Craig Rezac, MD

Rutgers Robert Wood Johnson Medical School

• Associate Professor of Surgery
• Section Chief, Colon and Rectal Surgery

Craig Rezac, M.D., is a Double Board Certified Surgeon with clinical interest in Colon and Rectal Surgery. American-born, Dr. Rezac received his doctorate degree from Pisa Medical School in Pisa, Italy in 1995, and his undergraduate degree from Adelphi University in Long Island, NY in 1981. Dr. Rezac is licensed to practice in New Jersey and the Republic of Italy.

Currently, Dr. Rezac serves as Associate Professor of Surgery, Section Chief Colon and Rectal Surgery at Rutgers Robert Wood Johnson Medical School (RWJMS) in New Brunswick, NJ. He also serves as Staff Physician, General Surgery at Somerset Medical Center in Somerville, NJ.

After receiving his medical degree, Dr. Rezac completed a Surgical Externship at La Spezia Hospital in La Spezia, Italy. He then completed a General Surgery Internship at the Monmouth Hospital in Long Branch, NJ. This was followed by a General Surgery Residency at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, NJ, and a Colorectal Surgery Fellowship at UMDNJ-Robert Wood Johnson Medical School in Edison, NJ. Lastly, Dr. Rezac completed a Laparoscopic Fellowship at Hackensack University Hospital in Hackensack, NJ.

Dr. Rezac holds numerous medical certifications as follows: Cyberknife, Davinci Laparoscopic Robotic Surgery, Davinci Advanced Laparoscopic Robotic Surgery for Colon and Rectal Surgery, American Heart Association (BLS/CPR), Trans Anal Endoscopic Microsurgery (TEM), and Stapled Trans Anal Rectal Resection (STARR). Dr. Rezac has the distinct honour of being the first doctor in New Jersey to be certified in both TEM and STARR.

Dr. Rezac is a member of several professional associations, including: American College of Surgeons (Fellowship), American Society of Colon and Rectal Surgeons, Society of Laparoendoscopic Surgeons, American College of Surgeons, New Jersey Chapter, and the New Jersey Chapter of American Society of Colon and Rectal Surgeons (past-President).

Dr. Rezac has received a number of honors and awards for outstanding performance both academically and professionally. He currently serves on several major committees, in addition to school and hospital committees, while continuing to meet various teaching and clinical responsibilities.

Dr. Rezac has received substantial grant support for medical studies and has been widely published in national and international medical journals, books, monographs, chapters, and articles. Dr. Rezac has generously shared his time and talents to deliver over 30 scientific and clinical presentations around the world.

Lateral Temporal Bone Resection: A Detailed Look

In this webinar we will cover the basic steps of lateral temporal bone resection for cancers involving the ear canal. Attendees will be able to ask questions about the preparation and procedure along with the potential risks and complications it may present.

Alveolar Bone Graft Surgery: Tips and Tricks

This webinar will focus on the surgical management of alveolar clefts with bone grafting and fistula closure. Our panel of experts will share various techniques and graft source materials including tips and tricks learned along the way. Our guest moderator will lead a panel discussion at the end of the session to discuss some of the controversies and key points in alveolar grafting.

Cleft Lip Revision: Tips and Tricks

Attendees will learn various tips and tricks to a successful cleft lip revision procedure. There will be a Q&A session to address common challenges and how to address them.

Course Directors

Panelists

Pediatric Cricotracheal Resection: A Step by Step Surgical Presentation

This talk will focus on the surgical principals of resective airway surgeries with a step by step discussion on the surgical technique of Pediatric Cricotracheal resection.

Sohit Paul Kanotra , MD

Director, Complex Pediatric Airway Program / Associate Professor of Otolaryngology Head and Neck Surgery & Pediatrics
University of Iowa Hospitals & Clinics

Dr. Sohit Kanotra is a Clinical Associate Professor in the Department of Otolaryngology – Head and Neck Surgery and the Department of Pediatrics at the Roy J. and Lucille A. Carver College of Medicine at University of Iowa and the Director of the Complex Pediatric Airway program at University of Iowa Hospitals & Clinics. He has clinical expertise in the management of children with complex airway disorders including open airway reconstructive surgeries. He also has clinical interest in the management of Head and Neck vascular anomalies, pediatric thyroid disorders, minimally invasive endoscopic ear surgery and robotic airway surgery. Dr. Kanotra joined University of Iowa in 2019 prior to which he was the Director of the Pediatric Aerodigestive Center and the surgical director of the vascular anomalies’ clinic at Children’s Hospital of New Orleans in Louisiana.

Cleft Primary and Revision Rhinoplasty: Tips and Tricks

Tune in for the latest in our series on Cleft Surgery featuring Dr. Raj Vyas from UC Irvine and Dr. Usama Hamdan with the Global Smile Foundation. The discussion will focus on making sure that attendees know proper procedures as well as common complications and how to avoid them.

Larry Hartzell, MD FAAP is an Associate Professor of Otolaryngology Head and Neck Surgery at Arkansas Children’s Hospital. He is the Director of the Pediatric Otolaryngology fellowship. Dr Hartzell also has been the Cleft Team Director in Arkansas since 2012. He is passionate about international humanitarian mission work and dedicates much of his research efforts to cleft surgical and clinical care as well as velopharyngeal insufficiency. Dr Hartzell is actively involved in multiple academic societies and organizations including the AAO-HNS and ACPA.

Dr. Goudy is a professor at Emory University School of Medicine and the director of the division of otolaryngology at Children’s Healthcare in Atlanta. Dr. Goudy’s clinical job involves repair of craniofacial malformations including cleft lip, cleft palate, and Pierre Robin sequence, and he also participates in head and neck tumor resection and reconstruction.

Dr. Hamdan is President and Co-Founder of Global Smile Foundation, a 501C3 Boston-based non-profit foundation that provides comprehensive and integrated pro bono cleft care for underserved patients throughout the world. He has been involved with outreach cleft programs for over three decades. Dr. Hamdan is an Otolaryngologist/Facial Plastic Surgeon with former university appointments at Harvard Medical School, Tufts University School of Medicine and Boston University School of Medicine. For his philanthropic service to the people of Ecuador, he was awarded the Knighthood, “Al Merito Atahualpa” En El Grado De Caballero, by the President of Ecuador in March 2005. He received Honorary Professorship at Universidad de Especialidades Espíritu Santo, School of Medicine, in Ecuador on March 5, 2015 for his contributions in the field of Cleft Lip and Palate.

Dr. Vyas obtained his BS from Stanford and his MD from UCLA before completing integrated plastic surgery residency at Harvard and a fellowship in Craniofacial Surgery at NYU. He is an active clinician, scientist and educator with over 200 peer-reviewed publications and presentations, 20 book chapters, dozens of invited lectures, and multiple NIH and foundational grants. Dr. Vyas is passionate about advancing knowledge and skill for cleft care worldwide, partnering with Global Smile Foundation as both a clinician and Director of Research.

After completing a pediatric craniofacial fellowship at Boston Children’s Hospital, he joined the Division of Plastic and Reconstructive Surgery at Washington University in St. Louis 2011. He is Director of Craniofacial and Medical Director of the Operating Rooms at Saint Louis Children’s Hospital (SLCH). He treats patients with craniosynostosis or other craniofacial abnormalities (congenital or traumatic). He obtained a Master of Science in Clinical Investigation in May 2017 at Washington University to advance his ability to perform high quality clinical research and this program allows him to take advantage of the tremendous resources available for faculty and residents. His research focus is in craniofacial with particular interest in craniosynostosis and cleft lip and palate.

Dr. David Yates MD, DMD, FACS is passionate about serving children with Cranial and Facial deformities and Cleft Lip and Palate. He is a Board Certified Oral and Maxillofacial Surgeon and was recently awarded the inaugural “Physician of the Year” award by El Paso Children’s Hospital. He is the Division Chief of Cranial and Facial Surgery at El Paso Children’s Hospital and has been critical in bringing complex craniofacial surgery to the region. In addition to being a partner with High Desert Oral and Facial Surgery, he directs the craniofacial clinic at El Paso Children’s Hospital and the craniofacial clinic at Providence Memorial Hospital. He has also been integral in starting a clinic for children with Cleft Lip and Palate in Juarez, Mexico at the Hospital De La Familia (FEMAP). He is now happily settled with his wife and four kids serving the greater El Paso/Las Cruces/Juarez region.

Endoscopic Frontal Sinusotomy with Osteoma Removal

A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention. Methods: ENT Fusion Navigation system was used during the entire case. A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety. The natural ostium of the right maxillary sinus was then visualized. Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma. In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down. A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly. This ethmoid bulla was removed along with several other anterior ethmoid cells. After this was done, a frontal sinus seeker was used to identify the right frontal osteoma. The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract. Image guidance was meticulously used to identify the osteoma. A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible. Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned. Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient. Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD. Institution: Department of Otolaryngology - Head and Neck Surgery at the University of Arkansas for Medical Sciences.

RESECTION OF THE POSTERIOR GASTRIC WALL: ANOTHER STRATEGY AGAINST GIST WITH ENDOLUMINAL GROWTH

Gastrointestinal stromal tumors (GIST) occur most frequently at the gastric level. Surgical resection is the mainstay of treatment and can usually be performed using laparoscopic approaches (1). The resection strategy must be adjusted to each case, the selection of location, size and growth pattern of the tumor (2). We present the case of a 78-year-old female patient who, after going to the Emergency Department due to symptoms of upper gastrointestinal bleeding, showed a 5 cm heterogeneous tumor depending on the muscular layer itself in a posterior gastric wall, endoluminal growth, and without objectifying others injuries in the study of extension. A wide posterior resection of the gastric posterior wall and primary closure with a barbed suture was performed laparoscopically. The postoperative evolution was satisfactory. The histopathological study shows low-risk GIST (5 mitosis / 50 CGA) with free margins; during follow-up, no recurrence was observed. Simple laparoscopic resection of gastric GIST tumors seems to be a useful strategy in terms of oncological safety, reducing excessive resection of tumor-free tissue and increasing gastric remnant.

