Video Article Research Articles

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description.

ObjectiveTo describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DesignStepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB. SettingDepartment of Obstetrics and Gynaecology, Imelda Hospital, Belgium. InterventionA circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture. DiscussionAbdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5,6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7]. ConclusionThis is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

Diaphragmatic endometriosis: robotic approaches and techniques

To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. Endometriosis center. Patients undergoing excision of diaphragmatic endometriosis. Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. N/A. The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

8883 Total Laparoscopic Bladder Resection in the Management of Deep Endometriosis: “Take It or Leave It.”

<h3>Study Objective</h3> To highlight laparoscopic surgical anatomy for bladder resection in deep endometriosis (DE). <h3>Design</h3> Video article. <h3>Setting</h3> Laparoscopic 4K OR in IRCCS Sacro Cuore Don Calabria Hospital, Trendelenburg position under general anesthesia. <h3>Patients or Participants</h3> 35 years old woman complaining chronic pelvic pain and urinary specific symptoms, looking for pregnancy for 4 years. <h3>Interventions</h3> Opening and development of paravescical spaces, Bogros and Retzius spaces, bladder nodule isolation and resection of the whole-thickness portion of the nodule. En-bloc posterior eradication of DE after opening and development of para-rectal space and recto-vaginal space. <h3>Measurements and Main Results</h3> Duration of the surgical procedure was 180 minutes, blood loss 50cc, inpatient stay 12 days, Foley catheter was removed after 7 days (cystography was performed to assess bladder closure). <h3>Conclusion</h3> Laparoscopic bladder resection might be less invasive and precise if anatomical spaces are properly prepared and the resection is limited to the infiltrating portion of the nodule.

Pyrocarbon Disc Interposition Arthroplasty (PyroDisk) for the Treatment of Carpometacarpal Thumb Joint Osteoarthritis.

Preoperatively, review radiology images to confirm that the osteoarthritis is limited to the thumb CMC joint and that all appropriate tools for inserting the disc are available before beginning surgery. Next, the patient is placed with their arm on an arm rest. The CMC thumb joint is exposed via a dorsal longitudinal skin incision, sparing the dorsal radial nerve branches and the radial artery and accompanying venes. The capsule is opened with an H-incision. With 2 parallel cuts to the joint surface, the articular surfaces of the joint are removed. After resection of the articular joint surfaces, the residual width and height of the joint space after resection are measured. The central point in the joint surfaces is marked for the bone tunnels. With an awl, tunnels are created from the center of the joint surface to the proximal (trapezial bone) and distal (first metacarpal bone) and the dorsal side. The implant size is measured with the trial implants for correct size of the disc. A tendon strip of either APL (abductor pollicis longus) or FCR (flexor carpi radialis) tendon is harvested for use securing the disc. The disc is secured with the tendon strip from proximal through the trapezium, through the disc and distal through the first metacarpal, and is secured to itself at the trapezial bone. The position is checked under fluoroscopy. When the disc in the right position, the joint capsule and skin are closed and a plaster cast is applied with the thumb in abduction. Alternative treatments include hemitrapeziectomy without interposition; full trapeziectomy, with or without ligament reconstruction and/or tendon interposition; and joint resurfacing prostheses. The advantage of pyrocarbon disc interposition arthroplasty over other treatment options is the preservation of the STT joint1. Therefore, the procedure is minimally harming the surrounding anatomy despite open surgery and has a high success rate in reducing pain while preserving function and strength. The risk of complications is comparable with that of other CMC joint arthroplasty techniques. A relatively high survival rate has been reported at a mean follow-up of 7 years (range, 5 to 12 years). In cases of recurrent pain, all other surgical options remain possible ("no bridges are burned"). The main disadvantage is the cost of the disc. Our recent study of this technique showed good patient-reported outcomes, pain reduction, patient satisfaction, and preservation of strength and range of motion at a mean follow-up of 7 years1,2. The survival rate was 91%, with 3% failing as a result of disc dislocation. Other reasons of failure were STT osteoarthritis and pain without a specific cause. Preoperatively, make sure that only the CMC thumb joint has osteoarthritis and that the STT joint does not. In cases in which it is unclear whether the osteoarthritis is isolated to the CMC thumb joint, perform computed tomography to make certain10.Only a few millimeters of bone must be resected from the first metacarpal base and the distal trapezium. Both bone cuts must be made parallel to each other and perpendicular to the longitudinal axis of the first metacarpal bone.Bone tunnels must be exactly centered in the cut joint surfaces for proper implant positioning and to decrease the chance of subluxation.Size the implant properly and check movement and stability. OR = operating roomFCR = flexor carpi radialisAPL = abductor pollicis longusPRWHE = Patient-Rated Wrist and Hand EvaluationDASH = Disabilities of the Arm, Shoulder and Hand QuestionnaireMHQ = Michigan Hand QuestionnaireROM = range of motionFU = follow-upCRPS = complex regional pain syndromeLRTI = ligament reconstruction and tendon interpositionMRI = magnetic resonance imagingCT = computed tomography.

