Single-stage Resection Research Articles

Single-stage resection of uterine fibroids and intravascular leiomyomatosis: a case report

BackgroundUterine Fibroids (UFs) are common benign tumors in the female reproductive tract, but their progression to intravascular leiomyomatosis (IVL) is rare. Presently, there are few reports on single-stage resection of UFs and IVL.Case presentationA 47-year-old woman, G2P2, had been diagnosed multiple UFs four years ago and now developed heart failure. Imaging examinations revealed that UFs had invaded the right iliac vein and extended into the right atrium through the inferior vena cava. Through multidisciplinary collaboration and a single-stage resection, the patient has survived for over 24 months post-surgery, and her heart function has significantly improved compared to preoperative levels, with no recurrence of UFs observed.ConclusionsSingle-stage resection of IVL and UF is feasible and advantageous for this case, and selecting the appropriate surgical approach is crucial.

Anatomical determinants of occipitocervical fusion in skull base chordoma resection: a systematic review of the literature with illustrative cases.

Skull base chordomas are rare, locally osseo-destructive lesions that present unique surgical challenges due to their involvement of critical neurovascular and bony structures at the craniovertebral junction (CVJ). Radical cytoreductive surgery improves survival but also carries significant morbidity, including the potential for occipitocervical (OC) destabilization requiring instrumented fusion. The published experience on OC fusion after CVJ chordoma resection is limited, and the anatomical predictors of OC instability in this context remain unclear. PubMed and Embase were systematically searched according to the PRISMA guidelines for studies describing skull base chordoma resection and OC fusion. The search strategy was predefined in the authors' PROSPERO protocol (CRD42024496158). The systematic review identified 11 surgical case series describing 209 skull base chordoma patients and 116 (55.5%) who underwent OC instrumented fusion. Most patients underwent lateral approaches (n = 82) for chordoma resection, followed by midline (n = 48) and combined (n = 6) approaches. OC fusion was most often performed as a second-stage procedure (n = 53), followed by single-stage resection and fusion (n = 38). The degree of occipital condyle resection associated with OC fusion was described in 9 studies: total unilateral condylectomy reliably predicted OC fusion regardless of surgical approach. After lateral transcranial approaches, 4 studies cited at least 50%-70% unilateral condylectomy as necessitating OC fusion. After midline approaches-most frequently the endoscopic endonasal approach (EEA)-at least 75% unilateral condylectomy (or 50% bilateral condylectomy) led to OC fusion. Additionally, resection of the medial atlantoaxial joint elements (the C1 anterior arch and tip of the dens), usually via EEA, reliably necessitated OC fusion. Two illustrative cases are subsequently presented, further exemplifying how the extent of CVJ bony elements removed via EEA to achieve complete chordoma resection predicts the need for OC fusion. Unilateral total condylectomy, 50% bilateral condylectomy, and resection of the medial atlantoaxial joint elements were the most frequently described independent predictors of OC fusion in skull base chordoma resection. Additionally, consistent with the occipital condyle harboring a significantly thicker joint capsule at its posterolateral aspect, an anterior midline approach seems to tolerate a greater degree of condylar resection (75%) than a lateral transcranial approach (50%-70%) prior to generating OC instability.

Pediatric anterior thoracic wall reconstruction: a successful case of extensive resection and repair

BackgroundThoracic tumors are a challenge for pediatric surgeons. They comprise a heterogeneous group of neoplasms classified based on histological variety, location, presentation, biological behavior, treatment response, and prognosis. Primary tumors of the thoracic wall in children and adolescents are sporadic, accounting for only 1–2% of all pediatric thoracic neoplasms, with two-thirds of them being malignant.Case presentationWe present the case of a 16-year-old male patient with osteoblastic osteosarcoma localized in the right anterior rib cage. The patient underwent extensive tumor resection using titanium bars.ConclusionThoracic reconstruction following extensive resection in pediatric cancer patients has been underexplored and poorly described. Nevertheless, it has been demonstrated to be feasible, particularly considering the 5-year survival rate of 60% following tumor resection. This approach helps prevent anatomical and physiological complications that may arise without reconstruction. We report a successful single-stage resection and thoracic reconstruction case in a pediatric patient. This case underscores the importance of considering reconstruction in patients with thoracic tumors, as it can contribute to improving prognosis and preventing associated complications.

