Semi-lateral Decubitus Position Research Articles

Abstract P3-19-21: Semi-lateral decubitus position using Alexandria left breast board-16. A prospective study regarding dose distribution and reproduciblity

Abstract Purpose: Organs at risk sparing without compromising adequate coverage to the target volumes is the main challenge during left breast cancer adjuvant radiation therapy. Advanced radiotherapy techniques have been investigated to improve the dose distributions and to reduce toxicities. These techniques includes deep inspiration breath hold, accelerated partial-breast irradiation, Intensity Modulated Radiation Therapy. Supine positioning (SP) is the most commonly used and the standard tangent set-up for breast radiotherapy. Our purpose is to compare the Semi-lateral decubitus position(SLDP) versus SP regarding the dose distribution to the left Chest wall/Whole breast (WB), ipsilateral left axilla, contra-lateral breast, thyroid, spinal cord, ipsilateral lung, heart, LAD (Left Anterior Descending Artery), as well as determining the reproducibility of the Alexandria left breast board-16 (ALB-16) by portal image verification. Methods: We invented a new breast board ALB-16 to induce SLDP allowing tilting the patient towards the right side, elevating the patient's left side at a certain angle adjusted according to the patient’s body surface area and the gantry width of the CT simulator. Simulation process was performed in two different positions whilst the patients were freely breathing, the first scan in SLDP and the second in SP. Fifty women with a left sided breast cancer who underwent either mastectomy or lumpectomy were enrolled in this study for dosimetric comparison between the SLDP and the SP. The mean radiotherapy dose to the CW/WB, axilla, thyroid, left lung, heart, LAD, Spinal cord and the contra-lateral right breast in SLDP and the SP for the same patient were compared. Secondly, analysis was conducted on the fifty patients who were treated in SLDP by ALB-16 in comparison with a control group treated in SP to determine ALB-16 reproducibility. Results: On dosimetric analysis of the two positions, SLDP was found to significantly decrease the mean dose to the heart when compared with SP (2.2Gy vs. 2.9Gy respectively), LAD (5.4Gy vs. 7.2Gy) and the Spinal cord Dmax (7.5Gy vs. 12.6Gy) with a (p<0.01), while maintaining a similar coverage to the axillary lymph nodes levels I, II and III and the SCV group (91.13%, 89.9%, 88.9% and 93.9% vs. 91.3%, 90.2%, 89.5% and 94.1% respectively)(p =0.73, 0.37, 0.29 and 0.67) SLDP improved coverage to the target PTV mean dose (95.2% vs. 94.2%, p<0.01). SLDP decreased the mean dose to the contralateral breast (2.27Gy vs. 2.52Gy, p= 0.08). However, it achieved slightly a higher mean dose to the thyroid gland (79.8Gy vs. 16.8Gy, p= 0.56). The mean dose to the ipsilateral lung was slightly higher than SP (22.5% vs. 20.3%) with a statistically significant difference (p<0.01). For the secondary analysis, setup error in lateral (x) direction was higher in SLDP (0.66cm vs.0.49cm, p=0.028), setup error in vertical (y) direction in SLDP was lower than SP (0.39cm vs. 0.55cm, P=0.013). For the changes in longitudinal direction (Z), there was a slight difference between both positions (0.49cm vs. 0.39cm, p= 0.56). The length of deviation vector (3D vector) was (0.95cm in SLPD vs.0.87 in SP), the mean difference between vector lengths was only (0.08 cm) and this difference wasn’t statistically significant (p= 0.441) indicating the overall reproducibility of the ALB-16 breast board in comparison to standard supine breast board. Conclusions: ALB-16 Breast board is considered a reproducible method of setup for patients receiving left breast cancer adjuvant radiotherapy. It is comparable with the conventional supine breast board in regards of setup errors variability. SLDP spared the heart, LAD and the spinal cord, with a better WB/CW PTV coverage. SLDP can be used in patients whom regional nodal irradiation is indicated while maintaining low contralateral breast dose. Citation Format: Omar Saeed Emam, Mohamed Abouegylah, Rasha Elsaka, Amr Munir, Fady Aziz, Abdelsalam Attia Ismail, Amr Abdelaziz Elsaid. Semi-lateral decubitus position using Alexandria left breast board-16. A prospective study regarding dose distribution and reproduciblity [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-21.