Successful Laparoscopic Surgical Removal of a Caesarean Scar Pregnancy (CSP) Using Temporary Uterine Artery Ligation

To demonstrate a laparoscopic technique to remove a scar pregnancy. Stepwise demonstration of the surgical technique. Santa Croce and Carle Hospital, Cuneo. Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall. Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively.

Endometrial preservation during resection of type II and type III submucosal fibroids.

Hysteroscopic myomectomy is considered the gold-standard treatment of submucosal fibroids. However, it is associated with disruption of the endometrium which may lead to complications such as intrauterine adhesions and loss of functional endometrium. In this video article we describe a technique to resect Type III and Type II fibroids whilst minimising the loss of overlying endometrium. We present two patients with type II/III submucosal fibroids with minimal or no intracavitary component. The resection technique we demonstrate comprises either making an endometrial incision or making a small opening in the overlying endometrium to expose the fibroid pseudocapsule. Subsequent steps of resection are then performed through this small opening. Thus, complete resection is achieved without further resection of the endometrium. Evidence of endometrial healing and absence of intrauterine synechiae on follow up outpatient hysteroscopy or ultrasound scan. Full resection was achieved in both patients with no or minimal loss of overlying endometrium. A follow up outpatient hysteroscopy was performed 8 weeks later in the first patient, demonstrating completely healed uterine cavity. She had a successful conception and delivery following IVF treatment for male factor infertility. The second patient is currently in the process of IVF treatment. Our technique enables endometrial preservation and potentially better reproductive outcomes following resection of type II and type III submucosal fibroids. Larger scale studies are required to elucidate long term outcomes on bigger patient population.

A rare case of extrauterine schwannoma-ike leiomyoma after transvaginal hysterectomy: laparoscopic management.

Schwannomas (neurilemomas) are encapsulated tumours made entirely of benign neoplastic Schwann cells. They are the most common tumour of peripheral nerves, but very uncommon in gynaecologic practice. The objective is to demonstrate unusual histology mimicking schwannoma in a case of leiomyoma in a woman who had a history of vaginal hysterectomy. We report a case of a 50-year-old hysterectomised patient who was referred with complaints of dull pain in the left inguinal region of the abdominal cavity during the last 3 months. The narrated surgical video article demonstrates the dissection of the left parametrium, tumour removal, colpotomy, specimen extraction, and vagina laparoscopic suturing. Pre-operative CT-scan images of the pelvis with retroperitoneal tumour and macroscopic and histological views of the schwannoma are also provided. Full recovery of the patient after laparoscopic removal of the tumour. As a result of the surgical treatment, the patient has fully recovered. Schwannoma-like leiomyomas are rare tumours. They can be extra peritoneally located, without any connection to the uterus and adnexa. They are difficult to diagnose before surgery. The laparoscopic approach is the best option for the treatment of such rare extra organic tumours.

Multi-Stream Perfusion Bioreactor Integrated with Outlet Fractionation for Dynamic Cell Culture.

Certain cell and tissue functions operate within the dynamic time scale of minutes to hours that are poorly resolved by conventional culture systems. This work has developed a low-cost perfusion bioreactor system that allows culture medium to be continuously perfused into a cell culture module and fractionated in a downstream module to measure dynamics on this scale. The system is constructed almost entirely from commercially available parts and can be parallelized to conduct independent experiments in conventional multi-well cell culture plates simultaneously. This video article demonstrates how to assemble the base setup, which requires only a single multichannel syringe pump and a modified fraction collector to perfuse up to six cultures in parallel. Useful variants on the modular design are also presented that allow for controlled stimulation dynamics, such as solute pulses or pharmacokinetic-like profiles. Importantly, as solute signals travel through the system, they are distorted due to solute dispersion. Furthermore, a method for measuring the residence time distributions (RTDs) of the components of the perfusion setup with a tracer using MATLAB is described. RTDs are useful to calculate how solute signals are distorted by the flow in the multi-compartment system. This system is highly robust and reproducible, so basic researchers can easily adopt it without the need for specialized fabrication facilities.

Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina

To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina. Surgical video article. Local institutional review board approval and written permission from the patients were obtained. Tertiary referral center. The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina. Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery. Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery. The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases. Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

Superior Pubic Ramus Screw Placement During Complex Acetabular Revision: Acetabular Distraction for Treatment of Pelvic Discontinuity.

With the patient in the lateral decubitus position, the acetabulum is exposed from a standard posterior approach for a revision THA. The location of the superior pubic root is identified after making a recess within the anteroinferior capsule. In order to ensure that the appropriate trajectory is obtained, C-arm imaging (inlet view and orthogonal obturator outlet views) is utilized to safely predrill the screw trajectory into the superior pubic ramus. A Kirschner wire (K-wire) is then placed into the hole. With use of a metal-cutting burr on the back table, customized peripheral screw holes are placed and then the acetabular component is slid and impacted into place over the K-wire. After cup insertion, the K-wire is removed and the superior pubic ramus screw can be placed and confirmed on fluoroscopy. In general, chronic pelvic discontinuity requires surgical management with revision THA and has historically employed the use of a cup-cage construct, custom triflange implants, and/or jumbo acetabular cups with modular porous metal augments1-5. With these treatment options, it is typically necessary to insert "kickstand" screws, which function to prevent abduction failure of the acetabular cup4,5. However, in many cases of discontinuity, there may be severe ischial osteolysis, making ischial screw placement difficult or impossible. The superior pubic ramus, however, remains a reliable option that can be utilized for inferior screw fixation, even in cases of severe acetabular bone loss, and thus is especially beneficial in these difficult cases. The technique of acetabular distraction was developed because of limitations with alternative techniques. This procedure achieves cementless biologic fixation and eventual discontinuity healing as a result of lateral or peripheral acetabular distraction and resultant medial or central compression across the pelvic discontinuity. Acetabular distraction allows for intraoperative customization and cement unitization of the acetabular construct. This procedure requires the use of a "kickstand" screw or of inferior screw fixation in order to prevent abduction failure of the cup. These screws may be placed into either the ischium or superior pubic ramus. If the patient has substantial ischial osteolysis, ischial screw fixation may not be possible. If not placed in a systematic manner, pubic ramus screws can be technically challenging, and incorrect placement can result in neurovascular injury. The present video article demonstrates a reproducible technical method for safely placing a screw in the superior ramus to aid in optimal fixation of the acetabular component in cases of pelvic discontinuity. Thus far, short-term survivorship of acetabular distraction with use of a jumbo cup and kickstand screws has been about 95%. In the largest study to date assessing patients with chronic pelvic discontinuity who underwent revision THA with use of the acetabular distraction technique, only 1 of 32 patients required revision for aseptic loosening6. An additional 2 patients had evidence of radiographic loosening but did not undergo revision, and 3 had migration of the acetabular component into a more stable configuration. Radiographically, 22 of 32 patients in the study demonstrated healing of the discontinuity6. In another study assessing the survivorship of porous tantalum acetabular shells in revision THA to treat severe acetabular defects, patients with inferior screw fixation with superior pubic ramus or ischial screws had a significantly lower incidence of proximal translation of components compared with those without inferior screw fixation7. For reproducible, successful execution of this technique, it is important to confirm correct placement of the acetabular retractors at the correct anatomical locations to ensure adequate surgical visualization of the acetabulum for easy identification of the superior pubic root.It is also critical to check placement of the drill via fluoroscopy with an inlet and obturator outlet views prior to drilling.The drill should be advanced on the oscillate setting to avoid inadvertently perforating the cortical bone and damaging surrounding neurovascular structures. OR = operating roomf/u = follow-upvac = vacuum-assisted closureRSA = radiostereometric analysis.

Surgical technique for laparoscopic removal of bulky para-aortic nodes without repositioning surgical field during laparoscopic debulking for advanced ovarian cancer.

