Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Avoiding Complications in Gigantomastia

Gigantomastia is a disabling condition for patients and presents unique challenges to plastic surgeons. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.

Segmental and global lordosis changes with two-level axial lumbar interbody fusion and posterior instrumentation

Background

Loss of lumbar lordosis has been reported after lumbar interbody fusion surgery and may portend poor clinical and radiographic outcome. The objective of this research was to measure changes in segmental and global lumbar lordosis in patients treated with presacral axial L4-S1 interbody fusion and posterior instrumentation and to determine if these changes influenced patient outcomes.

Methods

We performed a retrospective, multi-center review of prospectively collected data in 58 consecutive patients with disabling lumbar pain and radiculopathy unresponsive to nonsurgical treatment who underwent L4-S1 interbody fusion with the AxiaLIF two-level system (Baxano Surgical, Raleigh NC). Main outcomes included back pain severity, Oswestry Disability Index (ODI), Odom's outcome criteria, and fusion status using flexion and extension radiographs and computed tomography scans. Segmental (L4-S1) and global (L1-S1) lumbar lordosis measurements were made using standing lateral radiographs. All patients were followed for at least 24 months (mean: 29 months, range 24-56 months).

Results

There was no bowel injury, vascular injury, deep infection, neurologic complication or implant failure. Mean back pain severity improved from 7.8±1.7 at baseline to 3.3±2.6 at 2 years (p < 0.001). Mean ODI scores improved from 60±15% at baseline to 34±27% at 2 years (p < 0.001). At final follow-up, 83% of patients were rated as good or excellent using Odom's criteria. Interbody fusion was observed in 111 (96%) of 116 treated interspaces. Maintenance of lordosis, defined as a change in Cobb angle ≤ 5°, was identified in 84% of patients at L4-S1 and 81% of patients at L1-S1. Patients with loss or gain in segmental or global lordosis experienced similar 2-year outcomes versus those with less than a 5° change.

Conclusions/Clinical Relevance

Two-level axial interbody fusion supplemented with posterior fixation does not alter segmental or global lordosis in most patients. Patients with postoperative change in lordosis greater than 5° have similarly favorable long-term clinical outcomes and fusion rates compared to patients with less than 5° lordosis change.

Clinical and radiographic outcomes with L4-S1 axial lumbar interbody fusion (AxiaLIF) and posterior instrumentation: a multicenter study

Introduction

Previous studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5–S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4–S1 fusion.

Methods

In this retrospective series, 52 patients from four clinical sites underwent L4–S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24–51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom’s criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance.

Results

Mean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P < 0.001). Back pain clinical success (ie, ≥30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P < 0.001). ODI clinical success (ie, ≥30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom’s criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one).

Conclusion

The AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4–S1 disc pathology resistant to conservative treatments.

Endovascular repair of a blunt abdominal aortic injury

Blunt abdominal aortic injury is an uncommon traumatic finding. In the past, treatment options have traditionally consisted of open operative repair; however, the development of endovascular surgery has created new interventional possibilities. This case is presented to demonstrate the applications of endovascular abdominal aortic repair for a blunt traumatic injury.

Anatomic variation of the optic strut: classification schema, radiologic evaluation, and surgical relevance

Objective Anatomic variability of the optic strut in location, orientation, and dimensions is relevant in approaching ophthalmic artery aneurysms and tumors of the anterior cavernous sinus, medial sphenoid wing, and optic canal. Methods In 84 dry human skulls, imaging studies were performed (64-slice computed tomography [CT] scanner, axial view, aligned with the zygomatic arch). Optic strut location related to the prechiasmatic sulcus was classified as presulcal, sulcal, postsulcal, and asymmetric. Morphometric analysis was performed. Results The optic strut was presulcal in 11.9% specimens (posteromedial margin bilaterally anterior to limbus sphenoidale), sulcal in 44% (posteromedial part adjacent to the sulcus's anterior two thirds bilaterally), postsulcal in 29.8% (posteromedial margin posterior to the sulcus's anterior two thirds), and asymmetric (left/right) in 14.3%. Optic strut length, width, and thickness measured 6.54 ± 1.69 mm, 4.23 ± 0.69 mm, and 3.01 ± 0.79 mm, respectively. Optic canal diameter was 5.14 ± 0.47 mm anteriorly and 4.79 ± 0.64 mm posteriorly. Angulation was flat (>45 degrees) in 13% or acute (<45 degrees) in 87% specimens. Conclusions Anatomical variations in the optic strut are significant in planning for anterior clinoidectomy and optic-canal decompression. Our optic strut classification considers these variations relative to the prechiasmatic sulcus on preoperative imaging.

