Indocyanine Green-Guided Near-Infrared Fluorescence Enhances Vascular Anatomy in Robot-Assisted DIEP Flap Harvest.

SUMMARY: Indocyanine green-guided near-infrared fluorescence imaging has gained clinical acceptance lately. This technology can be particularly advantageous in the case of robotic flap harvest. This article presents a new approach to deep epigastric pedicle dissection using indocyanine green-guided near-infrared fluorescence in the setting of robot-assisted deep inferior epigastric perforator flaps.

Soft-Tissue Reconstruction after Composite Vertebrectomy and Chest Wall Resection for Spinal Tumors.

BACKGROUND: Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone. METHODS: The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall. RESULTS: One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03). CONCLUSIONS: Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Bilateral Breast Reduction Without Opioid Analgesics: A Comparative Study.

BACKGROUND: Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction. OBJECTIVES: This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids. METHODS: A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations. RESULTS: When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001). CONCLUSIONS: This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids. LEVEL OF EVIDENCE: 3.

Tissue Monitoring with Three-Wavelength Light Emitting Diode-Based Near-Infrared Spectroscopy.

Background Flap monitoring with near-infrared spectroscopy (NIRS) facilitates early detection of vascular compromise. However, standard NIRS devices that employ two wavelengths of light to assess tissue oxygenation (StO2) are susceptible to artifact from background noise and demonstrate significant variability in the clinical setting. As the number of wavelengths detected by a NIRS device is increased, the precision of StO2 measurements can be improved and additional chromophores other than oxyhemoglobin and deoxyhemoglobin can be measured. A three-wavelength light emitting diode NIRS device (Artinis, Zetten, the Netherlands) that also detects cytochrome aa3 , a measure of intracellular oxygen demand, was compared with the standard two-wavelength device commonly used for flap monitoring (ViOptix device, ViOptix Inc., Freemont, CA) to determine if there is an improvement in the precision of tissue oxygen measurements. Methods ViOptix and Artinis were applied to the forearms of human volunteers (n = 15) and a blood pressure cuff was placed around the upper arm to occlude arterial and venous flow. StO2 measurements were obtained from both devices. Artinis also yielded cytochrome aa3 oxidation state measurements. Results StO2 measurements from both devices were proportionate during ischemia (R2 = 0.79, p < 0.01). Monte Carlo stimulation showed Artinis outperformed ViOptix (p < 0.01) as a measure of change in StO2 during ischemia. Artinis did not detect a reduction in cytochrome aa3 associated with the decrease in StO2 during ischemia. Conclusion The addition of a third wavelength to NIRS monitoring may improve the precision of StO2 trend monitoring. However, the three-wavelength device lacked the sensitivity to reliably measure changes in cytochrome aa3 .

Calvarial Regeneration With Use of Acellular Dermal Matrix in Aplasia Cutis Congenita.

Aplasia cutis congenital (ACC) is a rare congenital anomaly, most commonly affecting the scalp, with a variable penetrance ranging from a small (<2 cm) area of missing skin to large defects characterized by absent skin, subcutaneous tissue, calvarium, and dura. Calvarial reconstruction in ACC can be challenging. Due to exposed neurologic structures, in large defects, ACC has a high mortality rate. A stable reconstruction is optimally achieved shortly after birth to minimize complications. Herein the authors present a case of a neonate with an extensive (4.5 × 7 cm) cutis aplasia defect associated with absent skin, subcutaneous tissue, calvarium, dura, and with exposed cortical surface and sagittal sinus. This defect was successfully reconstructed in a single stage with the use of an acellular dermal matrix/skin graft construct. The acelluar dermal matrix served as a scaffold for tissue ingrowth, promoting regeneration of the bony calvarium as well as soft tissue. At 18-month follow-up, the patient exhibits a 50% smaller calvarial defect as well as stable skin coverage.

Muscle-sparing blepharoplasty: a prospective left-right comparative study.

