The extraperitoneal laparoscopic TRAM flap delay procedure: an alternative approach.

INTRODUCTION: Ligation of the deep inferior epigastric vessels prior to transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction (delay procedure) was introduced to augment vascularity to the island flap through improved superior epigastric flow, thus decreasing flap morbidity. There are various surgical approaches described, including open and laparoscopic approaches, for ligation of inferior epigastric arteries. We describe an extraperitoneal laparoscopic technique (EPLT) and the outcomes of the procedure. METHODS: All patients who underwent EPLT prior to TRAM flap construction between July 2006 and December 2008 were included in the study. Data were analyzed retrospectively from a prospectively collected database. RESULTS: The study group included 11 female patients with mean age of 55 years and mean body mass index (BMI) of 34.4 kg/m(2). There were no conversions to open procedure. Ten patients had bilateral ligation of inferior epigastric arteries, and one patient had it only on one side. There were no complications related to the procedure. CONCLUSION: Extraperitoneal laparoscopic technique as a delay procedure for TRAM flap reconstruction is safe and feasible with no morbidity related to surgery.

Intolerance of short arm cast wear by patients with claustrophobia: case report.

We describe 4 recent patients with latent claustrophobia who presented with dissatisfaction about their short arm casts days after cast application. Although their initial reports of uneasiness did not seem unusual, these patients continued to describe intense squeezing of their hands, excessive tightness, and feelings of being trapped or confined in a manner outside the normal spectrum of patient discomfort. There were no objective findings on cast removal and recasting, but severe subjective symptoms persisted until cast removal.