Transverse Cervical Incision Research Articles

Pediatric Lipoblastoma of the Neck

Lipoblastoma is a rare, benign, and encapsulated tumor arising from embryonic white fat. Most of the cases occur in the extremities and the trunk; only a few cases in the head and the neck are reported. Thus, we present a case of lipoblastoma of the neck with a review of the literature. A 1-year-old male infant presented to our hospital, with a history of painless swelling in the left side of the neck for 3 months that was rapidly enlarged. His birth history and medical history were unremarkable. A physical examination demonstrated a soft and compressible mass in the left side of the neck. The mass was nontender to palpation and mobile without cellulitic changes in the overlying skin. A computed tomographic scan showed that the mass is heterogenous, has low attenuation in nature, and is 3.8 × 2.8 × 9 cm in size. Under general anesthesia, transverse cervical incision was made through the neck wrinkle, and there was no invasion of any of the neck structures. Complete surgical excision demonstrated yellowish-white, irregular lobules of immature fat cells separated by a loose and myxoid connective tissue. Grossly, the mass was a homogeneous tan-pink gelatinous mass. A microscopic examination demonstrated a small number of capillaries and mature fat cells, and differentiating immature lipoblastoma cells were detected in the myxoid stroma. A pathologic finding confirmed the diagnosis of lipoblastoma. The postoperative course was uneventful. The patient underwent follow-up for 1 year after the operation, and there was no evidence of recurrence. The most common presentation of lipoblastoma is a painless, rapidly enlarging neck mass. Published reports showed that most of them occur before the age of 3 years. Complete surgical excision is the treatment of choice. Although lipoblastoma is an extremely rare benign tumor, it should be considered in the diagnosis of neck mass in children younger than 3 years.

PP161: Applications for the sternocleidomastoid perforator flap

The conventional pedicled sternocleidomastoid (SCM) flap is a type II flap with a segmental vascular supply. It has a poor arc of rotation, limited volume and precarious vascularity. The author recently described a new technique for raising a SCM flap in which the flap has been fully mobilised by division of the upper and lower attachments of the muscle and is based solely on the perforating vessels of the superior thyroid vascular pedicle. This presentation reviews our experience with the SCM perforator flap. A case series based on a contemporaneous database over the last 3 years. All patients were managed for oral malignancy. The indications included; the patient was not suitable for free tissue transfer or pectoralis major flap, there was often substantial comorbidity, previous surgical and/or radiotherapy treatment, or recurrent disease. A conventional transverse cervical incision was preferred and most flaps were myocutaneous. The skin paddle was positioned directly over the mid to lower half of the SCM muscle. Minimal excision of proximal and distal muscle tissue was undertaken and the defect closed directly. The results of at least 10 patients will be presented. The greatly increased arc of rotation allowed placement in the floor of the mouth or tongue without tension. On one occasion there were no suitable vessels so a conventional superiorly based rotational flap was utilised. All perforator flaps survived without complication and functioned satisfactorily. The perforator flap is based on the dominant vessels (superior thyroid artery and/or branches of the external carotid artery) which supply the middle third. It may safely be used to reconstruct small to medium size defects of the oral cavity even when there has been previous surgical and/or radiotherapy providing there is a suitable perforating vessel. This technique is also a logical development of the increasing utilisation of perforator flaps to minimise donor site morbidity.

Rapid Intravenous Induction of Anesthesia for Dilatation of Severe Post-Intubation Tracheal Stenosis with Rigid Bronchoscopy: Report of 100 Cases

Background : Rigid bronchoscopic dilatation is the lifesaving method for management of severe tracheal stenosis which is carried out under general anesthesia. However, this procedure is a challenging practice for both anesthesiologist and bronchoscopist because loss of airway control and sever hypoxemia can occur following induction of anesthesia. Inhalational induction with avoiding muscle relaxants and preservation of spontaneous breathing is commonly recommended in these patients. However, this technique needs a long time to reach the appropriate levels of anesthesia and may be associated with the risk of complete airway obstruction during airway manipulation. This paper describes our experience in using rapid intravenous induction of anesthesia for dilation of severe tracheal stenosis with rigid bronchoscopy. Materials and Methods : We conducted a retrospective chart review of one hundred patients with benign severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis using intravenous sodium thiopental and succinylcholine for induction of general anesthesia. Results : In 97 patients adequate airway was established immediately after induction of anesthesia with the first attempt of rigid bronchoscope. In one patient, because of local bleeding and mild hypoxemia the airway was managed by a 4 mm tracheal tube and following improvement of oxygenation, dilatation of stricture was successfully done with rigid bronchoscope. In second patient, after passing the first bronchoscope, due to risk of rupturing the trachea, a small transverse cervical incision was made on the trachea and a tracheal tube was inserted through it for patient’s ventilation and dilatation of stricture was managed safely with the rigid bronchoscopes. In the third patient, due to failure of passing the bronchoscope, the trachea was intubated with a 4 mm endotracheal tube and tracheal resection and anastomosis was done successfully. Conclusion : in patients with severe post intubation tracheal stenosis, rapid intravenous induction of anesthesia is a safe method for passage of rigid bronchoscope for dilatation of stricture. Careful planning and close cooperation of the anesthesia and surgical teams is critical for safe and successful conduction of this procedure.

