Muscle-sparing thoracotomy: Anatomy and technique.

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes.  However, subsequent study results  have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

Occupational therapy for epidermolysis bullosa: clinical practice guidelines.

The purpose of this article is to summarize the Dystrophic Epidermolysis Bullosa Research Association (DEBRA) International evidence-based Clinical Practice Guidelines (CPGs) for the provision of occupational therapy (OT) for children and adults living with inherited epidermolysis bullosa (EB). This is a rare genetic disorder characterized by skin fragility leading to blister formation occurring spontaneously or following minor trauma. Current OT practice for persons with EB is based on anecdotal care, clinical expertise and trial and error with collaboration between caregiver and patient. Intervention based on research is needed to establish a foundation of knowledge to guide international practitioners to create and improve standards of care and to be able to work effectively with those living with the rare diagnosis of this condition.This CPG was created by an international panel with expertise working with persons with EB. The panel was made up of 11 members including OT's, a physiotherapist, a medical doctor, social worker, person with EB and a carer of a person with EB. It describes the development of recommendations for 5 outcomes determined by survey of persons with EB, caregivers, and experienced healthcare professionals. The outcomes include independence in activities of daily living (ADL), independence in instrumental ADL, maximization of hand function (non-surgical), fine motor development and retention, and oral feeding skills. The recommendations are supplemented with additional files that include photos and specific examples to further guide occupational therapists or, in situations where an OT is not available, other members of the healthcare team.As the disorder of EB is rare, evidence-based CPGs are needed to provide a base of knowledge and practice for OTs throughout the world with the goal of providing quality care to patients, while improving their functional independence and quality of life. In addition, this information is valuable as a basis for further research.

Use of Intraaortic Balloon Pumps in Acute Type A Aortic Dissection.

Cardiac failure may occur after repair of type A aortic dissections and contributes significantly to mortality. The use of an intraaortic balloon pump (IABP) for circulatory support in these patients is traditionally considered contraindicated because of concerns over extension of the residual dissection flap or aortic rupture. We propose that the use of an IABP may be appropriate and safe to improve cardiac function in patients after type A dissection repair. The two cases presented here contribute to increasing the body of evidence to support the appropriate use of IABP in these patients.

Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series.

BACKGROUND: Minimally invasive techniques are becoming increasingly popular in thoracic surgery. Although median sternotomy is the traditional approach for thymectomy, video-assisted thoracoscopic surgery (VATS) approaches now predominate. This study reports a case series of the novel uniportal subxiphoid-VATS approach to extended thymectomy. METHODS: Over the period of study (October 2014-January 2017) 17 patients underwent uniportal subxiphoid-VATS extended thymectomy for a thymic nodule at the Shanghai Pulmonary Centre. Ten patients were female, and the mean age of the cohort was 55 years. The mean size of nodule was 23.6 mm. RESULTS: The mean operative duration was 2.5 hours, with one conversion to thoracotomy for bleeding. The mean operative blood loss was 115 mL. The median length of hospital stay was 4 days. There were no episodes of phrenic nerve palsies. The 30-day survival was 100%. CONCLUSIONS: Uniportal subxiphoid-VATS is a feasible and safe surgical approach to extended thymectomy in selected patients, with good post-operative outcomes.

Uniportal subxiphoid video-assisted thoracoscopic bilateral segmentectomy for synchronous bilateral lung adenocarcinomas.

Uniportal subxiphoid video assisted bilateral segmentectomy is a minimally invasive option for the treatment of synchronous bilateral lung lesions. Its advantages over conventional multiportal or uniportal video assisted thoracoscopic surgery include avoidance of damage to the intercostal neurovascular bundle and allowance of bilateral lesion resection as a combined procedure via a single incision. This article presents a case from our centre to describe our surgical technique for this procedure.

The Shanghai Pulmonary Hospital uniportal subxiphoid approach for lung segmentectomies.

BACKGROUND: Lung segmentectomy may be considered an oncologic equivalent treatment to lobectomy for non-small cell lung cancer (NSCLC) sized 20 mm or smaller. Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) could further improve the surgical outcome reducing the surgical stress and completely avoiding the intercostal nerve injury. The aim of this manuscript is to illustrate the Shanghai Pulmonary Hospital surgical techniques for uniportal subxiphoid VATS (SVATS) segmentectomies. METHODS: A total of 79 consecutive patients underwent 84 subxiphoid segmentectomies for malignant or benign pulmonary diseases between September 2014 and January 2016. We here illustrate the surgical techniques and the early results. RESULTS: There were 45 segmentectomies in right-side group and 39 segmentectomies left-side group. The mean operation time was 2.38±0.77 hours, and mean operative blood loss was 126.09±136.17 mL. Nine segmentectomies (10.7%) had an intra-operative change of procedure and four were converted to thoracotomy, one had a lobectomy rather than a segmentectomy and four were converted to conventional VATS lobectomy. A total of 12 patients (15.1%) had postoperative complications, including 1 hematoma, 4 prolonged air-leaks and 8 arrhythmias. CONCLUSIONS: In the presented series that included our learning curve period we have experienced relative low conversion rates and few post-operatively complications showing that, SVATS segmentectomy can be considered a safe procedure with a relative low rate early post-operative complication.

Spontaneous splenic rupture: A rare life-threatening condition; Diagnosed early and managed successfully.

BACKGROUND: Splenic rupture is a potentially life-threatening condition, often associated with chest or abdominal trauma. Spontaneous rupture is very rare and is usually reported as being secondary to underlying pathological conditions. CASE REPORT: We discuss the case of a 56 year old man who presented with sudden onset left-sided abdominal pain, with no history of trauma. CONCLUSIONS: A computed tomography (CT) of the abdomen revealed a ruptured spleen with free fluid in the abdomen. Conservative management was ineffective and the patient underwent laparotomy and splenectomy, followed by routine post-splenectomy management. He was discharged home and remains well.

Oxidative stress and vein graft failure: a focus on NADH oxidase, nitric oxide and eicosanoids.

Recent interest has focused on superoxide and the upregulation of NADPH oxidase expression in the aetiology of vein graft failure. Implantation of saphenous vein grafts promotes upregulation of NADPH oxidase through a number of distinct interrelated mechanisms: (a) endothelial denudation, (b) factors released by adherent platelets, monocytes and neutrophils, (c) hypoxia and (d) altered prostacyclin (PGI(2)) and enhanced isoprostane formation. These, in turn, impact on neointima (NI) formation (vascular smooth muscle cell [VSMC] replication and migration) and metalloproteinase (MMP) expression, key events in vein graft thickening. NADPH oxidase in the aetiology of vein graft failure will be discussed in this review with particular reference to nitric oxide and eicosanoids and related drugs that inhibit its activity and expression.