Reconstruction of Transcribriform Skull Base Defects

A 51 year-old male presented to an outside otolaryngologist with recurrent facial pain and congestion. He was found to have a left-sided nasal mass. A work-up was performed, complete with biopsy, which was diagnosed as non-intestinal type adenocarcinoma. He underwent resection via the endoscopic endonasal transcribriform approach. In this video publication, we present our preferred method of reconstruction for sinonasal malignancies treated by endoscopic transcribriform resection using a multilayered closure with the following: a subdural DuraGen inlay graft, a fascia lata onlay graft, and an extradural, extracranial onlay pericranial flap via nasionectomy. A lumbar drain was placed at the end of the case for CSF diversion until the fifth postoperative day. Contributors: Paul A. Gardner, MD, Eric W. Wang, MD, Juan C. Fernandez-Miranda, MD, and Carl H. Snyderman, MD, MBA

Endoscopic resection of a vallecular cyst in a pediatric patient

Base of tongue masses are rare in the pediatric population, when present they can be remain asymptomatic for years or can cause acute respiratory distress. The differential diagnosis includes dermoid, vallecular cyst, thyroglossal duct cyst, lingual thyroid, lymphangioma, hemangioma, and teratoma (1). Vallecular cysts consist of mucus filled cysts or pseudocysts arising either from the mucosa on the lingual surface of the epiglottis or on the base of tongue (2). These benign mucous retention cysts most commonly present as stridor, difficulty feeding, respiratory distress but they can also remain asymptomatic and can be found incidentally (3,4). Vallecular cysts may occur in isolation, but they can be associated with laryngomalacia and GERD in a significant number of patients(5). Initial screening of the airway is done using flexible fiberoptic laryngoscopy which provides a quick assessment of the larynx and visualization of the cyst(6). Imaging (ultrasonography, CT, MRI) can also be useful for evaluation of the mass and more detailed visualization of the mass and surrounding structures(6). Conservative medical treatment is not adequate for the management of vallecular cysts. Several surgical options have been described, these include aspiration, transoral endoscopic excision, marsupialization and deroofing with CO2 laser or microdebrider (6). There is a high recurrence rate when simple aspiration is performed (7), and there is reported risk of recurrence with marsupialization techniques. Excision using transoral endoscopic technique ensures complete resection with adequate visualization and preservation of surrounding structures and mucosa with low risk of recurrence (4). Here, we describe transoral endoscopic approach for excision of base of tongue cyst in a 3 year-old female. The patient presented with the diagnosis of PFAPA and she was seen to discuss tonsillectomy and adenoidectomy. On physical exam, a 1.5 cm midline base of tongue cyst was seen when she protruded her tongue. The cyst had been increasing in size. Plan was to proceed with tonsillectomy & adenoidectomy and excision of base of tongue cyst. After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. Correct patient and procedure were identified and general anesthesia by mask was induced. A laryngeal mask airway was placed first. A red rubber catheter was placed through the left nostril after the Davis mouth gag was inserted with a small tongue blade. The soft palate and uvula were palpated to be normal. The adenoid was mildly enlarged and was cauterized completely with suction cautery. Following that, Afrin was placed in the nasal cavity. The child was intubated with a nasotracheal tube through her left nostril that allowed for exposure. A red rubber catheter was left in her right nostril. The side-biting mouth gag was used. Two separate 2-0 silk sutures were placed in the midline to retract her tongue. A 30-degree telescope was used for visualization of the base of tongue cyst. With the Hurd elevator and other means of retraction, an extended Colorado needle tip with a 45 degree bend at the distal portion, was used to completely remove the base of tongue cyst which was quite deep. At the distal part, there was mucus seen, but the cyst was completely excised. The wound was irrigated thoroughly. There was no bleeding. The side-biting mouth gag was removed and the Davis mouth gag reinserted. A complete tonsillectomy was then performed. She was then extubated without difficulty in the OR and transferred to PACU. Patient was discharged on oxycodone and amoxicillin. On her follow up visits, the oral cavity and tongue were healing well with no evidence of recurrence. Pathology result: consistent with extravasation mucocele. Mucin filled cystic space rimmed by a lympho-histiocytic reaction and granulation tissue. Minor salivary glands w/ dilated ducts focally surrounded by chronic inflammation are present in the surrounding fibromuscular tissue.

Robotic-Assisted Posterior Mediastinal Mass Resection

A 34-year-old non-hypertensive, obese female with a history of smoking, asthma, fibromyalgia presented at the ED with hemoptysis, dyspnea, and emesis for two weeks. At presentation the patient was afebrile, vital signs were stable and labs showed unremarkable CBC and BMP. Chest X-ray showed an abnormal soft tissue density within the subcarinal region. A follow-up chest CT with contrast revealed a posterior mediastinal mass measuring 5.4 cm x 3.6 cm in size with well-circumscribed borders. The patient was referred to cardiothoracic surgery for complete excision of the mass. She underwent robotic-assisted posterior mediastinal mass resection.

A Guide to Temporal Bone Dissection: Lateral Temporal Bone Resection (Part 3 of 6)

Authors Mohamedkazim M. Alwani, MD1, 3 Jon L. Harper, BS1, 3 Rick F. Nelson, MD PhD1, 2, 3 Author Affiliations Department of Otolaryngology – Head and Neck Surgery1 Department of Neurological Surgery2 Indiana University School of Medicine3 Video Description This video covers the key steps of a lateral temporal bone resection during lab dissection of the temporal bone. The goal of this video is to serve as a supplementary teaching resource for resident-level surgical trainees by demonstrating key surgical landmarks and proper lab dissection technique. This video builds on part two of our video series. This approach allows for the en bloc removal of the external auditory canal and demonstrates fundamental steps of the procedure including: the propagation of a superior trough between the tegmen and the superior aspect of the external auditory canal, the extension of the facial recess inferiorly with sacrifice of the chorda tympani, and the drilling of the hypotympanic bone towards the glenoid. At the completion of the demonstration, the viewer is afforded a labelled view of the medial wall of the mesotympanum, as well as the medial aspect of the external auditory canal with an intact tympanic membrane. Key surgical landmarks demonstrated in the course of this video include: tegmen, zygomatic root, malleus, incus, stapes, glenoid, eustachian tube, mastoid segment of the facial nerve, chorda tympani nerve, facial recess, hypotympanic space, annular bone, tensor tympani tendon, cochlear promontory, pyramidal process, round window, and lateral semicircular canal.

Robotic Loop Ileostomy Closure

71 yrs old male s/p robotic low anterior resection with primary coloproctostomy and diverting loop ileostomy for bulky, locally advanced rectal cancer. Robotic approach for loop ileostomy closure was planned due to obese body habitus. We utilized DaVinci Xi robotic platform. The set up consisted in 4-port placement, with ports # 2, 3 and 4 positioned starting in the left upper abdominal quadrant along MCL and port # 1 in suprapubic area. After docking and insertion of robotic instruments, the RLQ ileostomy was visualized. Appropriate orientation of efferent and afferent limbs was confirmed. Two enterotomies were created with electrocautery at the antimesenteric border of each limb, approximately 10 cm from the fascia. Head and anvil components of a robotic 60 mm stapler were then inserted in each enterotomy and the stapler fired in order to create a common channel between the lumens. After stay suture with 3-0 Vicryl was placed at the crotch of the anastomosis, common enterotomy defect was approximated with running 3-0 V-Lock suture in two layers. The matured portions of the loop ileostomy were then divided right below the fascia level with robotic 60 mm stapler after gentle dissection of the mesenteric border of each limb, while the mesentery was divided with robotic vessel sealer. The robotic system was then undocked and the ports removed. The remaining portion of the loop ileostomy was finally dissected from the abdominal wall at the mucocutaneous junction and the fascia defect approximated in the usual fashion (not included in the video).

Robotic-assisted Base of Tongue Resection for Adult Sleep Apnea

A 52-year-old female presented for an evaluation for sleep apnea surgery. She complained of choking sensation at night. She had an AHI of 6.7 events per hour, a oxygen saturation nadir of 71%, and BMI of 30.6. She and a prior history of adenotonsillectomy as a child. Flexible examination in the office revealed grade 4 lingual tonsil hypertrophy. She was deemed a candidate for lingual tonsillectomy and was taken to the operating for robotic lingual tonsillectomy. The technique for adult lingual tonsillectomy is shown in step-by-step fashion with tips for good results both operatively and functionally learned from robotic surgery for cancer of the unknown primary origin. Contributors: Jessica Moskovitz, MD, Leila J. Mady, MD, PhD, MPH, Umamaheswar Duvvuri, MD, PhD

Use of Surgical Theater to Facilitate Resection of an Arteriovenous Malformation

Hepzibha Alexander, BSN – Children’s National Medical Center, Division of Neurosurgery and Georgetown University School of Medicine Ehsan Dowlati, MD - Children’s National Medical Center, Division of Neurosurgery and Medstar Georgetown University Hospital Deki Tsering, MS - Children’s National Medical Center, Division of Neurosurgery Robert Keating, MD - Children’s National Medical Center, Division of Neurosurgery and George Washington University School of Medicine (corresponding author)

Extended Partial Cricotracheal resection with thyrotracheal anastomosis in Grade IV subglottic stenosis with posterior glottic involvement

The video goes over the steps of an extended partial Cricotracheal resection in a 8 year old child with Grade 4 subglottic stenosis with posterior glottis involvement.