Chest X-ray after tracheostomy is not necessary unless clinically indicated

BACKGROUND

Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays.

METHOD

This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications.

RESULTS

Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone.

CONCLUSIONS

Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.

Retrospective analysis of L5-S1 axial lumbar interbody fusion (AxiaLIF): a comparison with and without the use of recombinant human bone morphogenetic protein-2

BACKGROUND CONTEXT

Since approval by the Food and Drug Administration in 2002, use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to promote spinal fusion is increasing.

PURPOSE

In this comparative analysis, the authors assess fusion rates and clinical outcomes of patients who underwent a presacral axial lumbar interbody fusion (AxiaLIF) (TranS1 Inc., Wilmington, NC, USA) at L5-S1 with posterior instrumentation, with or without rhBMP-2.

STUDY DESIGN

Retrospective case-matched chart review.

PATIENT SAMPLE

A matched cohort of 99 patients underwent fusion performed by two surgeons at two institutions (2005-2007): Specifically, 45 patients at The Christ Hospital received rhBMP-2 and 54 patients at the University of Pittsburgh had no rhBMP-2.

OUTCOME MEASURES

Pre- and postoperative visual analog scale (VAS) scores were recorded, as was physiologic data on fusion rates, blood loss, and length of stay. Preoperative and postoperative Oswestry Disability Index (ODI) scores were obtained for patients treated with rhBMP-2. Odom's outcome criteria were obtained at 2-year follow-up for patients without rhBMP-2.

METHODS

Data were collected prospectively. Demographic data, including sex and age, were matched.

RESULTS

During the 2-year follow-up period, patients noted reduction in back pain and improved functional outcome measures. The most rapid reduction in VAS pain scores and improvement in ODI occurred within the first 3 months after surgery. Mean pre- and postoperative VAS scores improved 59% from 72.9 to 30.1 with rhBMP-2 and 72% from 81.3 to 22.6 without rhBMP-2. In rhBMP-2-treated patients, mean ODI scores were 54.4% preoperatively and 23.7% postoperatively, a 56.4% improvement at 2 years. In the non-rhBMP-2 patients, 80% reported excellent to good results using Odom criteria. Fusion rates were 96% with rhBMP-2 and 93% without rhBMP-2. Operative blood loss averaged 82 cm(3) with and less than 50 cm(3) without rhBMP-2. No differences in hospital length of stay were noted between the two groups or in the fusion rates with pedicle screws or facet screws. No major complications occurred with or without rhBMP-2.

CONCLUSIONS

In our case-matched series, clinical outcomes were similar for patients who underwent an AxiaLIF L5-S1 interbody fusion with or without rhBMP-2. The data strongly suggest that there is a high confidence for no effect on fusion rate by using rhBMP-2.

Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The primary aim of this study was to evaluate and report the 2-year clinical and radiographic outcomes associated with a L5-S1 interbody fusion procedure that employs an axial presacral surgical approach.

SUMMARY OF BACKGROUND DATA

There are a number of lumbar interbody fusion procedures used to treat painful, degenerated discs. However, despite their procedural differences (e.g., anterior vs. posterior), all of the current surgical approaches are undertaken in the same anatomical plane that requires disruption of musculoligamentous and osseous support structures as well as vascular and neurologic tissue to gain access the intervertebral disc space. The presacral procedure is distinct in that it uses an approach along an axis essentially perpendicular to the anatomical plane of traditional fusion procedures.

METHODS

One hundred fifty-six patients from four clinical sites were selected for inclusion if they underwent a L5-S1 interbody fusion via the presacral approach with the AxiaLIF system (TranS1, Wilmington, NC) and had both presurgical and 2-year radiographic or clinical follow-up. Back pain and functional impairment were evaluated with an 11-point numeric scale and the Oswestry Disability Index (ODI), respectively, preoperatively and at 2 years. Standard radiographic imaging techniques were used to determine fusion status.