Pros and Cons of Robotic Transaxillary Thyroidectomy

Many techniques using videoscopic (also referred to as endoscopic and laparoscopic) and robotic approaches for thyroidectomy in the treatment of benign and malignant thyroid disease have been described in the literature (1). One such approach is robotic transaxillary thyroidectomy, which was pioneered at Yonsei University, South Korea, and which has been used in some centers in the United States (2–8). This surgical approach has generated much interest in the medical and surgical fields, as well as in the lay public, partly due to heavy marketing of this technology. In this issue of Thyroid, Drs. Chung and Inabnet provide commentaries on the pros and cons of robotic transaxillary thyroidectomy. Because of the contributions of Kocher, today's conventional (open) thyroidectomy is associated with very low morbidity when performed by experienced surgeons with specialized training in endocrine surgery, and it remains the gold standard approach at many centers. Kocher introduced meticulous hemostasis, strict antisepsis, and, initially, a vertical incision for thyroidectomy. With more operative experience, he transitioned from the vertical incision to an incision along the anterior border of the sternocleidomastoid, and finally to a low, transverse cervical incision (9,10). Today most endocrine surgeons use a small, high cervical incision situated in a prominent skin crease because it results in superior cosmesis; however, not all patients are satisfied with their scar and in some cases, patients develop a hypertrophic scar and, rarely, a keloid scar. The main reason the videoscopic and/or robotic thyroidectomy approaches were developed was to avoid an incision in the neck (incisions in the axilla, chest, oral cavity, or around the ear, so-called “scarless” thyroidectomy) or to use only tiny incisions (1–5 mm) in the neck. The advantage of such approaches is cosmetic, although some suggest better visualization and magnification of the operative field with the videoscopic approach, and better surgeon ergonomics and dexterity with a robotic approach. Unlike videoscopic cholecystectomy, which was rapidly adopted into practice, conventional thyroidectomy is a subcutaneous operation associated with very low complication rates, minimal pain, and near nil mortality when performed by specialized, experienced endocrine surgeons. Thus, it is not surprising that the various new approaches for thyroidectomy reported in the literature have not been widely adopted. Nonetheless, many surgeons who developed these techniques have continued to use and refine their approaches in select groups of patients and have provided useful data on the feasibility, indications, and complications associated with these procedures (11–13). There has been much interest in the robotic transaxillary thyroidectomy. Using a robot allows for better dexterity than the videoscopic approach, which was used for the initial development of the transaxillary gasless approach, and data on hundreds of patients have been published (14). These data, as reported by the surgeons who developed this technique, suggest the approach is feasible, is associated with a learning curve of approximately 40–50 cases, and results in relatively low complication rates; however, significant complications, which are not usually encountered using a cervical incision, have occurred, albeit rarely (14,15). The indication for robotic transaxillary thyroidectomy has been extended to papillary thyroid cancer, and primarily to papillary thyroid microcarcinoma. Although the data suggest that the completeness of the robotic thyroidectomy is similar to conventional thyroidectomy, the follow-up time has been too short to truly assess the oncologic outcome (16). Many questions remain: For example, is the robotic transaxillary thyroidectomy cost effective? What guidelines should be used for training a surgeon to use this approach? What is the long-term outcome for clinically significant thyroid cancer? Are many patients likely to be candidates for this approach? For example, patients in the United States have larger body habitus and higher body mass index than those in South Korea. What new complications, and at what rate, would we observe if this approach rapidly proliferates in clinical practice? Drs. Chung and Inabnet provide us with cogent commentaries from their respective continents on the advantages and disadvantages of robotic transaxillary thyroidectomy and clarify its possible role in the future (17,18). Not all surgical innovations are rigorously put to the test of evidence-based medicine before their wide dissemination and implementation in clinical practice, as some innovations are clearly beneficial. However, robotic transaxillary thyroidectomy should be rigorously evaluated in prospective clinical trials to assess patient outcome, complications, cost, and patient satisfaction before it becomes widely accepted and utilized. Such future studies and increasing experience will provide a better understanding of the viability of robotic transaxillary thyroidectomy.