BACKGROUND: Standard upper blepharoplasty involves removal of both the skin and a portion of the underlying orbicularis oculi muscle. The senior author had observed sluggishness of eyelid closure, lagophthalmos as well as varying degrees of eye irritation in certain patients during the early postoperative period. He postulated that these findings could be due to orbicularis muscle excision. He therefore undertook a prospective study 27 years ago comparing standard blepharoplasty on one eyelid to skin-only excision on the fellow eyelid. METHODS: A randomized, prospective, single-blinded study was designed using the fellow eye as an internal control. 22 patients undergoing upper blepharoplasty procedure requiring greater than 5 mm of skin resection and with no history of ophthalmologic disease, dry eye, or previous eyelid surgery were selected. Upper blepharoplasty was performed with skin-only removal on one side, and combined skin-muscle removal on the other side. Patients were evaluated until six months after surgery except for two patients who were lost to follow-up after three months. Sluggish eyelid closure, lagophthalmos, dry eye and aesthetic result were outcome measures scored by patient survey, the operating surgeon, and a blinded expert panel. RESULTS: There were comparable aesthetic outcomes in both eyelids. The incidence of sluggish eyelid closure, lagophthalmos and dry eye syndrome were significantly higher in eyelids where wide segments of muscle had been resected. CONCLUSIONS: Muscle-sparing upper blepharoplasty produces similar aesthetic outcomes as conventional blepharoplasty, while significantly reducing the complications of sluggish eyelid closure, lagophthalmos and dry eye disease. The authors therefore recommend muscle-sparing upper blepharoplasty.

Single-incision laparoscopic cholecystectomy at community hospitals in Honolulu, Hawai'i: a case series.

This study aims to demonstrate the feasibility of implementing single-incision laparoscopic cholecystectomy in a community hospital setting. Minimally invasive surgical approaches for cholecystectomy achieve equivalent outcomes to the open surgical approach with less post-operative pain, improved cosmesis, shorter hospital stays, and decreased complications. Surgeons are attempting to reduce incisional trauma further by decreasing the number of incisions. A retrospective chart review was conducted for demographics, operating time, blood loss, conversion rate, length of stay, and presence of operative complications on patients undergoing single-incision laparoscopic cholecystectomy at two community hospitals between 2008 and 2011. One hundred and three patients (79 females and 24 males) underwent single-incision laparoscopic cholecystectomy. The mean age was 49.8 years (range 18-88). Ninety-six patients (93.2%) underwent elective procedures while 7 patients (6.8%) underwent urgent procedures. The mean operating time was 89.7 (± 28.3) minutes and the average blood loss was 33.7 (± 27.4) milliliters. Ninety-five (92.2%) of the procedures were successfully completed with a single-incision approach and 8 (7.8%) were converted to a multi-incisional approach, while none were converted to an open approach. The median length of stay was 4.75 hours. The post-operative complication rate was 7.4% (7/95) and included four superficial wound infections, one bile leak, one acute renal failure, and one urinary tract infection. These outcomes for single-incision laparoscopic cholecystectomy are comparable to other case series reported in the literature, and this retrospective review illustrates that single-incision laparoscopic cholecystectomy is feasible in a community setting.

Treatment of median arcuate ligament syndrome via traditional and robotic techniques.

Median arcuate ligament syndrome (MALS) is a rare entity characterized by extrinsic compression of the celiac artery and symptoms of postprandial epigastric pain, nausea, vomiting, and weight loss mimicking mesenteric ischemia. We present two patients diagnosed with MALS, the first treated with an open laparotomy by a vascular surgeon and the second using a robot assisted laparoscopic approach by a general surgeon with a vascular surgeon on standby. This is the second ever report of this approach. Both patients recovered without complications and experienced resolution of their symptoms. A discussion of the pathophysiology, literature review, and multispecialty treatment approach are presented.

Prescription drug cost reduction in Native Hawaiians after laparoscopic Roux-en-y gastric bypass.

OBJECTIVE: Native Hawaiians (NH) represent a unique population where socioeconomic factors have contributed to higher incidence rates of obesity and related comorbidities than in the general population resulting in substantial prescription medication costs. Studies demonstrate that laparoscopic Roux-en-y gastric bypass (LRYGB) surgery results in significant weight loss, improvement of comorbidities, and decreased costs for prescription medications in Caucasians. This study aimed to analyze the effects of LRYGB surgery on Native Hawaiians and their prescription drug costs. METHODS: Demographics, baseline body mass index (BMI), comorbidities, preoperative, and postoperative data were analyzed for NH patients who underwent LRYGB between January 2004 and April 2009. Medication costs were determined using the online pharmacy . Generic drugs were selected when appropriate, while vitamins and nutritional supplements were not included in this study. RESULTS: Fifty (14 Men, 36 women) NH patients had sufficient data and follow-up for analysis. Average preoperative BMI was 49 kg/m(2), while at one year follow-up it decreased to 33 kg/m(2) (P<.001). This correlates to an average of 61% excess body weight lost (P<.001). The average number of prescription medications decreased from 3.5/patient preoperatively to 1.1/patient at one year (P<.001), equating to a monthly cost savings of US $195.8/patient (P<.001). CONCLUSIONS: LRYGB provided substantial weight loss for morbidly obese NH patients, resulting in significantly less prescription medication use and substantial cost savings. Thus, bariatric surgery for weight management has the potential to improve the overall well-being and lower the financial burden of medical care in socioeconomically disadvantaged communities such as the NH.