Excision of Macrocystic Lymphatic Malformation

This patient is a 9-month-old with a macrocystic lymphatic malformation (LM) of the left neck. LMs, the second most common type of head and neck vascular malformation, are composed of dilated, abnormal lymphatic vessels thought to occur due to abnormal development of the lymphatic system. A complete resection was performed, and LM was confirmed by pathology. Soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process.

Middle Fossa Approach for Vestibular Schwannoma (Acoustic Neuroma) Resection

This video demonstrates the operative setup and surgical steps of a middle fossa approach for the resection of vestibular schwannoma (acoustic neuroma). Authors: Cameron C. Wick, MD (cameron.wick@wustl.edu) 1 Samuel L. Barnett, MD (sam.barnett@utsouthwestern.edu) 2 J. Walter Kutz Jr., MD (walter.kutz@utsouthwestern.edu) 3 Brandon Isaacson, MD (brandon.isaacson@utsouthwestern.edu) 3 1 - Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 2 - Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX 3- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX

Augmented Reality In A Hybrid Or For Pulmonary Nodule Localization And Thoracoscopic Resection - Feasibility Of A Novel Technique

from the APSA 2018 Annual Meeting proceedings AUGMENTED  REALITY IN A HYBRID OR FOR PULMONARY NODULE LOCALIZATION AND THORACOSCOPIC RESECTION - FEASIBILITY  OF A NOVEL TECHNIQUE John M. Racadio,  MD, Meera Kotagal, MD, Nicole A. Hilvert, RT(R)(VI), Andrew M. Racadio, BS, Daniel von Allmen, MD. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA. Purpose:  To assess the feasibility of utilizing a novel technique of augmented reality on a hybrid operating  room C-arm system  for image-guided localization and thoracoscopic resection of pulmonary  nodules. Methods: After obtaining IACUC approval,  silicone pulmonary  nodules were created and subsequently localized in a swine model in our research lab equipped as a hybrid operating room. Four optical cameras embedded in a C-arm system  allowed video co- registration  with a C-arm cone  beam  CT. Skin marker fiducials allowed for optical tracking and motion compensation. An integrated navigation system  enabled optically guided nodule localization without the need  for fluoroscopy,  thus reducing  radiation exposure. The optical augmented reality navigation was used  to both create and localize nodules. Localization was performed with microcoils. Thoracoscopic resection of the nodules was accomplished using direct visualization and fluoroscopic guidance. Results: As demonstrated in the video, realistic pulmonary  nodules were created and imaged  using the C-arm cone  beam  CT and an optical/image guidance system  to direct placement. Lesions  were accurately localized using optical/image guidance, enabling placement of microcoils  at the nodules.  Combined  thoracoscopic and fluoroscopic guidance allowed accurate wedge  resection of the nodules. Conclusions: Injection of silicone creates a realistic pulmonary  nodule  model. Image guidance using emerging  technology combining radiographic and optical imaging is effective in creating  and localizing pulmonary  nodules.  Real-time imaging combined with thoracoscopic visualization facilitates wedge  resection of nodules marked  with microcoils. The hybrid operating  room simplifies the radiographic localization and resection of pulmonary  nodules by eliminating the need  to move the patient from radiology to the operating  room. A collaborative approach combining the skill sets  and technologies of Interventional Radiology and Surgery  offers new opportunities for image guided  surgery.

Breast Reduction Mammoplasty: Inferior Pedicle Technique

Patient X is a 20-year-old Caucasian woman who suffers from symptomatic macromastia. A Wise pattern skin resection was drawn, beginning by marking a point 20.5cm from the suprasternal notch on each breast along the breast meridian, indicating the apex of the skin resection and position of the future nipple placement. A triangle was then drawn with sides of 8cm each and a base of 7cm, with the apex again at the point noted above. The base of the inferior pedicle was drawn by marks 5.5cm to either side of this intersection, giving a pedicle with a 11cm base. Additional anatomic landmarks were also marked, including the suprasternal notch, and the sternal midline.

Difficult Dissection during a Low Anterior Resection

It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot. The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.

Robotic-assisted Low Anterior Resection with Proximal Colotomy

Contributors: Dr. Jimmy Lin and Dr. Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions with faster recovery time, as well as better accuracy, flexibility and control. Many procedures which had previously been conducted with laparoscopy, or open surgery, are further improved upon with robotic surgery. This is a video of a robotic-assisted LAR in a male with a T4N2M0 rectal cancer with concern for invasion into the prostate and seminal vesicles. The patient also has a synchronous proximal tubulovillous adenoma which had been biopsied but not completely resected during a previous colonoscopy. He therefore also underwent an intra-operative colotomy and colon polyp resection. This video demonstrates the advantages of robotic-assisted surgery in conjunction with more traditional procedures in order to provide the best care possible for the patient.

Endoscopic Resection of Concha Bullosa

Concha bullosa represents a benign entity that can present problems for the endoscopic sinus surgeon by limiting access and visualization to the middle meatus. Additionally, this may be a significant contributor to a patient's nasal obstruction, or the leading factor for osteomeatal complex obstruction. Endoscopic removal provides a quick, safe, and reliable means to deal with this issue and provide the appropriate surgery for the patient.

Excision of Macrocystic Lymphatic Malformation

Introduction Lymphatic malformations (LM) are composed of dilated, abnormal lymphatic vessels classified as macrocystic (single or multiple cysts >2 cm3), microcystic (<2 cm3), or mixed. This patient is a 5-month-old with a right neck mass consistent with macrocystic lymphatic malformation on MRI. This low-flow vascular malformation required surgical intervention. Methods The site was marked in a natural skin crease. Subplatysmal flaps were raised and malformation was immediately encountered. Blunt soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process. Mass was removed in total and Penrose drain and neck dressing were placed. Results A complete resection was performed. LM was confirmed on pathology. Patient is doing well with no deficits noted. The drain was removed after 1 week. One-month follow-up showed no recurrence. Conclusion Macrocystic lymphatic malformations are amenable to surgical resection at low risk and without recurrence. By: Ravi W Sun, BE Surgeons: Luke T Small, MD Gresham Richter, MD Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Arkansas Children's Hospital, Little Rock, AR, USA Recruited by: Gresham T Richter, MD

Endoscopic Resection of Esthesioneuroblastoma with Dural Resection and Reconstruction

Contributors: Shaan Raza, Ehab Hanna, Peleg Horowitz Anterior skull base sinonasal malignancy previously biopsied as esthesioneurobastoma. Tumor extension through the left cribiriform plate and left lamina papyracea. Author Recruited By: Dr. Ehab Hanna

Robotic Assisted Small Bowel Resection for Meckel's Diverticulum

We present a case of a 21-year-old male with a one-day history of right lower quadrant pain and CT scan findings suspicious for a perforated Meckel’s Diverticulum who underwent a robotic assisted small bowel resection with an intracorporeal anastomosis. Contributors: Milind D. Kachare, M.D. Nisha Dhir, M.D., FACS University Medical Center of Princeton at Plainsboro, Rutgers - Robert Wood Johnson Medical School

Resection and modified purse-string closure of frontal hemangioma

Infantile hemangiomas occurring in the face may represent a real problem to a child. Clinical significance is ultimately determined by the degree of tissue deformation. Large dimensions; specific locations; and the presence of complications such as ulceration, bleeding, or infection indicate active treatment to minimize morbidity. The combination of clinical features and response to pharmacologic treatment are the main standpoints indicating surgery during the active phases of infantile hemangiomas. The concept of minimal possible scar is relevant, and the use of purse-string sutures, initially proposed by Mulliken et al., promotes a real reduction in the final scar dimensions. In this video surgical resection of a frontal hemangioma illustrates a modified purse string suture, to reduce the dimensions of a linear scar. Contributors Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School

Laparoscopic Nephrectomy for Wilms Tumor in a One-Year Old Girl

From the APSA 2011 Annual Meeting LAPAROSCOPIC NEPHRECTOMY FOR WILMS TUMOR IN A ONE YEAR OL D GIRL Authors:

• Guido Seitz, MD
• Steven W. Warmann, MD
• Martin Ebinger, MD
• Falko Fend, MD
• Jrg Fuchs, MD
• University Children`s Hospital, Tuebingen, Germany,
• University Hospital, Department of Pathology, Tuebingen, Germany

Thoracoscopic resection of a mature anterior mediastinal teratoma

This video is a step by step depiction of the diagnostic tools and the thoracoscopic mobilization and resection of a mature mediastinal teratoma.

Transanal Resection, How to Avoid Fecal Incontinence

from the APSA 2010 Annual Meeting proceedings TRANSANAL RESECTION, HOW TO AVOID FECAL INCONTINENCE Author: Alberto Pena, MD, Andrea Bischoff, MD, Marc A. Levitt, MD Cincinnati Children Hospital, Cincinnati, OH, USA Purpose: Transanal resection of the rectosigmoid is a valuable technique applicable for Hirschsprungâs disease, non-manageable idiopathic constipation, and idiopathic rectal prolapse. However, it represents a risk of producing damage to the continence mechanism. A series of important technical steps are crucial to avoid damage to the anal canal and sphincters. These are shown in a short video. Methods: In operations designed to remove the rectosigmoid and pull-through a new portion of colon it is mandatory to preserve the patientâs continence mechanism. This is achieved by avoiding damage to the sphincter and preserving the anal canal for up to 2 centimeters above the pectinate line. Damage to the continent mechanism can result from inadvertently resecting part, or the entire anal canal, leaving the patient without sensation. In addition, the striated sphincter mechanism may be resected or overstretched. Results: Over a period of ten years, 13 patients from other institutions were referred suffering from fecal incontinence following a transanal rectosigmoid resection. An examination under anesthesia demonstrated that the anal canal was non-existent or seriously damaged. During the same period of time we have done 125 transanal resections of the rectosigmoid and have made every effort to preserve intact the continence mechanism. As a result, we developed a series of technical recommendations that include: a) use of a Lone-Star retractor, b) placing and then replacing the eight hooks deeper so that the pectinate line is protected and hidden, c) placing multiple fine sutures on the rectal wall to apply uniform traction, d) starting the resection two centimeters above the pectinate line, e) avoiding overstretching of the anus using a three point exposure technique (one narrow malleable, a forceps or suction tip, and rectum; forming a triangle). Conclusions: With these technical maneuvers a transanal rectal and rectosigmoid resection can be performed preserving the continence mechanism.