RESULTS

Marked clinical improvements were realized in back pain severity and functional impairment through 2 years of follow-up. Mean pain scores improved from 7.7 ± 1.6 (n = 155) preoperatively to 2.7 ± 2.4 (n = 148) at 24 months, reflecting an approximate 63% overall improvement (P < 0.001). Mean ODI scores improved from 36.6 ± 14.6% (n = 86) preoperatively to 19.0 ± 19.2% (n = 78) at 24 months, or approximately 54% (P < 0.001). Two-year clinical success rates on the basis of change relative to baseline of at least 30% were 86% (127 of 147) and 74% (57 of 77) for pain and function, respectively. The overall radiographic fusion rate at 2 years was 94% (145 of 155).

CONCLUSION

Findings from this clinical series of patients treated with a presacral interbody fusion procedure, stabilized with the AxiaLIF rod, reflect favorable and durable outcomes through 2 years of follow-up.

Case Report: Successful non-operative management of spontaneous splenic rupture in a patient with babesiosis

Background

Babesiosis is a zoonotic disease transmitted by the Ixodes tick species. Infection often results in sub-clinical manifestations; however, patients with this disease can become critically ill. Splenic rupture has been a previously reported complication of babesiosis, but treatment has always led to splenectomy. Asplenia places a patient at greater risk for overwhelming post-splenectomy infection from encapsulated bacteria, Lyme disease, Ehrlichia as well as Babesia microti. Therefore, avoiding splenectomy in these patients must be considered by the physician; particularly, if the patient is at risk for re-infection by living in an endemic area.

Case Presentation

A 54 year-old male from the northeast United States presented with left upper quadrant abdominal pain associated with fever, chills, night sweats and nausea. A full evaluation revealed active infection with Babesia microti and multiple splenic lacerations. This patient was successfully treated with appropriate pharmacological therapy and non-operative observation for the splenic injury.

Conclusion

Patients diagnosed with Babesia microti infection are becoming more common, especially in endemic areas. Although clinical manifestations are usually minimal, this infection can present with significant injuries leading to critical illness. We present the successful non-operative treatment of a patient with splenic rupture due to babesiosis infection.

Image-guided neurosurgery

The linking of digitizing pointers to computer programs that reformat diagnostic studies has resulted in the development of image-guided surgery, also called frameless stereotactic surgery. With frameless stereotaxy, the neurosurgeon transposes the three-dimensional physical space of the patient's skull and cranial contents in the operating room with the three-dimensional image space of preoperative computerized tomography (CT) or magnetic resonance imaging (MRI) scans shown in the computer.

Extraforaminal lumbar disc herniations: microsurgical anatomy and surgical approach

OBJECT

Familiarity with the microsurgical anatomy of the far-lateral compartment is essential for operating in patients with far-lateral discs. In this report the authors address the microsurgical anatomy studied in 24 extraforaminal lumbar disc spaces in three cadavers.

METHODS

Cadaveric dissections confirmed the authors' operative experience in which they found an arterial arcade to be associated with the nerve trunk. The main trunk of the lumbar artery was located lateral to the exiting nerve root in the region of intervertebral foramen. The trunk of the lumbar spinal nerve descending from the level above was 7 mm (+/- 3 mm [standard deviation]) lateral to the lumbar artery.

CONCLUSIONS

Clarification of the microsurgical anatomy of the far-lateral compartment confirmed the authors' clinical impression that the optimum approach to far-lateral discs is via the inferomedial quadrant of the extraforaminal compartment. In this quadrant, exposure of the main nerve root can be facilitated by dividing the posterior primary ramus and a newly described arterial arcade that envelops the nerve trunk. Once this arcade is divided, the nerve can be retracted with relative ease and safety, and the disc can be removed more easily.

Permanent iodine-125 interstitial implants for the treatment of recurrent glioblastoma multiforme

OBJECTIVE

Brachytherapy with temporary implants may prolong survival in patients with recurrent glioblastoma multiforme (GBM), but it is associated with relatively high costs and morbidity. This study reports the time to progression and survival after permanent implantation of iodine-125 seeds for recurrent GBM and examines factors predictive of outcome.