Laparoscopic and left thoracoscopic Ivor-Lewis esophagectomy for Siewert type II esophagogastric junction cancer with right aortic arch: a case report

BackgroundRight aortic arch (RAA) is a congenital malformation detected in 0.04% of the population without heterotaxia and makes esophagectomy and mediastinal lymphadenectomy difficult. A left thoracic approach is recommended in patients with RAA, but a minimally invasive procedure has not yet been established.Case presentationThe case was a 40-year-old man with RAA and Siewert type II adenocarcinoma of the esophagogastric junction with metastases to the adrenal glands and paraaortic lymph nodes. Conversion surgery was performed when radiologic disappearance of metastatic disease was confirmed after first-line treatment consisting of 12 cycles of S-1 plus platinum-based systemic chemotherapy. Minimally invasive laparoscopic and left thoracoscopic Ivor-Lewis esophagectomy was performed in the right semi-lateral decubitus position. The esophagus was easy to see on left thoracoscopy because of the RAA. Esophagectomy with lower mediastinal lymphadenectomy and an intrathoracic esophagogastric anastomosis was performed successfully with laparoscopy and thoracoscopy without a position change. There were no surgical complications, and no residual cancer was detected in the resected specimen on pathological examination. There has been no recurrence during 21 months of follow-up.ConclusionsLaparoscopic and left thoracoscopic Ivor-Lewis esophagectomy in the right semi-lateral decubitus position is a minimally invasive, anatomically novel procedure for Siewert type II esophagogastric junction cancer in patients with RAA.

The Impact of the Semi-Lateral Decubitus Position Regarding Dose Distribution to the Ipsilateral Axilla in Comparison to Supine Position for Left Sided Breast Cancer Irradiation

The Impact of the Semi-Lateral Decubitus Position Regarding Dose Distribution to the Ipsilateral Axilla in Comparison to Supine Position for Left Sided Breast Cancer Irradiation

Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience.

The objectives of this study were to evaluate the feasibility and safety of robot-assisted thoracic surgery (RATS) using the da Vinci robotic system for mediastinal mass resection and to describe the surgical approach for masses in different mediastinal regions. We retrospectively reviewed data from 84 patients who underwent RATS for resection of a mediastinal mass from June 2015 to April 2019. The results were analyzed with descriptive statistics. The mediastinal mass was resected successfully in all patients, with one patient requiring conversion to conventional open surgery. There were no intraoperative complications. The most common diagnoses were thymoma (n=17), bronchogenic cyst (n=16), and schwannoma (n=12). The surgical approach was determined by the location of the lesion and the planned extent of surgical resection. Resection was performed in the lateral decubitus position in 29 patients with posterior mediastinal tumor, semi-lateral decubitus position in 42 patients who only need resection of anterior mediastinal mass, and reverse Trendelenburg position in 13 patients undergoing thymectomy. The mean (± standard deviation) operation time was 91.86±56.42 min, duration of chest tube use was 1.83±0.93 days, and postoperative hospital stay was 3.62±7.52 days. Three patients (3.5%) developed postoperative complications: one chylous fistula, which required reoperation, and one case each of atrial fibrillation and pulmonary infection, which were treated conservatively. Our experience demonstrated that different surgical approaches of RATS are safe and feasible for mediastinal mass resection. An appropriate approach can be selected based on the mediastinal region in which the tumor is located.

Endotracheal intubation with video laryngoscope at semilateral decubitus position: a case report of a pediatric patient with a back stab wound

Background: Endotracheal intubation is routinely performed in a supine position. However, this position might be difficult for some emergent patients. Although several alternative positions have been suggested for adult patients, such studies on pediatric patients are rare. Case presentation: We present a case of a female pediatric patient with a pencil stab wound to the back requiring an emergent operation under general endotracheal anesthesia. Placing her in supine position would have been inappropriate because of the protruding pencil. The patient was moved to a semilateral decubitus position for intubation. The endotracheal tube was inserted with a video laryngoscope. Her vital signs and oxygen saturation were stable during operation. The patient was discharged without complications. Conclusion: Semilateral intubation in pediatric patients using a video laryngoscope may be feasible under some specific conditions that make it inappropriate to place patients in a supine position.