In the last years, laparoscopy has been progressively introduced in the management of advanced- stage ovarian cancer (AOC) not only to evaluate tumour resectability, but also to perform primary or interval minimally invasive debulking surgery in selected patients. During laparoscopic debulking for AOC, the need to change the surgical field to treat disease in the upper abdomen can be a time-consuming procedure. To demonstrate feasibility, safety and effectiveness of laparoscopic approach to remove bulky para- aortic nodes in AOC with a 30-degree 3D-endoscope without repositioning the laparoscopic surgical field. A 51-year-old woman was referred to our centre due to AOC with bulky para-aortic nodes (7 cm polylobate mass at CT-scan). The narrated surgical video article demonstrates the surgical steps for laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope, maintaining the vision from the upper abdomen perpendicular to the main axis of the vascular structures for the whole duration of the surgery ("top-bottom" view), without repositioning surgical field. Complete laparoscopic excision of disease was achieved. Post-operative course was uneventful. Patient recovered from surgery and was able to start adjuvant chemotherapy within 30 days from surgery. Repositioning the surgical field to perform para-aortic dissection can be a time-consuming procedure during laparoscopic debulking for ovarian cancer. Laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope and "top-bottom view" is feasible, safe and effective.

The short video lecture for robotic bilateral axillo-breast approach to lateral neck lymph node dissection.

Lateral neck lymph node dissection (LND) along with total thyroidectomy is the standard treatment for thyroid cancer patients with metastases to the lateral neck lymph nodes. In general, lateral neck LND removes lymph nodes located at levels II to V ipsilateral to the thyroid cancer and preserves the spinal accessory nerve, internal jugular vein, and sternomastoid muscle during surgery. This video article was written to introduce the robotic bilateral axillo-breast approach for lateral neck LND and to describe the surgical method.

Methods for Rearing the Parasitoid Ganaspis brasiliensis, a Promising Biological Control Agent for the Invasive Drosophila suzukii.

Native to East Asia, the spotted-wing drosophila, Drosophila suzukii (Matsumura) (Diptera: Drosophilidae), has established widely in the Americas, Europe, and parts of Africa over the last decade, becoming a devastating pest of various soft-skinned fruits in its invaded regions. Biological control, especially by means of self-perpetuating and specialized parasitoids, is expected to be a viable option for sustainable area-wide management of this highly mobile and polyphagous pest. Ganaspis brasiliensis Ihering (Hymenoptera: Figitidae) is a larval parasitoid that is widely distributed in East Asia, and has been found to be one of the most effective parasitoids of D. suzukii. Following rigorous pre-introduction evaluations of its efficacy and potential non-target risks, one of the more host-specific genetic groups of this species (G1 G. brasiliensis) has been approved recently for introduction and field release in the United States and Italy. Another genetic group (G3 G. brasiliensis), which was also commonly found to attack D. suzukii in East Asia, may be considered for introduction in the near future. There is currently enormous interest in rearing G. brasiliensis for research or in mass-production for field release against D. suzukii. This protocol and associated video article describe effective rearing methods for this parasitoid, both on a small scale for research and a large scale for mass-production and field release. These methods may benefit further long-term research and use of this Asian-native parasitoid as a promising biological control agent for this global invasive pest.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

When enlarged cardiophrenic lymph nodes (CPLN) are resected the impact on survival is still uncertain, but resection contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is used to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. However, the transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. Costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach may be preferred to remove the costophrenic lymph nodes, in cases in whom diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes using only the subxiphoid approach in a case of advanced ovarian cancer. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After identifying any enlarged costophrenic nodes by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the single enlarged node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

Traumatic transection of inferior rectus muscle: technique for exploration and repair

This video article may be viewed at jaapos.org.We present a technique for exploring, identifying, and repairing an acutely transected inferior rectus muscle. A 9-month-old girl presented emergently at the Hospital for Sick Children, Toronto, after an unwitnessed fall from a bed. She was bleeding from her left eye, and her parents reported that she might have struck her eye on the sharp edge of a plastic toy. The patient had an inferior conjunctival laceration and new-onset left hypertropia.

The Feel of the Guitar in Popular Music Performance

Popular-music guitarists frequently reference the physicality of the fretboard when discussing songwriting and performance. Brittany Howard, for example, advocates that the feel of her guitar and physical gestures — chord shapes, licks, and riffs — are more critical to her craft than theoretical knowledge regarding pitch and harmony. However, in-depth gestural perspectives on musical organization are underrepresented in popular-music scholarship. This video article responds by investigating the relationship between fretboard gestures and popular music’s features in two contexts. First is a close analysis of “Short and Sweet” that focuses on how Howard coordinates chord voicings and larger left-hand shifts with important rhetorical moments reflected in the song’s lyrics. A following motion-capture study then surveys how similar gestural trends might generalize to performances by other guitarists. Data from performances by 14 local practicing guitarists demonstrate that the musicians typically prefer to articulate moments of formal transition with the largest physical gestures. Such findings suggest a degree of gestural intentionality and strategy amongst guitarists and clarify the contexts in which a guitarist might choose to maintain or abandon fretboard affordances.