Misdiagnosed cystic pancreatic neuroendocrine tumor with bilobar hepatic metastasis managed with single-stage resection — a case report

BackgroundPancreatic neuroendocrine tumors (PNET) account for less than 2% of all pancreatic tumors, while cystic PNETs account for only 10–18% of all resected PNETs. The most common site for metastasis is the liver. Few detailed guidelines currently exist for management of stage 4 cystic PNETs. This is a unique case that was managed with complete surgical resection in one sitting.Case presentationOur report is on a young male patient who was initially misdiagnosed as having a pancreatic pseudocyst and treated accordingly. He was finally diagnosed with PNET but was reluctant to undergo surgery until he developed bilobar hepatic metastasis. We performed a pylorus-preserving pancreaticoduodenectomy with a Roux-en-Y hepaticojejunostomy and wedge resection of both hepatic metastatic deposits.ConclusionCystic PNETs are rare and commonly misdiagnosed as pancreatic pseudocysts. Surgical resection is considered ideal, but sparse literature exists on the management due to a paucity of cases. We have reported this case as it was successfully managed with single-stage surgery for both the primary tumor as well as bilobar hepatic metastatic deposits, and no similar cases have been reported in literature. The follow-up scan revealed no residual disease.

Pediatrics, Craniofacial and Orthognathic Surgery Track: Juvenile Active Ossifying Fibroma of the Frontal Sinus: A Case Report of Single-Stage Resection and Reconstruction Using Virtual Surgical Planning and Patient-Specific Implants

Pediatrics, Craniofacial and Orthognathic Surgery Track: Juvenile Active Ossifying Fibroma of the Frontal Sinus: A Case Report of Single-Stage Resection and Reconstruction Using Virtual Surgical Planning and Patient-Specific Implants

Preoperative n-BCA embolization in the resection of submandibular lymphatic malformations refractory to sclerotherapy treatment: A pilot case series.

Lymphatic malformations in the submandibular neck pose unique challenges to treatment that elevate their risk of recurrence. This case series provides a review of five patients, previously treated with sclerotherapy or with a history of multiple infections, who were treated in a novel fashion: single-stage resection using preoperative n-butyl cyanoacrylate (n-BCA) glue embolization. We performed a retrospective medical record review of five patients who underwent single-stage n-BCA embolization by Interventional Radiology followed by surgical resection by Otolaryngology, including a review of their symptoms, previous treatments, and post-treatment surveillance, with follow-up ranging from 4 to 24 months after the treatment of interest. All study subjects had unremarkable perioperative courses, and four patients did not demonstrate any evidence of disease recurrence or persistence during the follow-up period. One patient was found to have a small area of persistent disease on post-treatment imaging, but has remained symptom free. Treatment of submandibular lymphatic malformations with n-BCA embolization followed by surgical resection can be performed in a single stage. This case series demonstrates that this approach can yield durable relief of symptoms, even in patients whose lesions were refractory to previous treatments.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RationalePropranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management. MethodsPatients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value <0.05 was taken as significant. ResultsIn Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049). ConclusionSandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Surgical Strategy for Primary Colorectal Carcinoma and Synchronous Pulmonary Metastasis Resection.

BackgroundThe surgical strategy for single-stage resection of primary colorectal cancer (CRC) and synchronous pulmonary metastases remains a matter of debate.MethodsPerioperative data of patients who underwent single-stage resection of primary CRC and synchronous pulmonary metastases were compared to those of patients who underwent 2-stage resections. The demographic data, number of metastases, type of pulmonary and colorectal resections, operation time, blood loss, postoperative complications, morbidities, mortality, medical costs, and length of hospital stay were analyzed.ResultsTwenty-two patients underwent single-stage resection of primary CRC and pulmonary metastases, while 27 patients underwent 2-stage resection. Tumor size and the number of pulmonary metastases were not significantly different between the 2 groups. The extent of pulmonary metastasectomy and abdominal procedures were similar in both groups, as was the thoracic surgical approach (video-assisted thoracic surgery vs. thoracotomy). However, open laparotomy was performed more frequently in the 2-stage group than in the single-stage group (p=0.045), which also had a longer total anesthetic time (p=0.013). The operation time, medical costs, estimated blood loss, complication rates, and severity were similar in both groups, but the length of hospital stay was shorter in the single-stage group (p<0.001).ConclusionSingle-stage colorectal and pulmonary resection shortened the overall hospital stay, with no significant changes in operation time, medical costs, hospital mortality, and morbidity. Therefore, single-stage resection could be a good surgical strategy in selected patients.