Modified Semilateral Decubitus Position for Shoulder Arthroscopy and Its Application for Open Surgery of the Shoulder (One Setting for All Shoulder Procedures)

Two standard patient positions for shoulder arthroscopy are the beach-chair and lateral decubitus positions. Both positions have advantages and disadvantages in many aspects. Surgeons choose the position based on their preferences, mainly the orientation of the anatomy. If an operation needs to be converted to an open procedure, a patient who is placed in the lateral decubitus position might need to undergo repositioning and re-draping, which result in extending the operative time and increasing the risk of infection. For this circumstance, the modified semilateral decubitus position offers the same advantages as the lateral decubitus position and can be adjusted to achieve a more upright position similar to the beach-chair position.

Retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuromas: our technique and clinical outcomes.

ABSTRACTObjective:To report our experience of retroperitoneoscopic technique in semi-lateral decubitus position for the retroperitoneal nonadrenal ganglioneuromas in 18 patients, and to evaluate its clinical outcomes.Materials and Methods:From January 2012 to May 2016, 18 patients with retroperitoneal nonadrenal ganglioneuromas underwent retroperitoneoscopic resection. With the patients in semi-lateral decubitus position, a 4-port retroperitoneal approach was used. Data were collected on the tumor size, tumor location, perioperative outcomes, pathology, and last-known disease status. We reviewed the operative videos to identify surgical tips and tricks.Results:All procedures were carried out successfully without converting to open surgery. The tumors had an average size of 5.2cm. The mean operative time was 86.5 min, with a mean estimated blood loss of 85.4mL. There were three patients suffering from intraoperative complications. Postoperatively, all patients achieved an uneventful recovery; the mean postoperative hospital stay was 5.5 days. The postoperative pathology revealed to be retroperitoneal ganglioneuromas. With a mean follow-up of 39.5 months, all patients were recurrence free. The review of the operative videos revealed several tips and tricks, including keeping peritoneum and posterior Gerota fascia intact to provide a favorable operative exposure of tumors, and placing the harmonic scalpel through different ports during tumor dissection.Conclusions:With the patient in semi-lateral decubitus position and a 4-port retroperitoneal approach, retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuroma is a feasible, effective, and safe procedure. This approach has distinct advantages including direct access to the tumor, optimal exposure of tumor and less intraperitoneal interference.

The impact of semilateral decubitus position on the dose-volume parameters of the heart and lung for left sided breast cancer patients: A comparative dosimetric study

PurposeWhen treating breast cancer with radiation therapy, the impact of treatment position on heart and lung dose-volume parameters (DVPs) is largely dependent on the maximal heart distance (MHD) and central lung distance (CLD). We evaluate how much heart and lung sparing can be achieved using the semilateral decubitus (SLD) position without and with breath hold compared with the standard supine position for left-sided breast cancer patients. A secondary aim was to investigate the impact of MHD and CLD on heart and lung DVPs. Methods and materialsThirty-five left-sided breast cancer patients were simulated in supine, free breathing SLD, and SLD with breath hold positions. A dosimetry plan was developed for each of these and 3 plans were compared for target coverage and organs at risk sparing. A correlation between CLD, MHD, and planning target volume, and heart and ipsilateral lung DVPs was tested. ResultsSLD breath hold position showed a significant reduction in percentage of heart receiving ≥5 Gy (V5Gy), V10Gy, V25Gy, V30Gy, mean dose and maximum dose (P < .001), ipsilateral lung V20Gy, and mean dose compared with supine (P < 001) and free breathing SLD (P = .003 and .006). There was also a significant reduction in the heart DVPs (P < .001) and ipsilateral lung DVPs (P < .001 and .007) with free breathing SLD compared with the supine position. SLD with or without breath hold were associated with significant reduction in MLD (P < .001) and CLD (P = .030 and .003) compared with the supine position. ConclusionTreatment plans for patients in the SLD position with or without breath hold for left-sided breast cancer patients demonstrated a superior heart and lung sparing compared with the supine position due to significant reduction in MHD and CLD. MHD and CLD are important simulation factors that affect the heart and lung DVP.