Isthmocele endometriosis: the relationship between cesarean section and endometriosis

To present a case of endometriosis within an isthmocele membrane and concomitant diffuse peritoneal endometriosis after cesarean sections. In addition, we describe a unique, color-contrasted surgical repair technique and propose a possible correlation between isthmocele formation and endometriosis. Narrated video article featuring the diagnosis, unique surgical management, and pathological findings of a case of isthmocele endometriosis. Informed consent was obtained from the patient, and all identifiers were removed. University-affiliated hospital. A 44-year-old patient with three prior cesarean sections and a laparoscopic appendectomy, in none of which endometriosis was visualized. She presented with progressive pelvic pain, dysmenorrhea, dyspareunia, and secondary infertility with recurrent embryo transfer failures. The progressively debilitating symptoms started 14 years ago, shortly after her last cesarean section. Magnetic resonance imaging and ultrasound demonstrated a retroverted uterus and a prominent, thin, fluid-filled cesarean scar defect with a residual myometrial thickness of 1.1 mm. A combined hysteroscopic and laparoscopic approach was performed to allow for complete resection of the defect and reconstruction of the myometrium. The bladder was backfilled with indocyanine green dye to help identify its borders. Methylene blue was added to the hysteroscopy irrigation solution to create contrast and assist with the isthmocele identification. Wide excision of the isthmocele was performed, followed by a three-layer closure and excision of all apparent peritoneal lesions using the Aqua Blue Contrast Technique. Restoration of normal anatomy, resection of isthmocele, and resolution of the symptoms. In the pathological assessment, multiple foci of endometriosis were identified within the isthmocele membrane, clearly differentiated from intrauterine endometrial tissue. Additionally, all seven excised peritoneal specimens contained peritoneal endometriosis. Two weeks after the procedure, a transvaginal sonographic scan confirmed a thick anterior uterine wall with a myometrial thickness of 9.2 mm, and the patient reported almost complete resolution of her symptoms. This case demonstrates endometriosis within the isthmocele membrane, with concomitant symptomatic peritoneal endometriosis. We propose a laparoscopic isthmocele excision technique and a three-layer reconstruction, followed by peritoneal endometriosis excision using methylene blue contrast. We suggest a possible link between isthmocele and endometriosis and emphasize the need for wide excision of the isthmocele margins and maintaining clean borders, given the possibility of endometriosis within the isthmocele, which may be a cause or a contributor to the tissue weakness and isthmocele formation.

The Rise of the ‘Immersive Virtual Online Avatar Society’: Does an Online Community Established in the Virtual Space Constitute a ‘Real’ Society?

Abstract This video article series investigates the emergence of a ‘digital haven’, that hosts a new type of society. These people are converging in digitally constructed realities for multiple reasons: some seek refuge from the harsh realities of the contemporary social order, others investigate new ways to socialise, or seek somewhere where the limitations of the real world don’t apply. Both science-fiction media and academics predicted that once virtual reality technologies (vr) reach the general consumer, society would change (Caddy, 2019; Gibson, 1984; Heim, 1993; Virtual Reality Society, 2017). In recent years the number of households with vr devices has increased (Bol, 2018; Petrock, 2021). This article suggests that vr technology has given birth to an ‘Immersive Virtual Online Avatar Society’. This society harbours many occasional visitors, but also some permanent virtual residents. Important questions arise; starting with: “Does an online community established in the virtual space constitute a ‘real’ society?” This will be investigated with sources from virtual worlds developed with the social multi-user vr software VRChat, drawn from academic research, from video recordings of interactions in VRChat and from philosophical inquiry into the author’s personal experiences and the experiences of other users.

Intramedullary Single-Kirschner-Wire Fixation in Displaced Fractures of the Fifth Metacarpal Neck (Boxer's Fracture).