In Reply: Residual and Recurrent Disease Following Endoscopic Endonasal Approach as a Reflection of Anatomic Limitation for the Resection of Midline Anterior Skull Base Meningiomas.

To the Editor: Drs McGahan, Magill, and Prevedello have provided a very thoughtful and logical algorithm1 for approaching 1 group of tumors discussed in our article.2 Their proposed approach selection for olfactory groove meningiomas demonstrates their experience and skill with all options, which is the ultimate goal of any skull base surgeon. We were glad to see that this article stimulated such a response, as it was written with the hope of clarifying the anatomic boundaries of the endonasal approach as 1 small step in elucidating the “right” approach for any given patient. The authors state that they prefer a “craniotomy” when olfaction is preserved. As they allude, the type of craniotomy may be critical, evidenced by the small series referenced by Jang et al,3 which showed improved olfactory outcomes compared with bifrontal craniotomy in the 21 patients who were selected for frontotemporal craniotomy based largely on unilateral dysfunction and lateral extension. Unspoken in this is that there is inevitably a less radical tumor removal inherent in leaving the cribriform plate (and olfactory fibers) untouched. This must also be considered in the context that the majority of patients with olfactory groove meningiomas have absent or severely impacted olfaction at presentation. For tumors not amenable to endonasal resection, a single-stage resection using a modified subfrontal transbasal approach allows complete tumor resection, including skull base/sinonasal invasion with pericranial flap reconstruction, while minimizing brain manipulation. This approach is mostly extradural with barely any brain exposure. Often, going back to traditional and properly done skull base approaches is the preferred choice. We agree completely with the authors of this letter with respect to the role of olfaction in approach selection for these tumors, but we believe that visual compromise should also be considered, given growing evidence that midline tumors presenting with vision loss may have better outcomes when treated with a midline approach. This is especially important for tuberculum and planum meningiomas, key groups in this article. In addition, neurosurgeons as a group have largely ignored the impact of anterior base meningiomas and surgical approach on neurocognitive outcomes. At a minimum, endonasal approaches minimize radiographic impact on the frontal lobes,3 and further study is needed to understand if there is a cognitive tradeoff for the potential olfactory preservation provided by craniotomy. Indeed, the staged approach discussed in this letter considers this and is an excellent option, especially when there is significant edema. Staging may also occasionally demonstrate an unexpected medial attachment with only pushing borders laterally on the skull base (rather than a true lateral attachment). It is our hope that the conversation that is ongoing via this paper and the resultant letter will continue to help all of us fully understand the impact of various approaches on the multiplicity of critical functions that midline anterior skull base meningiomas involve and how to balance radicality of resection with preservation of these functions. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

EP.WE.1015Management of Boerhaave Syndrome

Abstract Aim Boerhaave’s Syndrome is a rare and fatal condition, characterised by a distal oesophageal tear induced by an abrupt rise in intra-luminal pressure. Treatment remains controversial; we present a recent case and review relevant literature. Methods A retrospective analysis of case-notes was performed, and a literature review undertaken on PubMed. Results A 58-year-old male presented as an emergency with severe chest pain, having choked and vomited following the ingestion of steak. Computed tomograpy scan of the thorax demonstrated a large pneumomediastinum associated with an oesophageal perforation on the anterior wall and bilateral pleural effusions. A primary laparoscopic repair was performed with jejunostomy placement for feeding. The post-operative period was complicated by a prolonged stay on intensive care with sepsis secondary to mediastinitis. A contrast swallow performed eleven days post-surgery confirmed no persistent leak and the patient was discharged five days later. Boerhaave’s syndrome accounts for 10% of oesophageal perforations and is typically associated with a history of overindulgence and vomiting. Stable patients with a contained disruption and minimal contamination, can be managed conservatively. Endoscopic therapies include clipping small perforations, self-expanding stents for larger defects, and endoluminal vacuum therapy. Operative interventions comprise primary repair, debridement and drainage of thoracic cavity, diversion operations and single stage resection with or without primary reconstruction. Conclusion Boerhaave’s Syndrome is associated with significant morbidity and mortality, but with early recognition and prompt intervention, patients can be successfully managed. Options include conservative, endoscopic and surgical, depending upon the site and size of the perforation.

Single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation for the treatment of lumbar tuberculosis and psoas major abscess.

