Contributors: Kumar Patel, PA-C
Basic plastic surgery suturing techniques geared towards medical students and residents, including starting position, basic simple suture, deep dermal suture, vertical mattress, horizontal mattress and running subcuticular.
Laparoscopic adrenalectomy (LA) was first described by Gagner et al. in the early 1990s, and has since become the gold standard for removal of small and medium sized adrenal tumors.
Most commonly, LA is performed for unilateral benign adrenal lesions, however the minimally invasive technique is also routinely used for bilateral disease, as well as myelolipomas, adrenal cysts, adrenal hemorrhage and androgen-secreting tumors. Compared with the open approach, LA offers shorter hospital stay, improved patient satisfaction, decrease post-operative pain and markedly improved cosmesis. Even more, the difficulty in obtaining adequate open surgical exposure, combined with the diminutive size of the adrenal gland make laparoscopy an especially attractive option. Given this, we decided to proceed with LA approach for our patient who presented with NSCLC metastasis to his right adrenal.
Mellon MJ, Sethi A, Sundaram CP. Laparoscopic adrenalectomy: Surgical techniques. Indian Journal of Urologyâ€¯: IJUâ€¯: Journal of the Urological Society of India. 2008;24(4):583-589. doi:10.4103/0970-1591.44277.
Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.
The post-auricular flap is utilized for larger ear reconstructions. More commonly, it is reserved for defects that are not amenable to primary closure or helical rim advancement flaps.
Rib cartilage is the workhorse autogenic material for laryngeal airway expansion surgery. Most usually one will use the right-sided 5th or 6th rib as the donor site. A 2.5 cm incision is made directly over the rib, in the inframammary crease from the lateral aspect of the nipple to the sternal xyphoid process. Subcutaneous fat is removed. The overlying intercostal muscles are dissected up away from the rib, divided, and retracted– effectively exposing the rib. Perichondrium is sharply incised on the superior and inferior borders of the rib. A posterior tunnel is elevated in asub-perichondrial plane using blunt instruments, just medial to the osseocartilagenous (OC) junction. A Doyen elevator is inserted into the tunnel and the rib is transected right at the OC junction. The rib is then elevated from lateral to medial in the subperichondrial plane.
Such a manuever ensures that the plueral space will not be entered, protecting the pleural membrane from injury.
Once the rib has been elevated to the sternal attachment, it is completely released. The pleura is inspected directly to confirm it has not been injured. The wound is filled with normal saline and 30 cm of water pressure valsalva is applied by the anesthesiologist for 30 seconds, to ensure no air is escaping the lung. The wound is closed in layers over a rubber band drain placed in a dependent position.
One should be able to harvest 2.5-3 cm of cartilage. Post-operatively a chest radiograph is obtained to rule out pneumothorax
Contributors: Jonathan Isaacs and Amy Kite
Median nerve autogenous vein wrapping for revision carpal tunnel release due to traction neuritis.
Editor Recruited By: David Bozentka, MD