Contributors: Marco P. Fisichella
65 year old man who underwent a laparoscopic Nissen fundoplication in August 2015. Preoperative manometry was normal and DeMeester score was 25. Two months later he began to experience difficulty of swallowing solid foods, then liquids. After 2 dilatations, dysphagia persisted.
Referred By: Jeffrey B. Matthews
In contrast to major thoracic operations, per oral endoscopic myotomy for Zenker’s diverticulum offers the possiblity to resect a symptomatic Zenker’s under monitored anesthesia care (MAC) for patients to ill to undergo general anesthesia. Patients have similar functional results when compared to small Zenker’s treated with traditional operative approaches.
Contributors: Vincent Couloigner
We describe the excision of a nasal encephalocele obstructing the left nasal fossa with an anterior subcutaneous portion deforming the nasal pyramid in a four-year-old girl using endoscopic surgery combined to a Rethi approach. The anterior skull base defect was reconstructed using autologous conchal cartilage and temporal fascia.
Editor Recruited By: Sanjay Parikh, MD, FACS
Contributors: Reza Salabat and Marco P. Fisichella
Preoperative work-up and surgical technique of laparoscopic paraesophageal hernia repair.
The field of metabolic and bariatric surgery has recently switched from laparoscopic gastric banding (LGB) to laparoscopic sleeve gastrectomy (LSG) as the procedure of choice for weight loss surgery. As LGB has been replaced with LSG many patients who had complications with LGB or failed to loose a satisfactory amount of weight with LGB have had a conversation from their band to a sleeve gastrectomy.
Meticulous dissection takes place when removing a band, as the fibrotic scar capsule that surrounds the band must be resected in its entirety to avoid staple firings across fibrotic tissue rather than healthy gastric tissue. In addition to ensuring a healthy staple line by resecting the fibrotic capsule, we present a case where the band capsule was thought to be removed however was incompletely dissected and caused a postoperative strictured proximal stomach with complete PO intolerance. For this reason, we routinely perform intra-operative endoscopy to ensure the lumen of the stomach is patent prior to staple firing to complete the sleeve gastrectomy in band to sleeve patients.
Transcanal endoscopic tympanoplasty is illustrated with steps explained. This is a “realistic” case with bleeding and middle ear adhesions; tips to overcome these hurdles are discussed.
Editor Recruited by: Ravi N. Samy
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.
Schools: Children’s Hospital of Pittsburgh
Injection Laryngoplasty for type 1 laryngeal cleft is done with first identifying the deep cleft by palpation of the interarytenoid notch. Once a confirmation is made the larynx is suspended with a laryngoscope. Radiesse voice gel is then primed in a laryngeal needle and the needle is placed at the apex of the cleft. The needle is then pushed to palpate the cricoid cartilage with the bevel of the needle pointing towards the esophageal surface. The needle is then slightly retracted and about 0.2 ml of voice gel is injected. Care is taken not to make multiple punctures and the subglottisis watched so that the injection does not inadvertently go into subglottis.
An adolescent male presented with a few day history of right eye swelling, erythema, and edema. The eye swelling was determined to be a result of subperiosteal abscess of the medial orbit, as seen on imaging. The vision was progressively getting worse and the decision was made to urgently take the patient to the operating room. The surgical indications are at times controversial but include decreased range of motion of the eye as well as loss of vision/color discrimination. This patient only had markedly decreased range of motion of the eye. The patient was taken to the operating room; afrin pledgets were placed and the middle turbinate was medialized. At this time the edema and swelling of the ethmoid sinuses was evident. The traditional teaching is to remove the ethmoid air cells and open up the lamina papyrecea. For the past several years, the author has adopted a less is more approach – where the author opens up the ethmoid sinuses and exposes the lamina to allow the pus a route of egress. This video clearly epitomizes the less is more approach. The ethmoid cells have been opened up and there is a large route of egress for the pus which is under pressure. The video demonstrates that upon palpation of the right eye (the Stankiewicz maneuver), there is a massive amount of pus that drains out. The child recovered expeditiously. Endoscopic sinus surgery is an area where is there significant potential for errors and complications – especially inadvertent injury to the eye and brain. As such, the author believes that in some cases, a less is more approach ultimately benefits the patient.
The mystery of orbital fat should not be so intimidating. The surgical mantra for chronic rhinosinusitis is to not expose orbital fat, however in specific instances it is imperative to take down the lamina papyracea to expose the orbital fat. Instances where this would be necessary would be for infections, tumors, orbital decompression as well as others. Specifically in this case, we surgically opened the maxillary antrum and took down the anterior ethmoid air cells. From here, we dissected laterally to the lamina papyracea and opened up the lamina where the orbital fat is exposed. This video shows that when you compress on the orbit the orbital fat moves and is displaced towards the path of least resistance in this case the opened up lamina and hence the fat moves towards the ethmoid air cells (ie medial).