For this procedure, the injured arm of the patient is placed on an arm table. The incision is made 1 to 2 cm longitudinally over the ulnar base of the fifth metacarpal bone. The cortical bone is opened with an awl, and a bent 1.6-mm Kirschner wire is inserted into the medullary canal. After reaching the fracture region, the fracture is anatomically reduced. The Kirschner wire is then advanced into the head of the fifth metacarpal, securing the reduction. Malrotation can be addressed in this stage by rotating the wire under fluoroscopic control. After ensuring anatomical reduction clinically and by fluoroscopy, the wire is shortened under the skin, followed by closure of the incision. We utilize a mid-hand brace for splinting. Nonoperative treatment is common for fifth metacarpal neck fractures in the absence of malrotation, excessive angulation, and shortening. Other surgical techniques include a similar procedure that involves the use of multiple Kirschner wires, plate fixation, transverse Kirschner wire pinning, and, less commonly, retrograde headless screw fixation2,7-9. The main advantage of this technique is the preservation of the metacarpophalangeal joint and the minimal soft-tissue damage. Additionally, the use of a single Kirschner wire provides stability at low cost. With some experience, this surgery can be performed within 20 minutes1,9. This procedure provides good fracture reduction and stabilization8. The outcome is usually satisfactory, with very low Disabilities of the Arm, Shoulder, and Hand scores1. Malrotation, angulation, and shortening are sufficiently addressed, and the technique shows the same results as fixation performed with use of 2 intramedullary wires. Bending the Kirschner wire to ensure easy gliding in the medullary canal provides the opportunity to reduce the metacarpal neck once the wire is safely in the head.Aim distally as you open the cortical bone with the awl in order to facilitate the insertion of the Kirschner wire.The primary reduction should be made manually, not by the wire. Subacute fractures and substantially displaced fractures require direct force for a satisfactory reduction, which cannot be achieved by rotation of the wire only.The cortical bone on the metacarpal head is very thin. Take care not to drive the Kirschner wire through the cortical bone and into the joint.Shorten the wire under the skin approximately 1 cm above the bone surface; this ensures easy removal and prevents skin irritation. K-wire = Kirschner wire.

Arthroscopic Reduction and Internal Fixation of an Osseous Bankart Lesion.

The current surgical video article outlines a technique for an osseous Bankart repair in a patient with a displaced fracture as well as substantial pain and instability. First, the amount of bone loss is measured on 3-dimensionally reconstructed computed tomography (CT) imaging, with the humeral head digitally subtracted2. The procedure is then performed arthroscopically with the patient in the lateral decubitus position. A diagnostic evaluation, beginning with posterior and anterior portal placement in the rotator interval, is completed to assess any rotator cuff injury and the extent of labral tearing and osseous displacement. Next, the bone fragment is elevated into its anatomical position. This fragment is then reduced with use of a double-row suture technique, followed by concomitant capsulolabral repair. Nonoperative treatment with a sling can be utilized as long as post-reduction CT scans reveal anteroposterior centering of the humeral head on the glenoid3. Rehabilitation can include active-assisted and passive glenohumeral mobilization, as well as daily pendulum exercises and physiotherapy. Osseous Bankart repair has been shown to effectively improve patient-reported outcomes and normalize glenoid morphology1,3,4. Failure to recognize and appropriately treat an osseous Bankart fracture may lead to osseous erosion caused by repetitive episodes of subluxations or dislocations, along with substantial pain and weakness5. Indications for arthroscopic Bankart repair include young, active patients with a reducible fracture fragment, an anterior glenoid deficit of >10%, and a history of failed nonoperative treatment3-8. Clinical outcomes following the osseous Bankart repair procedure have been shown to be highly successful, with high rates of return to sport, minimal reduction in range of motion, and restoration of shoulder function and stability4. Additionally, long-term follow-up has shown successful osseous union and normalization of glenoid anatomy1. Apply tension to sutures with a suture retriever before the PushLock anchors (Arthrex) are placed during fracture reduction.Utilize a trans-subscapularis portal for anchor placement medial to the fracture on the glenoid neck.Perform adjustable tensioning during labral repair with knotless all-suture anchors.Utilize a lateral distraction device with the patient in the lateral decubitus position to completely visualize the anteroinferior glenoid.Chronic onset and late intervention may cause difficulties in the reduction of the bone fragment.Suture management may be difficult, particularly for surgeons at an early stage of the learning curve.A defect that is wide (from medial to lateral) may be difficult to maneuver around and reduce. GH = glenohumeralGHL = glenohumeral ligamentPts = patientsPMH = previous medical historyFE = forward elevationER = external rotationIR = internal rotationABD = abductionEXT = external rotationXR = radiographic imagingMRI = magnetic resonance imagingCT = computed tomographyROM = range of motionFU = follow-upRTS = return to sportsRTPP = return to previous level of play.