Parotidectomy through periauricular incision

Blair or modified Blair approaches that combine periauricular and cervical incisions are used in almost all parotid surgeries. The aim of this study was to evaluate the results of treatment of parotid surgical diseases using only periauricular incision. 36 consecutive patients with parotid tumors were reviewed. Pleomorphic adenoma (17 cases) was the most common pathologic type followed by other benign tumors (9 cases), carcinoma (5 cases), parotid cyst (3 cases) and chronic parotiditis (2 cases). All parotidectomies were performed through a periauricular incision. In presence of carcinoma, upper cervical lymphadenectomy was conducted through a transverse cervical incision. The wounds were closed with subcutaneous synthesis without skin suture. The parotid tumors were removed in all cases without complementary skin approach. The incisions had good esthetic result and almost imperceptible scars were verified after six months. The patients were very satisfied with the appearance of the operative scar. All patients complained hypostesia of the operative area during a period not longer than six months. Temporary postoperative facial weakness occurred after 28 operations and was permanent in three of patients operated upon for carcinoma. Transitory ear discomfort occurred in 22 patients. Two cases of local infection were recorded. All of these complications have been described previously by other authors using other incisions and are mostly due to removal of the gland. The results of the present study indicate that periauricular incision is a good and highly esthetic option for surgical approach of the parotid.

Transection of the Aerodigestive Tract After Blunt Neck Trauma

Survival after blunt neck trauma resulting in combined tracheal and esophageal injury is uncommon. We present the case of a young boy who sustained complete transection of the trachea and subtotal transection of the esophagus after a clothes line type injury.

Cervical Thymic Cysts in Adults

Three types of cervical thymic anomalies have been described: ectopia, thymic cyst, and thymoma. Thymic cysts are very rare causes of benign neck masses in adults and are usually not diagnosed before surgery. Their prevalence is less than 1% of all cervical masses, and they are usually noted in childhood. We systematically reviewed the literature concerning cervical thymic cysts (CTCs) in adults. We identified 36 adult patients with a CTC. Our analysis included age, gender, cyst size, location, type, symptoms, time from cyst appearance, treatment, pathology, and follow-up. The male/female ratio was 4/5, the mean age was 36 years. Most of the cysts were asymptomatic masses diagnosed by pathology. In only one case did the differential diagnosis include a thymic cyst. Surgery should be considered the treatment of choice, but the size and location of the lesion and its relationship to nearby vital structures should be defined as clearly as possible preoperatively. Excision can be made via a transverse cervical incision. It may be a demanding procedure because of the close anatomical relationship of the CTCs with the carotid sheath and major nerves of the neck (recurrent laryngeal nerve, glossopharyngeal nerve, hypoglossic nerve, and phrenic nerve), particularly if there is adherence of the CTC with those structures. CTCs are uncommon lesions causing neck swelling and are often misdiagnosed preoperatively. Surgical excision and histological examination of the specimen usually makes the diagnosis. The existence of normal thymus gland in the mediastinum should be confirmed intraoperatively, but this is not critical in adult patients. A CTC should be included in the differential diagnosis of cervical cystic masses.

Combined Unilateral-Thoracoscopic and Mediastinoscopic Thymectomy

To achieve maximal benefit, after thymic tissue and mediastinal fat were removed by thoracoscopic thymectomy, a transverse cervical incision allowed access to remove fat in the neck. A mediastinoscopy was then performed for removal of the fat in the retrosternal area superior to the innominate vein. In 15 cases, ectopic thymic tissue was found. There were three cases in which the residual superior horns of thymus were found in the neck and three in the retrosternal area. The combined use of a mediastinoscope and a thoracoscope can remove almost all the thymus, including ectopic tissues. Long-term results are still being awaited.