Lateral Decubitus All-Arthroscopic Latarjet Procedure for Treatment of Shoulder Instability

Shoulder instability can be a challenging condition to treat when it becomes refractory to soft-tissue procedures or when bone loss exceeds 25% to 27% of the glenoid. The Bristow-Latarjet procedure has been developed and popularized to deal with these concerns. Traditionally, the procedure has been performed as an open approach; however, this has been recently supplanted by novel arthroscopic techniques. We present a technique for the procedure performed with the patient in a semi-lateral decubitus position that assists with optimal graft placement on the native glenoid. We use the cannulated Bristow-Latarjet Instability Shoulder System (DePuy Mitek, Raynham, MA). After a diagnostic arthroscopic evaluation, we use multiple arthroscopic anterior portals to debride the rim of the glenoid. The coracoid is prepared and taken down arthroscopically, and the cannulated guide is attached and advanced through an arthroscopically created subscapularis split. With the shoulder held in a reduced position, we are then able to drill and anchor the graft to the native glenoid. The patient is able to begin gentle range-of-motion exercises immediately postoperatively.

Intrahepatic Glissonian Approach for Laparoscopic Right Trisectionectomy

A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placedin aleft semilateral decubitus position with the surgeon between the patient’s legs. Five trocars (three 12 and two 5mm) were used. The pneumoperitoneum is established at a pressure of 12mm Hg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left-liver fixation at the end of the procedure. The falciform and coronary ligaments are divided by using laparoscopic coagulation shears (Harmonic Scalpel LCS; Ethicon Endo-Surgery Industries, Cincinnati, OH)toexpose thesuprahepaticinferiorvenacava. After cholecystectomy, the right hepatic artery is ligated, resulting in an ischemic delineation of the right liver. Due to previous right-portal-vein embolization in this patient, the hepatic pedicle was not fully dissected. The right liver is then fully mobilized, and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle-right hepatic vein) is divided with a vascular endoscopic stapler. The right hepatic vein is finally encircled, and downward retraction permits the safe application of a vascular endoscopic stapler. The stapler is fired, leaving three lines of metallic clips. With this maneuver, the anterior surface of the retrohepatic vena cava is completely exposed. The main trunk, including the middle and left hepatic veins, is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection. At this time, the intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: An incision is performed on the right portion of the caudate lobe and another anterior incisionismadeinfrontofthehilum.Anendoscopicvascular

Trisegmentectomia hepática direita por videolaparoscopia

INTRODUÇÃO: Em 2007 os autores descreveram a primeira hepatectomia direita por videolaparoscopia realizada no Brasil. Hepatectomia direita ampliada, também conhecida como trisegmentectomia direita, é procedimento altamente complexo e implica em grande retirada do volume hepático. Os autores descrevem a primeira trisegmentectomia direita por videolaparoscopia realizada no Brasil. TÉCNICA: O paciente é colocado em posição supina em decúbito lateral esquerdo. O cirurgião se coloca entre as pernas da paciente. Utilizamos cinco trocartes, três de 12 mm e dois de 5 mm. Devido à embolização prévia da veia porta direita, o hilo hepático não é dissecado. O pedículo portal direito é seccionado com grampeador laparoscópico de carga vascular por meio de acesso intra-hepático, segundo técnica previamente descrita pelos autores. A seguir procede-se a mobilização do fígado direito seguido de dissecção da veia cava retro-hepática e secção da veia hepática direita. Estes passos são realizados sem manobra de Pringle. O fígado é seccionado com combinação de bisturi harmônico e grampeador endoscópico. O pedículo do segmento 4 é seccionado dentro do fígado. O espécime é retirado por meio de incisão supra-púbica e a área cruenta é revista para verificar hemostasia. O procedimento é encerrado e dreno de sistema fechado é posicionado junto à área cruenta. CONCLUSÃO: Trisegmentectomia hepática direita por videolaparoscopia é procedimento factível e seguro e deve ser considerado para pacientes selecionados. Este procedimento deve ser realizado em centros especializados e por cirurgiões com experiência tanto em cirurgia hepática como cirurgia laparoscópica avançada.

Laparoscopic options in the treatment of splenic artery aneurysms

The retrogastric and often intrapancreatic position of splenic artery aneurysms (SAA) has discouraged many surgeons from attempting the laparoscopic resection of SAA. Only two reports of successful laparoscopically resected SAA have appeared in the surgical literature. The successful laparoscopic resection of a large expanding SAA was accomplished using a modification of currently described techniques. The semilateral decubitus position affords excellent access to the lesser sac, allowing excision of SAA with good visualization of the splenic artery and splenic hilar vessels should splenic hypoperfusion demand splenic resection. Excision of SAA is preferred to ligation except when dense adhesions or intrapancreatic arterial course preclude safe dissection. Pseudoaneurysms from trauma or pancreatitis are likely best treated with intraarterial embolization but significant complications should be expected in this high-risk subset of patients.

