study was done on 100 consecutive women with pelvic tumors, all treated through four ports, two anterior and two posterior, measuring from 10 × 15 cm. to 12 × 15 cm. The left anterior and right posterior ports were treated with the control device. The right anterior and left posterior ports were treated with the cooling device. The aluminum sandwich measured 12 × 17 × 1.5 cm. over all. The aluminum used was 2 mm. in thickness. The technical factors were 200 kv, S.T.D. 50 cm., h.v.l. 1.25 mm. Cu. The patients received a conventional course of therapy, 150 to 200 r (air) to two ports daily, with a total of 2,400 r to 2,800 r (air) to each port in five to six weeks. The skin temperature of the cooled ports was approximately 10° C. Secondary radiation from the metal on the skin was constant on both the control and cooled areas. A flexible cooling device that would better fit the contours of the patient would be advantageous and is being developed. Results The evaluation of the procedure was made subjectively and objectively. Photographic records (in color) were kept of the treatment fields. The patients felt less discomfort at the ports that were cooled and 75 per cent claimed less “burning sensation” and less “itching” in the cooled ports.

Fetal tolerance to radiation. A case report.

Many observations indicate the harmful effects of large doses of radiation to man (3–5, 12–19). Occasionally, evidence is presented that such disastrous effects are not inevitable (7, 11, 12, 18). The purpose of this paper is to report an unusual case in which a large radiation dose was delivered to a human fetus without apparent damage. This child has been followed for eleven years. Case History Mrs. M. H., 40-year-old colored woman, gravida 11, para 10, was referred to the Tumor Clinic on May 19, 1949, with a pathological diagnosis of squamous-cell carcinoma of the cervix. She was about six and one-half months pregnant. The date of her last menstrual period was Oct. 22, 1948. Spotting had occurred in November and December, without associated pain or other symptoms. Fetal movements had been felt for seven weeks. Physical examination was negative except for the gynecological findings. The cervix was enlarged and its anterior lip was granular in appearance, but this change seemed to be confined to the cervix. The uterus was of normal size for a pregnancy of six and one-half months. Biopsies were taken at that time, and a recent review by the Pathology Department of the University Hospital confirms the initial diagnosis of squamous-cell carcinoma of the cervix. The decision of the members of the Tumor Clinic was to treat the carcinoma of the cervix and disregard the pregnancy. On May 24, 1949, external x-ray therapy was begun, through two anterior pelvic ports, 10 x 15 cm., and two posterior pelvic ports of the same size (Fig. 1). The beams were directed anteroposteriorly and dorsoventrally, respectively. Other factors were 200 kv, h.v.l. 1 mm. copper, target-skin distance 50 cm. Before the delivery, the patient received a total dose of 1,400 r in air to each one of the anterior ports and 1,200 r in air to each of the posterior ports. The calculated mid-pelvis dose was 754 r in two weeks. External irradiation was supplemented by an application of radium on May 21, 1949: 36.66 mg. of radium in the form of a plaque sutured against the anterior lip of the cervix plus a Kaplan colpostat with 26.66 mg. in each side, totaling 90 mg. of radium, left in place for forty hours. On June 8, 1949, the fetus was in a right occipitoanterior position, and labor was induced. The next day the patient delivered a premature male child of entirely healthy appearance. The external x-ray therapy was continued after the delivery, with a second application, on July 19, of 60 mg. of radium, left for fifty hours. The patient has been seen at the Tumor Clinic fourteen times between 1949 and 1959 by different observers, and no evidence of recurrent or metastatic tumor has been found. The usual local radiation reaction was observed in the immediate post-irradiation period and later stenosis of the vaginal vault developed.