Endoscopic Endonasal Approach for Pituitary Tumor Resection

Contributors: Timothy R. DeKlotz With the widespread use of the endoscope in pituitary surgery, many technical nuances have emerged. Some surgeons still use a sublabial incision and a speculum, despite using the endoscope for visualization, while others favor approaches that are purely endonasal. Some surgical teams, using an endoscope-holder, work sequentially and individually, while others prefers two surgeons working together simultaneously. In this video, we demonstrate an endoscopic endonasal approach, in which the tumor resection is performed with a 4-hand technique with both surgeons working simultaneously. DOI#: http://dx.doi.org/10.17797//bdxmmtst16

Translabyrinthine Approach for Vestibular Schwannoma (Acoustic Neuroma) Resection

Contributors: Bruce E. Mickey and J. Walter Kutz This video highlights key steps to the translabyrinthine approach for vestibular schwannoma resection. It emphases identification of the facial nerve and the benefit of facial nerve monitoring in lateral skull base surgery. DOI#: https://doi.org/10.17797/4w83z6uxam

Ultrasound Guided Thoracoscopic Dental Extraction

Contributors: Rodrigo Ruiz and Adele Brudnicki We present a minimally invasive approach for removal of an aspirated tooth that was not extractable via rigid / flexible bronchoscopy. The multimodal technique results in a successful extraction via non-anatomic wedge resection of the affected portion of the lung and thereby obviates the need for a formal lobectomy.

Laparoscopic Extracorporeal Repair of a Morgagni Diaphragmatic Hernia

Contributors: Anahita Jalilvand and Marco P. Fisichella This video describes a laparoscopic-extracorporeal repair with mesh of a Morgagni diaphragmatic hernia in an 81 year old female. We used Ventralight™ ST Mesh which is an uncoated lightweight monofilament polypropylene mesh on the anterior side with an absorbable hydrogel barrier based on Sepra® Technology on the posterior side for laparoscopic ventral hernia repair. The posterior side mesh does not cause adhesion with the abdominal organs. DOI: https://doi.org/10.17797/k8ktfjncgn A quick review of the literature of laparoscopic cases has shown that in a substantial amount of cases the hernia was reduced and the defect repaired with mesh placement without hernia sac resection . Therefore, non-resecting the sac is an acceptable option.

Microsurgical resection of an acoustic neuroma via the translabyrinthine approach

Contributors: H. Jeffrey Kim The translabyrinthine approach has often been reserved for large acoustic neuromas because it requires less retraction on the cerebellum when compared to the retrosigmoid approach for a similar tumor. However, the translabyrinthine approach is equally useful for smaller tumors, when the patients has no residual ipsilateral hearing. It allows for early visualization of the facial nerve, and thus better protection of this crucial nerve. DOI #: http://dx.doi.org/10.17797/168b12z8m4

Minimally Invasive Repair of Pectus Carinatum

MINIMALLY INVASIVE REPAIR OF PECTUS CARINATUM Robert Kelly, MD1, Sherif Emil, MD, CM2. 1Children’s Hospital of the King’s Daughters; East Virginia Medical School, Norfolk, VA, USA, 2Montreal Children’s Hospital; McGill University Health Centre, Montreal, QC, Canada. Pectus carinatum is a chest wall anomaly amenable to correction by a number of surgical and non-surgical techniques. Minimally invasive repair of pectus carinatum, also unknown as the Abramson or reverse Nuss procedure, is an innovative technique that can achieve correction without major cartilage resection, large incisions, or prolonged bracing. Like other innovative techniques, the operation has gone through several technical problem-solving stages, and has yet to be adopted widely. We present a high fidelity video that illustrates the required equipment and surgical maneuvers necessary to optimize safety and outcome of this new technique. The results in two teen-age boys are demonstrated. DOI: https://doi.org/10.17797/fo5h3wx5hz

Laparoscopic Transanal Total Mesorectal Excision: Rectal Cancer

Contributors: Justin A. Maykel MD The following video demonstrates a laparoscopic transanal total mesorectal excision (taTME) for the treatment of a locally advanced mid-rectal tumor. Eight weeks following neoadjuvant chemotherapy and radiation she was brought to the operating room for radical resection. DOI#: https://doi.org/10.17797/wvn5h86w7l Referred by Jeffrey B. Matthews

Transoral Resection of Stylohyoid Ligament

Contributors: Raj Dedhia, M.D Eagle’s Syndrome, also known as Styloid Syndrome, is defined by the presence of an elongated, misshapen, or calcified stylohyoid ligament. It is characterized by pain localized to either side of the throat, odynophagia, and referred otalgia. Transoral removal of the stylohyoid ligament consists of transecting the stylohyoid ligament to release tension and result in improvement of pain. DOI #: https://doi.org/10.17797/o3iz10qacz

Endoscopic Endonasal Resection of an Esthesioneuroblastoma with Dural Resection and Reconstruction

Contributors: Ehab Hanna and Peleg Horowitz Anterior skull base sinonasal malignancy previously biopsied as esthesioneurobastoma. Tumor extension through the left cribiriform plate and left lamina papyracea. Author Recruited By: Dr. Ehab Hanna

Robotic Sigmoid Resection and Intracorporeal Anastomosis

This is a 60 yo woman with diverticulitis not responsive to medical management. Open, laparoscopic, and robotic operative options were discussed. We agreed on robotic sigmoid resection in the Enhanced Recovery Pathway. This video demonstrates an intracorporeal colorectal anastomosis between the descending colon and upper rectum. Sigmoid colectomies are typically characterized by by specimen extraction through an open incision after minimally invasive mobilization of the colon and mesentery, placement of an anvil into the descending colon through this open incision, and then laparoscopic or robotic colorectal anastomosis with a circular stapler after re-establishing pneumoperitoneum. This intracorporeal anastomosis does not require stretching colon and mesentery to an open extraction site with the possible need for extending the open incision. There is less visceral manipulation and potentially less ileus and quicker return to gastrointestinal activity. The extraction site can be anywhere the surgeon chooses and the extraction incision size is limited only by the sixe of the pathology. DOI # http://dx.doi.org/10.17797/p11gskfc90 Recruited By: Vincent Obias

Endoscopic Excision of Concha Bullosa

Contributors: Gresham Richter Here we present endoscopic excision of a concha bullosa (a pneumatized middle turbinate) that was causing obstruction in the left nasal cavity.  This particular patient failed medical management of his chronic sinusitis including antibiotic and steroid therapy. The concha bullosa was causing obstruction of the maxillary sinus ostium and deviation of the nasal septum. Resection of the concha bullosa was necessary in order to complete a functional endoscopic sinus surgery afterward and septoplasty (not shown). DOI # 10.17797/pyzfxehca8 Author Recruited by: Gresham Ritcher

Lateral Temporal Bone Resection

Contributors: Paul W. Gidley, MD This video demonstrates the basic steps of lateral temporal bone resection for cancers involving the ear canal. The lateral temporal bone resection removes the ear canal en bloc, preserving the facial nerve and stapes. DOI: http://dx.doi.org/10.17797/mn4edyy57u Editor Recruited By: Ravi N. Samy, MD, FACS

Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Contributors: Sricharan Chalikonda and R. Matthew Walsh Two separate general approaches are described to perform minimally invasive pancreaticoduodenectomy (PD): pure laparoscopic and robotic. The technique shown is a hybrid utilizing laparoscopy for the resection and surgical robot for the reconstruction. We feel that this technique combines the advantages of both laparoscopic and robotic surgery.

Middle Fossa Transventricular and Subtemporal Approach for Meningioma Resection

Contributors: Micheala Lee This is a demonstration of using the transventricular and subtemporal corridors for resecting a large middle fossa, tentorial meningioma. The video details the microsurgical technique for detaching the tumor from the tentorial incisura, working near critical structures such as the oculomotor nerve, trochlear nerve, and posterior communiating artery. It also includes precise demonstration of how to separate the massive tumor from the feeding arterial supply stemming from the posterior cerebral artery. DOI: https://doi.org/10.17797/nbtj2jdx6l

Endoscopic Assisted Laparoscopic Transgastric Resection of GE Junction Gastrointestinal Stromal Tumor (GIST)

Contributors: Irving Waxman and John C. Alverdy Laparoscopic intragastric resection of a gastrointestinal stromal tumor 0.5cm distal to the gastroesophageal junction performed with oral endoscopic assistance. Related External Links: http://www.wjgnet.com/1948-5190/full/v7/i1/53.htm http://www.ncbi.nlm.nih.gov/pubmed/21224608 DOI: http://dx.doi.org/10.17797/5v0bdou315 Editor Recruited By: Jeffrey Matthews, MD

Laparoscopic-assisted Small Bowel Resection for Retained Endoscopic Capsule

Contributors: Anna Sabih and Edward Auyang This video depicts a laparoscopic-assisted approach for the retrieval of an endoscopic capsule retained within the small bowel. DOI: http://dx.doi.org/10.17797/prub9rczs1 Editor Recruited By: Jeffrey B. Matthews, MD