Damaged Univent[registered sign] Tubes

Univent[registered sign] endotracheal tube (Fuji Systems, Tokyo, Japan) damage is rare, but we have encountered two such cases: a fragmented tube and a fractured tube. Case Reports Case 1 The patient was a 62-yr-old, 158-cm, 58-kg man scheduled for surgery with a diagnosis of esophageal cancer. After placement of a 8.5-mm single-lumen cuffed Univent[registered sign] tube made of silicon, the built-in cuff was advanced into the right mainstem bronchus with the aid of fiberoptic bronchoscopy. The bronchial blocker cuff was inflated to permit one-lung ventilation that was confirmed by auscultation of the lungs. The patient was in a left semilateral decubitus position, and the operating Table wasrotated to the left according to the surgical procedure. During two-lung ventilation, analysis of arterial blood gases was normal, and pulse oximetry showed 99%-100% oxygen saturation. However, during one-lung ventilation, oxygen saturation decreased to 93%, and PaO2 gradually decreased from 130 to 52 mm Hg despite the inhalation of 100% oxygen. One-lung ventilation time was 90 min in total, and during this period, both lungs were ventilated manually a few times until oxygen saturation recovered to 100%. Surgery was completed in 6 h 20 min; the anesthesia time was 7 h 40 min. The patient entered the intensive care unit with the Univent[registered sign] endotracheal tube still in place. When the trachea was suctioned, using a fiberoptic bronchoscope, we found a foreign body at the proximal region of the left anterior segmental bronchus, and the object was removed. As it seemed to be a silicon fragment, the Univent[registered sign] endotracheal tube was replaced with a single-lumen tube, and we inspected the Univent[registered sign] tube carefully. The inner part where a slip joint (a tracheal tube connector) attached to the tube was broken, and the object that was removed from the patient's bronchus fit perfectly into the defective area (Figure 1). Neither atelectasis nor the foreign object was seen on chest radiograph taken immediately after the patient entered the intensive care unit.Figure 1: A fragmented Univent[registered sign] tube and a silicon tip that was removed from the patient's bronchus. The size of the fragment is approximately 9 x 3 mm. The outer diameter of the slip joint (the tracheal tube connector) shown on the right is apparently larger than the inner diameter of the tube.Case 2 The patient was a 57-yr-old, 160-cm, 56-kg man undergoing surgery for esophageal cancer. A 9.0-mm Univent[registered sign] tracheal tube was used. During surgery, the slip joint disconnected from the Univent[registered sign] tube several times and had to be reconnected. After extubation, we checked the Univent[registered sign] tube for fracture and noticed that the inside of the tube was damaged (Figure 2).Figure 2: The orifice of the Univent[registered sign] tube is fractured at the same place as in the first case.Discussion Before intubation, the tube and the slip joint must be joined together because the Univent[registered sign] tube itself and its connector, the slip joint, are packed separately. It seems to be easier to detach the slip joint from the Univent[registered sign] tube after inserting it into the tube if a fiberoptic bronchoscope with a large diameter is used to verify adequate placement of the tube. The inner diameter of the tube is smaller than the outer diameter of the slip joint by 1 mm (Figure 1). Consequently, if a tube and a slip joint are attached improperly, they can easily disconnect. However, so much force is needed to connect them properly that it may cause a fracture in the inner layer of the tube. The silastic Univent[registered sign] tubes are more elastic and fragile than conventional tubes made of polyvinyl chloride. In the first case, we assume that a silicon fragment chipped away from the tube on connection and traveled into the patient's bronchus [1] when we were performing fiberoptic bronchoscopy or when the airway was suctioned. Fortunately, the silicon tip fragment did not cause a serious complication, such as airway obstruction [2,3] or atelectasis. In the second case, the tube was fractured at the same place as in the first case, and this was not noticed until tracheal extubation. Our experiences illustrate that the tracheal tube connector can damage the Univent[registered sign] tube. The two parts should be connected cautiously.