Minimal access surgery — thyroid and parathyroid

The concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, MIT or MIP should properly be defined as operations through a short and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection.Parathyroid glands are particularly suitable for minimally invasive surgery as most parathyroid tumors are small and benign. MIP are performed through a limited or discrete incision when compared to classic open transverse cervical incision and are targeted on one specific parathyroid gland. The concept of these limited explorations is based on the fact that 85% of patients will have single-gland disease. MIP must be proposed only for patients with sporadic hyperparathyroidism in whom a single adenoma has been clearly localized by preoperative imaging studies.The minimal access approaches to the thyroid gland may be broadly classified into three groups: the mini-open lateral approach via a small incision, minimally invasive video-assisted thyroidectomy via the midline and various endoscopic techniques. Endoscopic extracervical approaches have the main advantage of leaving no scar in the neck but cannot reasonably be described as minimally invasive as they require more dissection than conventional open surgery.Initially the indications for MIT were a solitary thyroid nodule of less than 3 cm in diameter in an otherwise normal gland. Today, MIT are also proposed in patients with small nodular goiters, Graves's diseases and low risk papillary thyroid cancers. Some concern remains about the radicality of MIT in this latter group but preliminary results are comparable to those of conventional surgery both in terms of I-131 uptake and serum thyroglobuline levels.Demonstrating the advantages of MIT and MIP over conventional surgery is not easy. Main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in conventional surgery. Several studies comparing conventional surgery with minimally invasive techniques using a cervical access have shown a diminution of postoperative pain, and better cosmetic results with minimally invasive techniques. MIP and MIT seem overall to be an advance but only randomized studies will demonstrate the real benefit.

Technique for subclavian to carotid transposition, tips, and tricks

When performed properly, a transposition is the most efficient and most durable procedure for reconstructing the subclavian artery for proximal occlusive disease or to extend the landing zone in the aortic arch prior to endovascular therapy for thoracic aortic pathology. The proximal subclavian artery, on the right or on the left, is approached quite differently than it is for a bypass procedure. The technique is described in detail here. There are very few contraindications to transposition, the advantages over the alternate options are many, and it can be the approach of choice in the vast majority of patients.

Video-assisted thoracoscopic extended thymectomy for myasthenia gravis

To investigate the outcome of video-assisted thoracoscopic extended thymectomy (VATET) for myasthenia gravis. From January 2005 to February 2006, VATET had been performed for 41 patients of myasthenia gravis. Among them, 23 patients were female and 18 were male. The age ranged from 18 to 67 years old, and the disease duration ranged from 1 month to 3 years. In order to achieve maximal benefit, a transverse cervical incision was given access to the peri-thyroid space to remove fat in the neck which may contain ectopic thymus after all thymic tissue, including far-reaching ectopic sites. Peri-thymic adipose tissue in the anterior mediastinum was completely removed. In the 41 patients, mean operative time was 162 min. Sever patients sustained myasthenic crises that required reintubation and mechanical ventilation for a few days. Of all patients, 35 had lymphadenectasis, and 4 had ectopic thymus in the peri-thyroid space. After the 2 years' follow-up, the rate of complete stable remission was 41.4%, and the effective rate was 85.4%. Video-assisted thoracoscopic thymectomy represents a safe and valid approach for patients with myasthenia gravis. VATET may be a complement to completely remove all thymus including ectopic tissues.

Combined Transcervical and Unilateral-thoracoscopic Thymectomy for Myasthenia Gravis: 2 Years of Follow-up

To investigate the efficacy of combined transcervical and unilateral-thoracoscopic thymectomy for myasthenia gravis. There were 36 patients with nonthymomatous myasthenia gravis, undergoing combined transcervical and unilateral-thoracoscopic thymectomy and who have been followed-up for more than 2 years. To achieve maximal benefit, a transverse cervical incision was performed to give access to remove fat in the neck, which may contain residual or ectopic thymus after all thymic tissue and mediastinal fat were completely removed by thoracoscopic thymectomy. There were no perioperative deaths and no cases that required conversion to median sternotomy. The mean length of surgery was 162 minutes (range, 132 to 210 min). Three sustained myasthenic crisis. Seventeen patients had lymphadenitis and 4 had ectopic thymus in the neck. There were 2 cases in which the residual superior horns of thymus were found in the neck. Average specimen weights of the thymus, mediastinal fat, and cervical fat were 44.2, 32.5, and 3.6 g, respectively. The rate of complete stable remission was 16.7% at the end of the first year, and rose to 27.8% at the second year. The effective rate was 88.9% at the end of the second year. Thymectomy represents a safe and valid approach for patients with myasthenia gravis. Achieving a curative thymectomy and good cosmesis in myasthenic patients is possible with the combined transcervical and unilateral-thoracoscopic thymectomy as an effective alternative to open approaches.