To investigate the feasibility and clinical efficacy of the treatment for lumbar tuberculosis with psoas major abscess with single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation. Thisretrospectivestudy evaluated the clinical data of 24 patients (14 males and 10 females) with lumbar tuberculosis and psoas major abscess admitted to the Comprehensive Surgery from June 2016 to June 2019.All patients were treated with the single-stage posterior approach to remove the transverse process combined with the intervertebral foramina approach for debridement, interbody fusion, internal fixation. The quadruple anti-tuberculosis drug therapy was given both pre-operatively and post-operatively. Clinical symptoms and complications were investigated and recorded. The visual analogue scale (VAS), American Spinal Injury Association (ASIA), degree of lesion fusion C-reactive protein (CRP) levels, and erythrocyte sedimentation rate (ESR) were evaluated. The average follow-up period was 16. 5months (from 12 to 36months). The average VAS score at threemonths post-operation was significantly declined than the pre-operative VAS score [(2.17 ± 0.87) points vs (5.46 ± 1.22) points, t = - 11.534, P < 0.01)]. At the last follow-up, the neurological function of 20 patients recovered to grade E, whereas four patients were still in grade D. The ESR and CRP returned to normal levels in all patients. Bone fusion was achieved in nine cases at sixmonths, 11 cases at ninemonths, and four cases at 12months. The incisions of 23 patients had healed nicely without chronic sinus. Poor incision healing only happened in one case at the day 12 post-operation. The bone grafts among the lesions obtained bony fusion. Besides, there was no recurrence of tuberculosis, loosening or fracture of internal fixation during the follow-up. Single-stage posterior resection of the transversal process combined with an intervertebral foramina approach for debridement, interbody fusion, internal fixation is probably an effective and safe approach of the treatment for lumbar tuberculosis combined with psoas major abscess, producing few complications. This technique provides an alternative method for the surgical treatment of lumbar tuberculosis combined with psoas major abscess.

The surgical management of large bowel obstruction in patients with left colon and rectal cancer – a retrospective study

The optimal surgical attitude towards obstructed left colon and upper rectal cancer remains elusive, one of the main postoperative endpoints being to avoid the most dreaded complication of this type of procedures - the anastomotic leakage. Material and methods: We conducted a retrospective analysis of all patients with left colon and rectal cancer admitted and having emergency surgery performed in the surgical departments of the University County Hospital of Craiova, Romania, between 2001 and 2018. The timeline analysis showed an increasing interest for single-stage resection and anastomosis in the second decade (2011-2018) compared to the first decade of the study (28% vs. 11.2%). Results: The incidence of anastomotic leak for these types of procedures remained higher than for the two-stage procedure (15% vs. 4.8%), similar to the overall postoperative morbidity (30.3% vs. 20%) and mortality (3% vs. 1.1%). Postoperative morbidity and anastomotic leak rate were statistically higher in the single stage procedure group when compared with the two-stage procedure (p <0.05). Conclusions: Deciding between single-stage resection with anastomosis and a two-stage procedure requires a careful patient selection due to the relatively high risk of anastomotic leak in this specific category of patients.

Is single-stage resection and anastomosis for acute sigmoid volvulus, without intra operative colonic lavage a safe procedure?

Objective. This study was conducted to provide local data regarding the results and post-operative complications after single-stage resection and anastomosis for acute sigmoid volvulus, without intra operative colonic lavage. Study Design: Descriptive Cross Sectional. Setting: DHQ Charsadda. Period: May 2017 to December 2019. Material &amp; Methods: This clinical study was done on 50 patients who presented with the signs and symptoms of acute sigmoid volvulus excluding those with complications of the illness such as gangrene, perforation and peritonitis. Surgery for all patients was carried out under General anaesthesia. All the patients underwent emergency resection and primary anastomosis, without mechanical bowel preparation. Data were collected regarding post operation complication and analysis by using SPSS version 23. Chi square test was used to compare at level of significance &lt;0.005. Results: Median age of patients was 50 years with male to female ratio 5:3. Seven patients presented with wound infection, one dehiscence while zero Anastomotic leakage and zero death postoperative recorded. Conclusion: Single stage resection and primary anastomosis without preoperative colonic lavage for acute sigmoid volvulus is a simpler and short procedure with low mortality and morbidity rates.