Endoscopic Ampullectomy

Contributor: Darin L. Dufault This video illustrates two cases of ampullary adenoma treated with endoscopic papillectomy (a.k.a. endoscopic ampullectomy in many manuscripts). Along with local surgical ampullectomy and pancreaticoduodenectomy, endoscopic papillectomy is an established treatment option for benign lesions of the ampulla of Vater. For the majority of benign ampullary lesions, complete endoscopic resection of ampullary lesions is usually feasible. Limitations to endoscopic therapy include deep extension into the bile or pancreatic duct, > 50% lateral extension along the duodenal wall, and carcinomatous transformation. In general, endoscopic resection should be considered equivalent to local surgical ampullectomy in terms of its depth of dissection. In the first case, the patient was noted to have adenomatous appearing change of the ampulla on endoscopy. An electrocautery snare is used to remove the entire papilla. When technically feasible, cholangiopancreatography should precede tissue resection to evaluate for intraductal extension and identify the orifices for post-resection therapy. Since this was unsuccessful prior to resection, the pancreatic duct is then cannulated and a pancreatogram is obtained. A pancreatic duct stent is then placed after pancreatic sphincterotomy to minimize the risk of post-ampullectomy and ERCP pancreatitis, and to prevent stenosis of the pancreatic orifice long-term. Then, a cholangiogram is performed, confirming no intraductal extension and to facilitate a biliary sphincterotomy. The second case is a patient referred for further evaluation of cholestatic liver function tests and a dilated bile duct. Endoscopically, they were noted to have a protuberant papilla. Endoscopic ultrasound (EUS) showed a mass between the bile and pancreatic ducts and within the ampulla of Vater, along with a significantly dilated bile duct. The mass did not invade the duodenal wall, as showed by preservation of the muscularis propria. In cases where malignancy is not suspected and in smaller lesions, EUS may not be required. Prior to papillectomy, the pancreatic duct was cannulated and methylene blue injected into the duct to allow easier identification of the duct following papillectomy. The mass was also able to be seen on cholangiogram (green circle). It is preferred to remove the papilla en bloc, as shown in case one, although this is not always possible. There was a small amount of residual tissue at the core of the lesion that was further resected in piecemeal fashion using a hot snare with blended cut and coagulation current. Biliary and pancreatic stents were then placed to minimize the risk of post-ERCP pancreatitis, delayed post-ampullectomy bleeding, and orifice stenosis. These stents are typically removed after 1-2 months, at which time the resection site may be surveyed for residual adenomatous tissue. Last, a small amount of residual abnormal appearing tissue was ablated using APC. Editor Recruited By: Jeffrey Matthews, MD DOI: http://dx.doi.org/10.17797/ju7gthra0v

Bilateral Dacryocystoceles Resection

Contributor: Tyler McElwee Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst.  The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants.  It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction.  It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates.  Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions.  Ultrasound, CT scan or MRI can be used for diagnosis.  About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing.  The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele.   Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement.  Post-operatively patients are treated empirically with antibiotics and nasal saline.  No second look is usually planned unless patients develop significant nasal obstrctuion. Editor Recruited By: Sanjay Parikh, MD, FACS DOI: http://dx.doi.org/10.17797/16rnuq8n0y

Fully Laparoscopic Total Gastrectomy with Double Staple Anastomosis

Contributor: Joseph Kim This video demonstrates a fully laparoscopic total gastrectomy using a double-staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis. Fully laparoscopic total gastrectomy provides distinct advantages over the open laparotomy technique. An elderly gentleman was found to be anemic on routine bloodwork exam. Subsequent upper endoscopy revealed gastric cancer of the cardia, necessitating complete gastric resection. This video demonstrates a fully laparoscopic total gastrectomy using a double staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis. DOI: http://dx.doi.org/10.17797/i3nfwwigio Editor Recruited By: Jeffrey B. Matthews, MD

Transoral Robotic Assisted Radical Tonsillectomy

Contributors: Jeffery Scott Magnuson (University of Central Florida) 1) Purpose: The patient had a history of biopsy proven squamous cell carcinoma of the right palatine tonsil and elected for surgical resection as a primary treatment. 2) Instruments: The DaVinci surgical robot was used with the Maryland dissector and a monopolar cautery on the arms. The FK retractor was used to suspend the patient and gain exposure. 3) Landmarks: The right palatine tonsil is resected along with a cuff of pharyngeal musculature. 4) Procedure: In sequence, the initial incision on the anterior tonsillar pillar, the exposure of the parapharyngeal space, the removal of the specimen, and the final defect are shown. 5) Conflicts of interest: for JSM: Intuitive Surgical: Instructor/Proctor, Honoraria; Lumenis: Consultant, Honoraria; Medrobotics: Member Strategic Advisory Panel, Honoraria. 6) References: Chung, T. K., Rosenthal, E. L., Magnuson, J. S. and Carroll, W. R. (2014), Transoral robotic surgery for oropharyngeal and tongue cancer in the United States. The Laryngoscope. http://dx.doi.org/10.1002/lary.24870 DOI: http://dx.doi.org/10.17797/kjwgjsgxwk

laparoscopic pancreatectomy Dr Laje

Laparoscopic resection of a focal lesion of congenital hyperinsulinism.

Vocal Fold Cordectomy Type I (ELS classification) for Carcinoma In Situ of the Vocal Fold Using Carbon Dioxide Laser

Authors: Yonatan Lahav, MD, Doron Halperin, MD, Hagit Shoffel-Havakuk, MD. Subepithelial vocal fold cordectomy (Type I cordectomy according to the ELS classification) for Carcinoma In Situ, performed under general anesthesia with direct microlaryngoscopy and suspension using a free beam CO2 Laser. The resection respects the layered structure of the vocal folds and preserves the superficial lamina propria and its vasculature. The video follows the procedure step by step and includes detailed instructions.

da Vinci Assisted Low Anterior Resection and Colovesical Fistula Repair

Contributors: Jimmy Lin and Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions and faster recovery time, to better accuracy, flexibility and control.  Many procedures which had previously been conducted with laparoscopy, or open surgery, are becoming further improved upon in robotic surgery. This video demonstrates two such procedures, from different specialities, being performed; the low anterior resection and colovesical fistula repair. DOI#: http://dx.doi.org/10.17797/f1frvag53q

da Vinci Robot Assisted Low Anterior Resection with Diverting Loop Ileostomy

Contributors: Jimmy Lin and Craig Rezac This procedure is a da Vinci Xi Robot assisted low anterior resection with diverting loop ileostomy performed on a 64 year old male patient who on work-up of hematochezia and change in bowel habits was found to have a locally advanced rectal adenocarcinoma approximately 5-6cm from the anal verge. The patient was found to have a single subcentimeter metastatic liver lesion, which was treated with radiofrequency ablation. He was treated with neoadjuvant chemoradiation prior to undergoing surgery. DOI: http://dx.doi.org/10.17797/vk8yonl7gj Editor Recruited By: Vincent Obias, MD, MS

Combined Modality: Laparoscopic Assisted Colonoscopic Polypectomy

Laparoscopic assisted colonoscopic polypectomy aids in the safe excision of otherwise unresectable polyps with colonoscopy alone due to unfavorable locations or polyp charicteristics. A combined procedure allows for laparoscopy to assist in polypectomy by providing traction on the luminal wall, the ability to recognize a full thickness perforation and perform a segmental resection without delay and to spare the patient from multiple exposures to anesthesia. DOI# http://dx.doi.org/10.17797/d04no64kyu

Anterior Petrosectomy and Resection of a Meckel's Cave Schwannoma

Contributors: Daniel Felbaum and  H. Jeff Kim The video demonstrates the resection of a trigeminal schwannoma via a middle fossa craniiotomy and anterior petrosectomy. A large dumbbell-shaped tumor was essentially two tumors in one. The anterior petrosectomy provided access mainly to the posterior component of the tumor, which was compressing the pons, and obscured by the tentorium and petrous ridge. Mobilization of the lateral wall of the cavernous sinus freed the  anterior component and thus allowed the removal of the rest of the schwannoma. DOI# http://dx.doi.org/10.17797/8hbvtjdj0l

LAPAROSCOPIC ASSISTED RESECTION OF A TYPE IV SACROCOCCYGEAL TERATOMA IN A 6-MONTH-OLD GIRL

Contributors: Hans Joachim Kirschner, MD A three port technique was used for the minimal invasive approach in supine position. After abdominal dissection of the teratoma, the child was repositioned in a prone jack-knife position. A posterior longitudinal midline incision was carried out to remove the tumor completely.

Laparoscopic Portal Vein Resection

Key aspects of vascular isolation and control for en bloc PV resection during laparoscopic whipple. Xenograft vein patch is used for reconstruction DOI: http://dx.doi.org/10.17797/ee9p182opy Editor Recruited by: H. Leon Pachter

Low Anterior Resection for Diverticulitis

Contributors: Craig Rezac, MD Treatment for recurrent or complicated diverticulitis is surgical resection. Minimally invasive techniques are associated with decreased length of stay and decreased post operative pain. However, laparoscopic low anterior resection is challenging especially in the narrow pelvis. Robotic surgery may overcome these obstacles and allow more surgery for divertiuclitis to be performed minimally invasively. These surgeons always do a LAR for diverticulitis because they transect on the proximal rectum. They take down the lateral stalks in order to mobilize the rectum and get the eea stapler through the rectum easier. Bilateral ureteral stents are routinely placed to better identify the ureters. This is especially important in cases of chronic/active diverticulitis or diverticulitis that has been complicated by abscess or fistula. This is the preference of the surgeon. DOI# http://dx.doi.org/10.17797/y1f1omu3mt

Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3 Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior. Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children's Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management. Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy. First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue. She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children's Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

Redo Posterior Fossa Decompression with Duraplasty for the Treatment of Chiari Type I Malformation

Chiari decompression is a common neurosurgical procedure. Chiari malformations present with a number of symptoms including Valsalva-induced headaches, swallowing dysfunction, and sleep apnea. Chiari malformations can also cause syringomyelia and syringobulbia. Surgical procedures used for the treatment of Chiari malformation include bone-only decompression (posterior fossa craniectomy +/- cervical laminectomy), craniectomy/laminectomy with duraplasty, and craniectomy/laminectomy/duraplasty with shrinkage or resection of the cerebellar tonsils. The procedure used depends on the specifics of the patient’s condition and the preference of the surgeon. The patient presented here had undergone a prior Chiari decompression at the age of 20 months. This was bone-only with posterior fossa craniectomy and C1-2 laminectomy. The dura was not opened due to the presence of a venous lake. He initially had improvement in his symptoms. However, his headaches and snoring recurred, balance worsened, and dysphagia never improved. Therefore, a repeat Chiari decompression at the age of 28 months was performed as presented here.