3-ENDOSOCOPIC THYRIOD SURGERY

Thyroid resection is one of the most common operations performed throughout the world. This procedure is classically realized through a transverse cervical incision and associated with a very low morbidity and mortality rate. However, the visible scar on the anterior surface of the neck is disliked by many patients, especially by young women in whom this

Repair of acute postinfarction atrioventricular dehiscence in a patient with posterior left ventricular aneurysm

the brachial plexus and excluding neural foramina extension. There are several surgical approaches for thoracic outlet pathology. These include supraclavicular, transaxillary, and posterior thoracoplasty for first rib excision in thoracic outlet syndrome. For Pancoast tumors, an anterior (Dartevelle), posterior (Shaw-Paulson), and hemiclamshell or Masaoka approach have been described. The Masaoka approach involves a transverse cervical collar incision and proximal median sternotomy extended to the third or fourth anterior intercostal space. We used this approach, and it provided excellent exposure. We resected the first rib subperiosteally from inside the chest, as described by Nomori and colleagues. This improves exposure by facilitating lateral retraction of the anterior chest wall flap and avoids the need to divide or resect the medial third of the clavicle, which can lead to postoperative shoulder girdle dysfunction. Vanakesa and Goldstraw reported that the anterosuperior approach provides excellent exposure for tumors at the base of the neck. It was associated with low morbidity, a short postoperative stay, and adequate exposure for subclavian vessel resection or reconstruction. CONCLUSIONS We present the resection of a large bilobed thoracic outlet mass. We recommend an anterior hemiclamshell surgical approach because it provides excellent exposure for tumor removal, first rib resection, and vascular reconstruction. Bipolar electrocautery is essential to avoid any iatrogenic neuropraxias when dissecting the brachial plexus or should any bleeding be encountered around the neural foramina. Monitored somatosensory evoked potentials and free running electromyelogram similarly decrease the risk of neurologic injury.

Technique of right single-lung transplantation for idiopathic pulmonary fibrosis using cross-field ventilation

airway management. Corsten and associates’ 4 meta-analysis demonstrated a signif icant survival advantage in those patients who were treated by a combined drainage of the neck and mediastinum versus cervical drainage alone. The authors recommend a formal thoracotomy to drain the chest. Brunelli and colleagues, 5 however, recommend a cervicomediastinal drainage (cervical incision to enter the thorax) of the mediastinum for cases of superior mediastinitis, with a formal thoracotomy reserved for those cases in which the DNM involvement extends beyond the carina. Our surgical approach through a median sternotomy associated with a transverse cervical incision was based on the fact that the patient had a compromised cardiac output and CT findings consistent with a predominant anterior and middle mediastinitis. The posterior and infracarinal mediastinum were less affected by the disease. Our purpose was to decompress the heart along with a proper debridement. Inotropic requirements after surgery were significantly lower. Abscesses tend to reform in the days after surgery, and a daily cervical wash is necessary to release collections and to collapse forming abscesses. Irrigation and drainage of the mediastinum are conducted daily. Management of DNM should always be surgical, with broad, extensive, open cervicotomy together with ample mediastinal drainage and associated thoracotomy, if necessary, to ensure the adequate drainage of all mediastinal compartments.

Marzouk’s Procedure: A Novel Combined Cervical and Anterior Mediastinotomy Technique to Avoid Median Sternotomy for Difficult Retrosternal Thyroidectomy

Surgery for retrosternal goiter is uncommon. Most of the benign retrosternal goiters can be delivered and resected through a standard cervical incision. However, there are cases in which resection of the retrosternal goiter requires additional thoracic access to the standard transverse cervical incision in the form of partial or complete median sternotomy or even a thoracotomy. We propose and describe a novel technique of combining anterior mediastinotomy to the cervical incision as an adjunct to facilitate delivering the difficult retrosternal goiter by bi-manual manipulation. This technique avoids the trauma and postoperative morbidity of a median sternotomy or thoracotomy and proves effective in solving the technical, functional, financial, and aesthetic problems.