Novel technique for preoperative localization of colorectal tumors for laparoscopic resection.

Minimally invasive surgery for resection of colon tumors is being utilized with increasing frequency making accurate preoperative tumor localization essential to proper surgical planning and patient positioning. Traditional endoscopic localization techniques such as lesion distancing from the anal verge are adequate in the majority of patients. Patients with a significantly tortuous and redundant colon, however, are at increased risk for ambiguous and incorrect lesion localization. The use of endoscopic submucosal marking by injection to tattoo the site of interest may increase the accuracy of tumor localization, but its efficacy can be technique dependent. We present a novel technique for endoscopic tumor localization using endoscopic clip placement, followed by immediate abdominal radiograph, to accurately locate a colonic lesion in preparation for laparoscopic colonic resection.

Dry eye syndrome due to botulinum toxin type-A injection: guideline for prevention.

Dry eye syndrome is a potential complication of botulinum toxin type-A injection (BTX-A) into the lateral canthal rhytids (crow's feet). The early manifestations of this syndrome are subtle and are rarely reported to the treating physician. A guideline for early detection of dry-eye state is proposed, in order to avoid more troublesome adverse effects that may develop with repeated injections of BTX-A into the crow's feet region. If suspected early, clinical manifestations remain minor and are reversible. However, delayed diagnosis may lead to troublesome and persistent symptoms. A novel and practical grading scale of lower eyelid snap-back and distraction tests is offered that helps in documenting patient's clinical progress and in deciding when BTX-A injections should be delayed or discontinued.

Subcutaneous emphysema, pneumopericardium, pneumomediastinum and pneumoretroperitoneum secondary to sigmoid perforation: a case report.

A 50-year-old woman presented with chronic epigastric abdominal pain and constipation. She underwent diagnostic upper and lower endoscopy for further evaluation. Several hours following the procedure, she developed chest and subcutaneous emphysema of her upper chest, neck, and face. A chest X-ray demonstrated marked subcutaneous emphysema, pneumopericardium, and pneumomediastinum. A CT scan revealed a small leak at the rectosigmoid junction. Because the patient did not have peritoneal signs, she was treated conservatively and discharged on hospital day seven. The complications of both esohagogastroduodenoscoy, and colonoscopy are discussed, with an emphasis on perforations.

Case report and management of suspected acute appendicitis in pregnancy.

Suspected cases of acute appendicitis in pregnancy are considered surgical emergencies due to the potentially devastating outcomes for both mother and unborn child if the appendix perforates. Acute appendicitis is also the number one cause of non-traumatic acute abdomen in pregnancy, as well as the number one cause of fetal death. We present a case report with a typical presentation of suspected acute appendicitis in a pregnant woman. The work up and diagnostic tools available are discussed at length, as well as the finer points in treatment of this population.

Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections.

BACKGROUND: Perfusion through the right axillary artery is an alternative to aortic or femoral artery cannulation during surgery for ascending aortic dissections. The results of this strategy, particularly beyond the immediate postoperative period, are not well described. METHODS: Eighty-three patients (median age, 58 years) with acute or subacute ascending aortic dissection underwent surgical repair with right axillary artery perfusion through an interposition Dacron graft. Sixty-five patients (78%) had DeBakey type I dissections. Procedures performed concomitantly with ascending aortic replacement included root replacement (n = 16; 19%), aortic valve repair or replacement (n = 51; 61%), and coronary artery bypass grafting (n = 13; 16%). Hypothermic circulatory arrest with antegrade cerebral perfusion was used in the majority of patients (n = 60; 72%). We retrospectively studied short-term and midterm outcomes, including survival and complications relating to the axillary cannulation. RESULTS: No patient incurred intraoperative axillary artery injuries or had arm ischemia. Fourteen patients (17%) died in the hospital or within 30 days of surgery, and 9 patients (11%) had strokes. Actuarial survival was 73% +/- 5% at 1 year and 64% +/- 6% at 3 years. Forty-six of the 57 surviving patients could be contacted by telephone; they reported few late complications related to the axillary artery cannulation site. These complications included 1 case each of right-arm weakness and right-arm numbness. CONCLUSIONS: Surgical repair of acute aortic dissection with right axillary artery perfusion can be performed safely, with a relatively low risk of stroke and a high probability of midterm survival.