RESECTION OF DUODENAL WEB USING HYBRID NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)

Contributors: Maria Carmen Mora, MD1 We performed an incisionless resection of the duodenal web via the existing gastrostomy site. Initially the plan was to use the endoscope for visualization and the gastrostomy site for instrumentation; however, the endoscope visualization was inadequate. The gastrostomy site was dilated and an extra small wound protector was placed with a sterile glove over it allowing insufflation and access via the fingers for the laparoscope and 3mm instruments. A 70-degree laparoscope was used for visualization. The opening of the web was cannulated using a Fogarthy catheter prolapsing the web towards the stomach. A 3mm hook cautery and then the LigaSure were used to incise and excise the anteriolateral aspect of the duodenal web. Intraoperative CXR ruled out free air. A 1cm 14-French Mickey button was placed at the completion of the procedure. The length of the operation was 100 minutes.

Robotic Assisted Redo Rectopexy and Low Anterior Resection

Contributors: Craig Rezac, MD Low anterior resection and rectopexy is the optimal treatment for well functioning patients with rectal prolapse. Reoperations for rectal prolapse may be challenging due to significant adhesions. Use of the robot for low anterior resection and rectopexy is safe, feasible and may be more useful than laparoscopy especially in challenging cases. DOI:http://dx.doi.org/10.17797/vkp7axh60l

Robotic Inferior Mesenteric Artery, Common Iliac Artery, and Retroperitoneal Lymph Node Dissection

David Schwartzberg MD, Tushar Samdani MD, FASCRS, Mario M. Leitao MD, FACOG, FACS, Garrett M. Nash MD, MPH, FACS, FASCRS Recent data has shown an improved survival with metastasectomy for metastatic rectal cancer. Metastasectomy on a minimally invasive plateform (robotic) can be used for an R0 resection in patients who have retroperitoneal metastasis from rectal cancer after control of the primary tumor. DOI # http://dx.doi.org/10.17797/wd7d09sjgc

Robotic Sigmoid resection for Colovesicular Fistula and use of Firefly

Contributors: Ben Biteman, MD 61 year old male with diverticulitis and colovesicular fistula. Patient underwent robotic sigmoid colectomy with takedown of fistula. Firefly used to help identify if fistula still present. Editor Recruited By: Vincent Obias, MD, MS DOI# http://dx.doi.org/10.17797/9qxwhlr1q5

Robotic-Assisted Transanal Polyp Resection

Contributors: Benjamin Biteman and Vincent Obias Robotic Transanal minimally invasive surgical removal of 1.8cm villous adenoma with high grade dysplasia at 22cm. DOI#:https://doi.org/10.17797/kzimoid3xj Editor Recruited By: Vincent Obias

Suboccipital retrosigmoid approach for resection of cerebellopontine angle tumor

This is a demonstration of the retrosigmoid approach for microsurgical resection of a cerebellopontine angle tumor. Th patient presented with gait disturbance and normal hearing. A suboccipital craniotomy was used for access to the cerebellopontine angle. Using microsurgical technique, the tumor was dissected away from the glossopharyngeal nerve. Pathological analysis confirmed that the tumor was a schwannoma of the glossopharyngeal nerve. DOI# http://dx.doi.org/10.17797//r3wbfb5hkv

Robotic Abdominoperineal Resection with en Bloc Prostatectomy

Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5 Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5. Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.

Two Layered End-to-side Duct to Mucosa Pancreaticojejunostomy

Contributors: David Caba-Molina, MD and Mark S. Talamonti, MD The following video depicts our technique for performing a two layered end-to-side duct to mucosa pancreaticojejunostomy without the use of a pancreatic duct stent, following the resection phase of a standard Whipple operation. DOI: http://dx.doi.org/10.17797/wvi4b33r6r Editor Recruited By: Jeffrey Matthews, MD

Scalp Reconstruction with a Free Anterolateral Thigh Flap: Flap Inset

This procedure demonstrates the inset of the anterolateral thigh (ALT) flap into a large composite wound after oncologic resection.

Inferior Oblique Myectomy

Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle. The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon's capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture. No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved. Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.

Donghang Huang’s procedure for thyroidectomy

Donghang Huang’s procedure, also termed as direct-access single-port endoscopy assisted mini-incision thyroidectomy, is a hybrid surgery conducted in the following 3 major steps: 1.A mini-incision of approximately 2.5-3 cm long on the central neck is made. A working space under the platysmal muscle or strap muscles for single-port endoscopic surgery is constructed with carbon dioxide insufflation (performed under direct vision). 2.Mobilization of the superior and inferior pole of the thyroid lobe, and exposure of the recurrent laryngeal nerve (performed under single-port endoscopy). 3.Extraction and resection of the thyroid lobe. (performed under direct vision). Donghang Huang's procedure can provide shorter incision and better cosmetic results while maintaining adequate exposure.

A Pediatric Case of Levator Palpebrae Resection

In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis. In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved. Thank you for watching!

Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.

Endoscopic Nd:Yag and Bleomycin Injection for the management of a Hypopharyngeal Venous Malformation

Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1 Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM. Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction. The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets. The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.

Endoscopic Resection of Forehead Arteriovenous Malformation

This video describes the novel approach to removing an arteriovenous malformation (AVM) of the forehead using an endoscopic technique in a trichial incision. A 17-year-old presented to the Otolaryngology clinic with facial pain and headaches, as well as a pulsatile mass on her forehead. Angiography was performed and proved the mass to be an AVM. Angiography also revealed that one of the feeders was coming directly off the ophthalmic artery. She had no other neurological or ophthalmological symptoms. However, because of the ophthalmic artery feeder, embolization could not be performed due to the risk of blindness. We made an incision in the hairline, down to the subgaleal plane, and the entirety of the mass was revealed. Using endoscopy for visualization, the feeder vessels were carefully tied off using a knot pusher and ligated. The vessels were then cut and the mass removed. The skin was closed and a pressure dressing placed. At her post-operative visits, the patient was very pleased with the cosmetic outcomes of the surgery. Of note, there was no facial numbness, facial nerve weakness, or vision changes. We will continue to monitor the child, but as of yet there has been no evidence of recurrence of her AVM.

Arteriovenous Malformation (AVM) Resection

Abstract Introduction: Arteriovenous malformations (AVMs) are abnormal connections between arteries and veins that lack an intervening capillary network. The high flow of arterial blood directly into veins can lead to the weakening of venous walls, potentially resulting in life-threatening hemorrhages.The primary treatment modalities for cerebral arteriovenous malformations (AVMs) include surgical resection, endovascular embolization. Case presentation: A 34-year-old female presented with a roughly 7x7 cm arteriovenous malformation (AVM) located in the right temporoparietal area. The AVM extended both superficially and deeply into the infratemporal fossa and laterally towards the orbit. Imaging revealed the presence of multiple large contributing vessels in the preauricular area. The patient underwent embolization with interventional radiology one day prior to the surgical procedure. Methods: Markings were made along the right upper hairline after trimming and continued down the preauricular skin. A #15 blade was utilized to make incisions through the epidermis and dermis, reaching the subcutaneous tissues. The temporoparietal and temporal flap fascia were dissected and carefully raised. Once the AVM was detached from the surrounding temporalis muscle and the zygomatic bone, its feeder vessels were ligated near the tragal pointer using hemoclips to aid in future localization. Hemostasis was successfully achieved with bipolar cautery. The temporalis muscle and its adjacent fascia were sutured closed with vicryl suture. Closure of the deep dermal layer was accomplished with 4-0 PDS, and the skin was closed in a running subcutaneous fashion using 5-0 monocryl. Conclusion : We present a successful surgical resection of Arteriovenous Malformation with a prior embolization by interventional radiologist Surgeons: Coleman, Madison, MD, Aryan D Shay ,MD Gresham T Richter, MD, FACS Conflicts of Interest: None Funding: This research received no external funding Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Arkansas Children’s Hospital, Little Rock, AR, USA

Excision of greater occipital nerves and 3rd occipital nerves

Abstract Introduction: Occipital headache is a common, costly and debilitating disease process.When traditional therapies such as medication management and physical therapy fail to provide relief, surgical interventions may be considered. This procedure involves the excision of the 3rd and both greater occipital nerves. Case presentation: 36 years old. female with history of chronic refractory occipital headaches involving both greater occipital nerves and 3rd occipital nerves who presented for resection of those nerves. Methods: A 10cm incision was marked on the posterior neck, positioned inferior to the occipital skull base. Subsequently, the incision was carefully extended through the subcutaneous tissue. By means of both blunt and sharp dissection through the posterior muscle fascia where it inserts into the skull base, the right greater occipital nerve was identified and dissected into the paravertebral muscles and several centimeter of the nerve was resected so it could not grow back together. A corresponding procedure was employed for the left greater occipital nerve, located approximately 3 cm from the midline, and excised using the same technique. Additionally, the third occipital nerves situated in the midline were excised to address the entirety of the issue. Following these procedures, the wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was diligently maintained throughout the surgical intervention using both monopolar and bipolar cautery. To alleviate postoperative discomfort, 0.5% Marcaine with epinephrine was carefully injected into the nerve areas. The fascia needs to be closed with strong sutures and the skin and subcutaneous tissue were closed in two layers. Conclusion :The excision of greater occipital nerves presents a viable option for the management of chronic occipital headaches when conservative treatments prove ineffective. This case report highlights the successful outcome of such a procedure in a 36-year-old female suffering from debilitating headaches Surgeons: Dang-Khoa Nguyen, MD James Y Suen,MD Conflicts of Interest: None Funding: This research received no external funding Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Excision of supratrochlear and supraorbital nerves

