Outcomes of Anterior Exposure for Spinal Surgery at an Independent Academic Medical Center.

INTRODUCTION: Anterior exposure for spinal surgery has expanded and is used for common spinal procedures, including anterior lumbar interbody fusion, disc replacement, and vertebral corpectomy. With this approach, vascular injuries have been reported ranging from 1% to 25%. The impact of resident participation on intraoperative and postoperative outcomes within an independent academic medical center has not been widely reported. The objective of this study was to determine the incidence of complications during anterior exposure spinal surgery at an independent academic medical center. METHODS: After institutional review board approval, we conducted a retrospective review of medical records of patients who underwent elective anterior exposure for spinal surgery from 2000 through 2014. RESULTS: The study included 335 patients; 60.3% were female. Thirty-day postoperative complications included surgical site infection (4.2%), urinary tract infection (2.7%), need for blood transfusion (2.1%), retrograde ejaculation (1.2%), and deep vein thrombosis (0.9%). There were 12 vascular injuries overall (3.6%); 2.7% were major vascular injuries. Surgery residents participated in 34% of cases. Resident involvement increased over the course of the study. There was no difference in operative time or complications with resident involvement. CONCLUSIONS: The overall incidence of major vascular injury was 2.7%. Levels of exposure and blood loss were associated with vascular injury. Overall postoperative complication rates as well as major vascular injury rates compared favorably to published benchmarks. Complication rates were unaffected by surgical resident involvement.

Video. Laparoscopic distal pancreatectomy and splenectomy for splenic artery aneurysm.

BACKGROUND: Large splenic artery aneurysms are rare but comprise 60% of all visceral artery aneurysms. Most are found incidentally and rupture in the nonpregnant patient has an approximate 25 to 36% mortality rate. Historically these have been managed with an open surgical approach for resection. METHODS: We present the case of a 43-year-old man with a recent episode of bacterial endocarditis with an incidental finding of a large 6-cm splenic artery aneurysm. There was noted to be splenic vein occlusion and multiple splenic infarcts versus abscesses on preoperative imaging. There were concerns that this represented a mycotic aneurysm. He underwent laparoscopic en bloc splenic artery aneurysm resection with splenectomy and distal pancreatectomy with preoperative prophylactic balloon catheter placement. RESULTS: His large splenic artery aneurysm was adjacent to the splenic hilum. Due to the splenic vein occlusion, there were large collateral vessels complicating the dissection. Additionally, the aneurysm had dense adhesions to the tail of the pancreas from a desmoplastic reaction. To safely remove the aneurysm, a distal pancreatectomy was included with resection of the spleen. The specimen was successfully removed intact using the laparoscopic approach. The patient had an uneventful recovery and was discharged home on postoperative day 2. Final pathology revealed no evidence of bacterial etiology. CONCLUSIONS: Laparoscopic distal pancreatectomy with splenectomy is an appropriate minimally invasive option for the treatment of splenic artery aneurysms. This video demonstrates the technical challenges and management options for successfully completing a distal pancreatectomy and splenectomy in the face of a splenic artery aneurysm.

Traumatic fracture of polytetrafluoroethylene axillofemoral bypass graft.

We report traumatic disruption of a ringed polytetrafluorethylene (PTFE) axillofemoral bypass (AFB) graft due to a fall. We also review the literature of previously reported blunt traumatic PTFE graft disruptions. A 75-year-old man with previous bilateral AFB grafting presented with a painful left chest wall mass after a fall from standing height. Chest computed tomography (CT) revealed a large chest wall hematoma. The patient underwent evacuation of the hematoma, resection of the fractured graft, and placement of an interposition PTFE graft. Two prior case reports have documented the midportion PTFE graft disruption from blunt trauma. Our case report demonstrates the potential for disruption of the midportion of ringed PTFE AFB grafts with direct blunt trauma. The diagnosis was confirmed by CT scan and the graft was successfully repaired with an interposition graft.

Seconds from disaster: lessons learned from laparoscopic release of the median arcuate ligament.

Median arcuate ligament syndrome (MALS) is a rare entity that manifests as abdominal pain, nausea, vomiting, and diarrhea. The median arcuate ligament is a fibrous band that connects the crura of the diaphragm. In some people, the ligament is positioned in a way that compresses the celiac axis, which in a subset of individuals causes the symptoms associated with MALS. Surgical release of the ligament can relieve these symptoms. After viewing a video that described the laparoscopic median arcuate ligament release technique at the 2006 SAGES meeting and reviewing the online video, we report our experience with two cases and discuss the lessons learned in performing the procedure within a training program. We also discuss the extent to which surgical resident participation contributes to intraoperative complications during a new and complex surgery.

Delayed neurologic deficit after infrarenal endovascular aortic aneurysm repair.

Spinal cord ischemia is a rare and devastating complication after elective abdominal aortic aneurysm repair. It has recently been reported to occur after endovascular aortic aneurysm repair. We report the first case of delayed neurologic deficit after endovascular aortic aneurysm repair using the Zenith (Cook) device.