224 Use of Novel Decellularized Cadaveric Dermis (dCELL) In Single-Stage Resection and Reconstruction of Non-Melanomatous Skin Cancer of The Head and Neck

Abstract Background This study examines the use DCELL, a novel acellular dermis product produced in the UK for the reconstruction of these skin defects. Method This was a single-centre, prospective study of patients undergoing single stage wide local excision of non-melanomatous skin cancer and reconstruction with decellularised dermis. Our inclusion criteria included any patient that required a curative excision but had risk factors where conventional local flap or free tissue transfer could have a potential adverse outcome. Results Thirty-seven wounds were treated with DCELL in thirty-one patients. Mean age was 81.6 years (range 61-94 years) and at the time of operation, 25 patients (80.7%) were ASA 3 or above. The scalp was the most common anatomical area operated on (n = 28, 75.7%). The overall proportion of wounds with complete closure was 89.2% (33 out of 37 wounds), with a failure rate of 10.8% (4 complete graft failures). Device-related complications included one episode of crusting over the graft which resolved with topical antibiotics, and a hypertrophic scar over the wound edges. Cosmesis was satisfactory in all cases. Conclusions DCELL demonstrated a very good take rate with equally satisfactory cosmetic outcomes in patients where standard reconstructive approaches may have adverse outcomes.

A giant posterior mediastinal malignant peripheral nerve sheath tumor and benign neurofibroma in body surface: a case report

BackgroundNeurofibromatosis comprises neurofibromatosis type 1 (NF1) and type 2 (NF2). Major tumor type of NF1 are neurofibroma recognized as benign peripheral nerve tumor, malignant peripheral nerve sheath tumor (MPNST), and glioma.Case presentationWe report a woman with a special condition, whose tumors in body surfaces were benign neurofibroma and tumors in posterior mediastinum are MPNST. The chest-enhanced CT suggested a round soft tissue density in posteriormediastium. The diagnosis was established by pathology and immunohistochemistry. A single-stage thoracoscopic mediastinal mass resection was performed. The whole operation went smoothly and the CT scan of lungs did not show relapse of tumor three months later.ConclusionsThe appearance of neurofibroma should draw particular attention to the possibility of developing MPNST. More careful imaging examinations should be carried out, and pathological examination could diagnose it.

Use of Novel Decellularized Cadaveric Dermis (DCELL) in Single-Stage Resection and Reconstruction of Nonmelanomatous Skin Cancer of the Head and Neck

Reconstructive options in nonmelanomatous skin tumors of the head and neck region are limited in the frail, elderly patient group, where split skin thickness or full thickness grafts may not be a viable option. This study examines the use decellularized cadaveric dermis (DCELL), an acellular dermis product produced in the United Kingdom for the reconstruction of these skin defects. This was a single-center, prospective study of patients undergoing single stage wide local excision of nonmelanomatous skin cancer and reconstruction with decellularized dermis. Our inclusion criteria included any patient that required a curative excision but had risk factors where conventional local flap or free tissue transfer could have a potential adverse outcome. Thirty-seven wounds were treated with DCELL in 31 patients. Mean age was 81.6 years (range 61-94 years) and at the time of operation, 25 patients (80.7%) were ASA 3 or above. The scalp was the most common anatomical area operated on (n = 28, 75.7%). The overall proportion of wounds with complete closure was 89.2% (33 out of 37 wounds), with a failure rate of 10.8% (four complete graft failures). Device-related complications included one episode of crusting over the graft which resolved with topical antibiotics, and a hypertrophic scar over the wound edges. Cosmesis was satisfactory in all cases. DCELL demonstrated a very good take rate with equally satisfactory cosmetic outcomes in patients where standard reconstructive approaches may have adverse outcomes. Further research is needed to better define its role in the management of these skin cancers.

Comparison of two different titanium cranioplasty methods: Custom-made titanium prostheses versus precurved titanium mesh.

Background: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses.Methods: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants.Results: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500).Conclusion: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies.

Exoscope-Guided (VITOM 3D) Single-Stage Removal of Supratentorial Cavernous Angioma and Hemangioblastoma: 3-Dimensional Operative Video.