Abstract Introduction: Frontal headache is a common, costly and debilitating disease process.When treatments, including medication management and physical therapy, prove ineffective, surgical interventions become a viable consideration Among these interventions, the excision of supratrochlear and supraorbital nerves stands out as a potential therapeutic option. Case presentation: 24-year-old female with history of chronic frontal headaches who presents for resection of supraorbital and supratrochlear nerves. Methods: A 4 cm incision was carefully made along the right eyebrow. This incision extended through the subcutaneous tissue. Employing a combination of blunt and sharp dissection techniques, we successfully identified supratrochlear nerves, observing multiple branches emerging from the orbit. All branches were excised via scissors . Subsequently, we located the supraorbital nerve exiting through a foramen, just above the mid-orbital rim, and proceeded to excise it. The wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was maintained throughout the procedure using both monopolar and bipolar cautery. Closure of the incision was executed in a layered fashion, employing 3-0 Monocryl and 5-0 Chromic sutures. To minimize postoperative discomfort, 0.5% Marcaine with epinephrine was injected into the nerve areas. Conclusion :The excision of the supraorbital and supratrochlear nerves offers a promising option for managing chronic frontal headaches when conventional treatments prove ineffective. This case report underscores the successful outcome of this procedure in a 24-year-old female who had been enduring debilitating headaches. Surgeons: Dang-Khoa Nguyen, MD James Y Suen,MD Conflicts of Interest: None Funding: This research received no external funding Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Laparoscopic Low Anterior Resection - A Stepwise Approach

Laparoscopic surgery is a technically demanding procedure that requires a significant level of experience and expertise. Since surgery is the mainstay treatment of rectal cancer, comprehending the complexities of multilaminar structures and interfascial spaces is imperative. This is the case of a 68-year-old woman who was evaluated for a positive fecal occult blood test. Colonoscopy found a vegetative lesion 15 cm from the anal verge, occupying ~1/2 of the lumen. Biopsy and distal tattooing were performed. Pathology study confirmed the presence of a moderately differentiated adenocarcinoma. The CT-scan showed no lung or liver metastasis. MRI revealed an upper rectal cancer, 11.4 cm from the anal verge, with no pathological lymph nodes, staged as cT2 N0 Mx CRM-. After discussion in a multidisciplinary meeting, a laparoscopic anterior rectal resection was proposed. By segmentation of the surgery into well-organized stages, this video demonstrates all the important technical steps to fasten the learning curve and master the procedure without compromising the oncologic principles.

CO2 ENDOSCOPIC RESECTION TRACHEOPLASTY OF A-FRAME DEFORMITY

This video shows how we manage A-frame deformity in cases post tracheastomy or post laryngeal reconstruction. Important steps of the procedure highlighted in the video.

Robotic-Assisted Low Anterior Resection of a Rectal Tumor with Concern for Invasion of the Seminal Vesicles

We present a case of a 60-year-old male with low-lying rectal cancer initially staged as a T4b tumor with concern for seminal vesicle invasion. A multidisciplinary decision was made to proceed with a jejunal-sparing operation, resecting only the seminal vesicles to preserve urinary continence. The anatomy of the Denonvilliers’ fascia remains controversial, with important implications for the surgical management of rectal cancers affecting adjacent urogenital structures. The anterior and posterior layers of the Denonvilliers’ fascia were successfully dissected, preserving the seminal vesicles and prostate. Pathology confirmed a mucinous adenocarcinoma with negative margins, and the patient is scheduled for ileostomy reversal. This case highlights how meticulous robotic-assisted dissection of the Denonvilliers’ fascia can avoid the need for urostomy and colostomy, preserving urinary function and demonstrating the potential benefits of improved anatomical understanding in pelvic surgery.

Robotic Ultra-Low Anterior Resection of a Presacral Prostate Cancer Recurrence

We present the case of a 70-year-old male with a presacral tumor known to be recurrent prostate cancer with an operative plan of a low anterior resection versus abdominoperineal resection. Intraoperatively, the presacral tumor was adherent to both the sacrum and rectum. Careful dissection of the tumor off of the sacrum allowed for full mobilization of the colon and rectum, which in turn allowed for a stapled coloanal anastomosis with preservation of the sphincter complex and restoration of function.

Double-Chambered Right Ventricle

Double-chambered right ventricle repair for an adolescent male who presented with a subaortic perimembranous ventricular septal defect, a subaortic membrane with associated left ventricular outflow tract obstruction, and a double-chambered right ventricle. This video highlights a VSD patch closure and the surgical resection of the subaortic membrane and RVOT muscle bundles.

Endoscopic Excision of Juvenile Nasopharyngeal Angiofibroma (JNA)

Abstract Introduction :Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but a locally aggressive vascular tumor. This usually affects the prepubertal or adolescent males. This video highlights a safe and affective endoscopic technique for JNA resection with minimal intraoperative bleeding and morbidity . Case presentation : A 17-year-old male presented with recurrent right sided epistaxis and constant nasal obstruction. Imaging revealed a hypervascular mass in the right nasopharynx extending into right nasal cavity and pushing the septum towards left side. Method: 6 vessel cerebral angiogram was performed and the feeding vessels were embolized with cyanoacrylate glue. The patient underwent endoscopic endonasal resection using a bi-nostril, four-handed technique with image guidance. Conclusion: Endoscopic resection of JNA offers excellent visualization and reduce morbidity. Proper preoperative planning, embolization, and anatomical knowledge are key to successful outcomes. Surgeons: Deepa Shivnani, MD Speed Olivia, MD Sidarth Patel, MD Gresham Richter, MD, FACS Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Arkansas Children’s Hospital, Little Rock, AR, USA Video description - This video demonstrates the endoscopic surgical excision of a Juvenile Nasopharyngeal Angiofibroma Juvenile Nasopharyngeal Angiofibroma or JNA is a relatively rare benign neoplasm generally seen in prepubertal and adolescent males, usually present with nasal airway obstruction, recurrent unilateral epistaxis, headache and facial swelling. JNA grows in close proximity to the posterior attachment of the middle turbinate near the superior border of the sphenopalatine foramen and can extend anteriorly into the nasal cavity and septum superiorly into the sphenoid sinus and laterally toward the pterego-palatine fossa. "This video demonstrates the endoscopic surgical excision of a Juvenile Nasopharyngeal Angiofibroma in a 17-year-old male presenting with recurrent epistaxis and nasal obstruction. Preoperative imaging revealed- A well-defined enhancing vascular lesion epicentered in right pterygomaxillary fissure and sphenopalatine foramen. The lesion measures approximately 4 x 3 x 3 cm in greatest dimensions. Superiorly there is erosion of floor of right sphenoid sinus with focal extension Inferiorly it extends in nasopharynx and right nasal cavity and abuts right middle and inferior turbinates. No intra-orbital or intracranial extension noticed. Patient underwent preoperative embolization of the right common carotid artery. 6 vessel cerebral angiogram was performed. The hyper vascular blush seen in the nasopharynx consistent with the diagnosis of JNA. It was primarily supplied by bilateral internal maxillary artery branches. Supplying arteries were embolized with cyanoacrylate glue. Patient was placed under general anesthesia with hypotensive technique. Nasal cavity was decongested with adrenaline-soaked patties. 0-degree and 30-degree rigid endoscopes were used throughout the procedure." Under the stereotactic guidance- Anterior and post ethmoidectomy & maxillary antrostomy was performed. The antrostomy was then widened circumferentially using the microdebrider until the maxillary sinus mucosa could be easily visualized. The middle turbinate was resected above the tumor and superior gently off of the tumor. Tumor was bluntly distracted slowly releasing areas of adhesions using a mixture of bipolar cautery and microdebrider from the left lateral and posterior wall from the face of the sphenoid sinus. The SPA was ligated with a hemoclip. Bipolar cautery was used to remove the final attachment and the tumor was freed. Once tumor was freed from all attachments except for the origin it was placed into the oropharynx. Careful blunt dissection was used to locate the neurovascular structures to check for any more tumor. The tumor was removed through the oral cavity. The nasal cavity was packed with thrombin soaked gelfoam followed by surgiflo. Merocel was placed in right nares. The tumor specimen itself measures approximately 3x 4 cm in diameter as seen here there were no complications during the procedure and the estimated blood loss was about 15 CC's the patient is admitted overnight for post-operative monitoring and deemed stable for discharge on postoperative day one. Histopathology confirmed JNA, To date the patient has no evidence of recurrence Tips and tricks Always evaluate the extent of the tumor on both CT and MRI. Identify feeding vessels and consider preoperative embolization if feasible. Perform posterior septectomy and extended medial maxillectomy when needed for optimal exposure. Don’t hesitate to switch to a 30- or 45-degree scope for better visualization of lateral extensions. Devitalize the tumor early by cauterizing or clipping the feeding branches from the internal maxillary artery. LigaSure or Bipolar cautery can significantly reduce intraoperative bleeding. Lastly, Maintain hypotensive anesthesia and use local vasoconstrictors. Have adequate suction ready and use hemostatic agents like Surgicel or Floseal as needed. Thank you

Laparoscopic abdominoperineal resection with partial vaginectomy for T4b rectal cancer

Rectal cancer with invasion of adjacent pelvic organs is uncommon and poses significant operative challenges. Multimodal treatment combining neoadjuvant therapy and precise surgical technique is often required to achieve negative margins while preserving function. We present a video of an 80-year-old female with low rectal adenocarcinoma (ypT4bN0M0) invading the posterior vaginal wall following chemoradiotherapy. A laparoscopic abdominoperineal resection with en bloc partial vaginectomy was performed, followed by reconstruction using a left gracilis myocutaneous flap. The minimally invasive approach provided excellent pelvic exposure and facilitated accurate dissection despite post-radiation fibrosis. The patient had an uneventful postoperative recovery and was discharged on postoperative day 14 with no complications. Pathology confirmed R0 resection with no nodal involvement. At 6-month follow-up, the patient remained disease-free with satisfactory functional recovery. This case demonstrates that, in selected patients and experienced centers, laparoscopic APR combined with reconstructive techniques offers a safe and effective option for locally advanced rectal cancer invading the vagina.