Slide tracheobronchoplasty in an infant

Slide tracheobronchoplasty in an infant

Slide cricotracheoplasty in an infant

Slide tracheoplasty was first described in 1989 by Tsang and colleagues and has now become the gold standard to treat long-segment tracheal stenosis. This technique presents several advantages: no graft material is required, it allows satisfactory enlargement of the trachea, and it does not hinder the functional growth of the trachea. 2,3 Recently, our team has reported the association of tracheal resection and slide tracheoplasty to manage an infant presenting with tracheal hypoplasia associated to a partial critical stenosis. 4 However, surgical management of a tracheal hyp oplasia extending up to the cricoid is still quite challenging. We therefore describe a variant of the slide tracheoplasty that allowed us to treat this difficult case.

Ressecção subcapsular da glândula submandibular

Introdução: A cirurgia das patologias inflamatórias das glândulas salivares está associada a uma maior incidência de paralisias temporárias pós-operatórias se comparada a cirurgia dos tumores. Tal fato se deve à dissecção mais laboriosa e mais traumática dos ramos motores do nervo facial, e sua exposição ao processo inflamatório dos tecidos vizinhos. A glândula submandibular é o tecido salivar mais freqüentemente ressecado devido à patologia inflamatória e a não rara paresia temporária do ramo mandibular é fonte de desconforto para o paciente. A remoção da gordura peri-glandular com seus linfonodos não tem a mesma importância que para os tumores. Objetivo: Portanto, temos realizado para sialolitíase e sialoadenites crônicas da submandibular a ressecção subcapsular da glândula. Forma de estudo: Propectivo randomizado. Material e método: Após uma incisão cervical transversa, a cápsula é aberta na parte inferior da glândula e descolada da mesma em sentido superior. O ramo mandibular do nervo facial não é identificado e os vasos faciais são preservados após cuidadosa ligadura dos ramos para a glândula. Na suspeita de patologia neoplásica mudamos o procedimento para a cirurgia tradicional. Resultados: Nos 5 casos estudados, 2 femininos e 3 masculinos, não foi observada paresia pós-operatória. Outras vantagens são a economia do tempo cirúrgico normalmente necessário para a dissecção do nervo e a preservação dos vasos faciais que podem ser usados no futuro como base de retalhos.

Spinal Anaesthesia with 0.25% Hyperbaric Bupivacaine for Cesarean Section

Comment: This carefully done study demonstrates that adequate analgesia for cesarean section can be obtained from hyperbaric 0.25% bupivacaine when doses of 10 mg or more of the drug are injected in volumes of ≥4 mL. In general, other studies using hyperbaric solutions of either 0.5% or 0.75% bupivacaine have found a minimum of 10 mg and, ideally, higher milligram doses of subarachnoid bupivacaine are required for adequate analgesia. From the data of this study, it would appear that the increased volume of doses greater than 10 mg of 0.25% bupivacaine result in very high cervical sensory levels and a higher incidence of more severe maternal hypotension. Hence, I can see absolutely no reason to use 0.25% hyperbaric bupivacaine over 0.5% or 0.75% hyperbaric bupivacaine. Our experience is that 0.75% bupivacaine in 8.25% dextrose, 15 mg (2 mL) given in the sitting position or 12.5 mg (1.7 mL) given in the lateral position, reliably results in a T2 sensory level in the average Caucasian woman who is ≥162 cm in height. It appears that the lower volume of this more concentrated solution enables a dense block, and its upper level is more controllable.1 The authors commented that their higher doses of local anesthetic resulted in more hypotension, a 70% vs. 40% incidence. Because this hypotension can be effectively treated, I consider this a lesser problem when one considers 14 (70%) patients in group 1 had pain, 4 (20%) of whom required general anesthesia compared with only 2 (10%) patients in group 3, neither of whom required general anesthesia. In addition, the objective of good or excellent analgesia was achieved in only 6 (30%) patients of group 1 compared with 15 (75%) and 18 (90%) in groups 2 and 3, respectively. Cesareans, as they are performed today using a low transverse cervical incision, require marked abdominal retraction before birth. After birth, most obstetricians exteriorize the uterus from the abdominal cavity for repair. These maneuvers require a high (≥T4), solid block if considerable maternal discomfort from visceral pain is to be avoided. With a high concentration (0.5–0.75%) of hyperbaric bupivacaine, perhaps, the addition of 25 μg of fentanyl or 7.5 μg of sufentanil appears indicated.