This video shows an exoscope-guided single-stage resection with 3-dimensional technology of a supratentorial cavernoma and a supratentorial hemangioblastoma during the same surgical procedure. The patient is a 42-yr-old man with a history of generalized tonico-clonic seizures. Contrast-enhanced magnetic resonance (MR) revealed the presence of a left frontal cavernoma and a left T1 non-enhancing hypointese temporal lesion (hemangioblastoma). The operation was carried out in the lateral position with the sole use of a 3D-exoscope (VITOM-3D, Karl Storz GmbH&Co, Tuttlingen, Germany). The operating room set-up included the surgeons standing at the head of the patients with the operating and navigator screens in the front of them and the exoscope arm entering from the left side. As recently highlighted, the 3D-exoscope carries several advantages: (1) it allows neurosurgeons to operate in a confortable and stable position; (2) it is less space-occupying in comparison to the microscope; (3) the optics and 3D-screen offer an optimal stereoscopic view in comparison to the 2D-exoscope, important for both surgical and training purposes; (4) although sharing with the endoscope, the image quality and confortable surgeon's position, there is no conflict between the surgical instruments and the scope in the surgical field. The adopted strategy enabled a complete resection of both lesions. The postoperative course was uneventful and the patient was seizure-free; the antiepileptic drugs were discontinued 3 mo after surgery. The 3D-exoscope represents a promising surgical tool, which may become part of the neurosurgical armamentarium. Nevertheless, the conceivable capability to improve neurosurgical results will have to be explored. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient has consented to the submission of the surgical video for submission to the journal.

Computer-aided methods for single-stage fibrous dysplasia excision and reconstruction in the zygomatico-orbital complex

Purpose Computer-aided design and additive manufacture (CAD/AM) technologies are sufficiently refined and meet the necessary regulatory requirements for routine incorporation into the medical field, with long-standing application in surgeries of the maxillofacial and craniofacial regions. They have resulted in better medical care for patients and faster, more accurate procedures. Despite ever-growing evidence about the advantages of computer-aided planning, CAD and AM in surgery, detailed reporting on critical design decisions that enable methodological replication and the development and establishment of guidelines to ensure safety are limited. This paper aims to present a novel application of CAD and AM to a single-stage resection and reconstruction of fibrous dysplasia in the zygoma and orbit. Design/methodology/approach It is reported in sufficient fidelity to permit methods replication and design guideline developments in future cases, wherever they occur in the world. The collaborative approach included engineers, designers, surgeons and prosthetists to design patient-specific cutting guides and a custom implant. An iterative design process was used, until the desired shape and function were achieved, for both of the devices. The surgery followed the CAD plan precisely and without problems. Immediate post-operative subjective clinical judgements were of an excellent result. Findings At 19 months post-op, a CT scan was undertaken to verify the clinical and technical outcomes. Dimensional analysis showed maximum deviation of 4.73 mm from the plan to the result, while CAD-Inspection showed that the deviations ranged between −0.1 and −0.8 mm and that the majority of deviations were located around −0.3 mm. Originality/value Improvements are suggested and conclusions drawn regarding the design decisions considered critical to a successful outcome for this type of procedure in the future.

Large Intradural Tympanojugular Paragangliomas. A Contribution on Surgery and Management

Large intradural growth of tympanojugular paragangliomas (TJ-PGs) into the cerebellopontine angle is an infrequent condition that can determine an extensive involvement of vessels and brainstem, representing a surgical challenge. The current classifications lack accuracy for defining large intradural TJ-PGs and assessing their operability. This study aims to retrospectively reappraise the management of a large intradural TJ-PGs surgical series, discussing operability criteria, treatment strategies, and resection techniques. Over a series of 63 class D TJ-PGs operated on between 1973 and 2008, patients with large intradural tumors were retrospectively reviewed. Surgical techniques and outcomes with long-term follow-up were analyzed. Seven patients presented with large intradural tumors, ranging from 4 cm to 5.5 cm in diameter. These cases were treated either via a petro-occipital transsigmoid approach in a single-stage resection (4 patients) or via a petro-occipital approach as a second-stage surgery after a previous infratemporal fossa approach on the extradural tumor (3 patients). Complete tumor resection was obtained in 5 cases through wide removal of the petro-occipital skull base and exposure of the dural root of the tumor, which carries its main blood supply and allows preemptive hemostasis. No new postoperative cranial nerve losses were observed. The surgical procedure was aborted in 2 cases because of cerebellar edema and carotid artery tear, respectively. Large intradural TJ-PGs can be effectively surgically managed with an appropriate technique combined with relevant nonsurgical strategies. Thus, operability criteria for these lesions can be extended. To share objective experience on large intradural TJ-PGs, a redefinition of Di3 tumors is recalled.