Meet our Presenters for Day 2!

The International Adult Airway Symposium is coming up this weekend! For more information view the itinerary or register here!

Dr. Vyvy Young

Associate Professor and the Associate Residency Program Director in the Department of Otolaryngology-Head and Neck Surgery

University of California – San Francisco

VyVy Young, MD, is an Associate Professor and the Associate Residency Program Director in the Department of Otolaryngology-Head and Neck Surgery at the University of California – San Francisco. Dr. Young received her undergraduate and medical degrees from the University of Louisville, in Louisville, Kentucky, where she also pursued her Otolaryngology training. She then completed a fellowship in Laryngology and Care of the Professional Voice at the University of Pittsburgh Voice Center. She currently serves the American Academy of Otolaryngology – Head and Neck Surgery as member of the Annual Meeting Program Committee and Executive Committee for ENThealth.org. She is immediate past-chair of the Voice Committee and the Women in Otolaryngology Communications Committee and was recently selected as chair of the Finance and Audit Committee of the American Broncho-Esophagological Association.

Justin Roe, PhD, FRCSLT

Clinical Service Lead - Speech and Language Therapy – National Centre for Airway Reconstruction

Imperial College Healthcare NHS Trust

Dr. Roe is a clinical-academic and service lead, specialising in dysphagia in benign and malignant head and neck disease. He leads the speech and language therapy service for the National Centre for Airway Reconstruction at Imperial College Healthcare NHS Trust and is a consultant and service lead at the Royal Marsden NHS Foundation Trust. He is an Honorary Clinical Senior Lecturer at Imperial College London and an investigator on a number of NIHR portfolio studies. He is currently on an NIHR Imperial Biomedical Research Centre/ Imperial Health Charity funded post-doctoral research fellowship. He is an elected council member for the British Laryngological Association and British Association of Head and Neck Oncologists.

Professor Anil Patel MBBS PhD FRCA

Clinical Anaesthetist / Chairman of Department of Anaesthesia

Royal National ENT & Eastman Dental Hospital

Professor Anil Patel graduated from University College London in 1991. He is a clinical anaesthetist and continues to develop and refine the largest experience of anaesthetising adult airway patients under general anaesthesia (> 6,000 procedures) in the UK, probably Europe and possibly the world. His research interests include all aspects of shared airway and difficult airway management. Professor Patel has been an invited speaker to over 300 national and international meetings in 38 countries. He has over 130+ peer reviewed publications, 25 book chapters, over 4,500 citations and an h-index of 25.

Robbi A. Kupfer, MD

Associate Professor, Department of Otolaryngology-Head & Neck Surgery

University of Michigan

Dr. Kupfer is an Associate Professor of Otolaryngology-Head & Neck Surgery at the University of Michigan who specializes in Laryngology and Bronchoesophagology. She is the Program Director for the Laryngology Fellowship as well as the Otolaryngology Residency at the University of Michigan.

Alexander T. Hillel, MD, FACS

Associate Professor

Johns Hopkins University School of Medicine

Dr. Alexander Hillel is a Laryngologist, Residency Program Director, and Vice Director of Education in the Johns Hopkins Department of Otolaryngology – Head & Neck Surgery. His clinical practice and research centers on the treatment, prevention, and causes of laryngotracheal stenosis (LTS).

Dale Ekbom, MD

Associate Professor of Otolaryngology / Director of Voice Disorders/Laryngology

Mayo Clinic

Residency in Otolaryngology/Head and Neck Surgery at the University of Michigan with a fellowship in Laryngology/Care of the Professional Voice at Vanderbilt University Medical Center. Clinically specializing in voice, especially management of vocal fold paralysis, Zenker’s diverticulum and Cricopharyngeal muscle dysfunction, early laryngeal cancer, and airway compromise due to laryngeal, subglottic, and tracheal stenosis. Research interests include idiopathic subglottic stenosis and GPA with surgical and medical management of the airway, vocal fold paralysis, new injectables using Jellyfish collagen.

Dr. Ricky Thakrar

Consultant Chest Physician

University College London Hospital

Dr. Ricky Thakrar qualified in Medicine from Imperial College London. He trained in Respiratory Medicine at the Royal Brompton Hospital and completed his training in Northwest London. He was appointed to a three-year academic fellowship at UCL where his PhD examined state of the art bronchoscopy techniques for managing cancers arising in central airways and lung. He is a Consultant in Thoracic Medicine and his main interests are in interventional bronchoscopy procedures (laser resection, airway stenting, cryotherapy, photodynamic therapy and brachytherapy) for pre-malignant and malignant disease of the tracheobronchial tree.

Dr. Michael Rutter

Director of the Aerodigestive Center

Cincinnati Children's Hospital

Dr. Rutter is an ENT surgeon specializing in pediatric otolaryngology with an emphasis on airway problems in children, adolescents and young adults. His interests include tracheal reconstruction and complex airway surgery. Always a problem-solver, he strives to involve the patient in their own care by having them help evaluate the issue and then craft a solution together. He was drawn to his career by the challenge and highly individualized nature of pediatric airway problems and management. Dr. Rutter enjoys working in a multidisciplinary team setting and focusing on coordinated care for complex childhood airway conditions. He was honored to receive the 2016 Gabriel Frederick Tucker Award from the American Laryngological Association, and the 2018 Sylvan Stool Teaching Award from the Society for Ear Nose and Throat Advancement in Children (SENTAC). These awards are for his contributions to the field of pediatric laryngology. In addition to caring for patients, he is also dedicated to his research trying to find improvements in airway management.

Christopher T. Wootten, MD, MMHC

Director, Pediatric Otolaryngology—Head and Neck Surgery

Vanderbilt University Medical Center

Dr. Wootten has a longstanding interest in surgical management of congenital and acquired airway disorders.  To better equip himself to lead the Pediatric ENT service through expansion, evolution of practice models, and differentiation into multidisciplinary care, Dr. Wootten obtained a Masters of Management in Health Care at Vanderbilt’s Owen School of Business in 2017.  Areas of his professional research emphasis include airway obstruction in children and adults and aerodigestive care. He innovates minimally invasive surgical techniques in the head and neck.  Dr. Wootten is actively investigating the role of eosinophil and mast cell-based inflammation in the pediatric larynx.

Karla O'Dell, M.D.

Assistant Professor / Co-director

USC Voice Center, Caruso Department of Otolaryngology Head and Neck Surgery @ University of Southern California / USC Center for Airway Intervention and Reconstruction

Karla O’Dell, MD, specializes in head and neck surgery and disorders of the voice, airway and swallowing. She is cofounder and codirector of the USC Airway Intervention & Reconstruction Center (USC Air Center).

Jeanne L. Hatcher, MD, FACS

Co-Director of the Emory Voice Center and Associate Professor of Otolaryngology

Emory University School of Medicine

Dr. Hatcher has been at Emory since 2014 after completing her laryngology fellowship with Dr. Blake Simpson; she specializes in open and endoscopic airway surgery as well as voice disorders. Dr. Hatcher is a member of the ABEA and post-graduate member of the ALA and also serves on the Ethics and Voice Committees for the American Academy of Otolaryngology Head and Neck Surgery.

Mr. Lee Aspland

Patient / Freelance Artist

Lee Aspland Photography

Lee Aspland is a photographer, author and mindful practitioner who creates photography that reflects his feelings about living in such a glorious world. He specializes in Mindful Photography, capturing a fleeting feeling or thought, a hope or fear, a frozen single moment in time.

Gemma Clunie, MSc, BA (Hon), MRCSLT

Clinical Specialist Speech-Language Pathologist (Airways/ENT) and HEE/NIHR Clinical Doctoral Research Fellow

Imperial College Healthcare NHS Trust/ Imperial College London, Department of Surgery & Cancer

Gemma is a Clinical Specialist Speech and Language Therapist with an interest in voice and swallowing disorders that is particularly focused on the benign ENT, head and neck, respiratory and critical care populations. Gemma is a current NIHR/HEE Clinical Doctoral Research Fellow at Imperial College London. Her PhD studies focus on the voice and swallowing difficulties of airway stenosis patients. She is based at Charing Cross Hospital in London where she has worked for the last six years as part of the National Centre for Airway Reconstruction, Europe’s largest centre for the management of airway disorders.

Niall C. Anderson, CPsychol, MSc, BSc

Lead Psychologist (formerly Respiratory Highly Specialist Health Psychologist)

Bart's Health NHS Trust (formerly Central & North West London NHS Foundation Trust)

Niall is a HCPC Registered & BPS Chartered Practitioner Health Psychologist, and BPS RAPPS Registered Supervisor. Niall has specialist experience of working within healthcare systems with people with long-term health conditions at all system levels to support physical, psychological and social wellbeing. Niall worked in the Airway Service at Charing Cross Hospital (London, UK) between January-December 2021 in order to develop and implement the Airway Psychology Service.

Introducing our presenters for the upcoming Cleft Lip Revision webinar!

This webinar comes as the latest in a long line of installments dealing with the Cleft Palate. In this session, attendees will learn various tips and tricks to a successful cleft lip revision procedure. There will be a Q&A session to discuss common challenges and how to address them.

Meet the Course Directors

Meet the Presenters

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