METHODS

Forty patients with recurrent GBM were treated with maximal resection plus permanent placement of iodine-125 seeds into the tumor bed. A total dose of 120 to 160 Gy was administered, and patients were followed up with magnetic resonance imaging scans every 2 to 3 months.

RESULTS

Actuarial survival from the time of implantation was 47 weeks, with 7 of 40 patients still alive at a median of 59 weeks after implantation. Survival was significantly better for patients younger than 60 years, and a trend for longer survival was demonstrated with gross total resection and tumors with a low MIB-1 (a nuclear antigen present in all cell cycles of proliferating cells) staining index. Median time to progression was 25 weeks and, on multivariate analysis, was favorably influenced by gross total resection and patient age younger than 60 years. After implantation, 27 of 30 patients with failure had a local component to the failure. No patient developed symptoms attributable to radiation necrosis or injury.

CONCLUSION

Permanent iodine-125 implants for recurrent GBM result in survival comparable with that described in previous reports on temporary implants, but with less morbidity. Results are most favorable for patients who are younger than 60 years, and who undergo gross total resection. Despite this aggressive treatment, most patients die as a consequence of locally recurrent disease.

Stereotactic resection of brain metastases in eloquent brain

We have treated 14-patients with metastatic tumors located in eloquent cortical areas by a stereotactic-guided keyhole craniotomy and total microsurgical excision utilizing the Pelorus stereotactic device. Patients ranged in ages from 26 to 82 years with a median age of 59 years. There were 9 women and 5 men. Ten patients presented with hemiparesis and 4 with aphasia. Primary tumor location was lung in 7, colon in 2, melanoma in 2, and breast, renal, and bone in 1 case each. Gross total resection was accomplished in all cases, with postoperative imaging confirmation of complete removal. Single metastatic tumors were removed in 12 cases, and multiple lesions in 2 cases. Twelve patients had postoperative whole brain irradiation (30 Gy/10 fractions); 2 patients had previously received whole brain irradiation, yet demonstrated tumor growth. Complete resolution of neurologic deficits was accomplished in 8 patients, 3 had improved and 2 were unchanged. One patient had resolution of preoperative deficit but developed hemiparesis secondary to a hemorrhagic infarction contralateral to the operative site. Nonneurologic morbidity includes deep venous thrombosis in 3 patients, and pneumonia in 1. Thirty-day perioperative mortality is zero, and to date no patient had died of intracranial disease. We believe that with the assistance of stereotactic localization, metastases in vital regions of the cortex can be removed with very low neurologic morbidity, and with a high proportion of patients having improvement in their level of neurologic function. The morbidity in this series compares favorably with that of stereotactic radiation series reported in the literature with local disease control and resolution of neurologic deficits that equals or exceeds stereotactic radiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Implantation of intracerebral depth electrodes for monitoring seizures using the Pelorus stereotactic system guided by magnetic resonance imaging. Technical note

The Pelorus stereotactic system guided by magnetic resonance imaging was used to implant intracerebral depth electrodes for monitoring seizure activity. This stereotactic system is frameless and does not require the use of a computer. It is based on the concept of a ball-and-socket type stereotactic arc director and uses the center-of-arc principle to establish a trajectory for electrode placement. The system not only allows the use of the orthogonal approach, but also provides ample working space and flexibility to choose different entry points and trajectory angles.

Acute effect of the Nd:YAG laser on the cerebral arteriovenous malformation: a histological study

The acute effect of Nd:YAG laser beam on cerebral arteriovenous malformations (AVMs) was examined. Histological examination of the specimens after treatment with the Nd:YAG laser revealed that the most prominent effect of the laser was shrinkage of the collagen of the vessels of the AVM, which led to laser-induced narrowing of blood vessels. The brain tissue confined to the resected AVM did not contain any histological evidence of acute damage. The resection of 10 cases of AVMs was safely accomplished with no morbidity or increased neurological deficits attributable to the laser technique.

Multiple intracranial aneurysms in identical twins

Familial intracranial aneurysms are well documented, with the highest association occurring among siblings. Five pairs of identical twins with subarachnoid hemorrhage have been previously reported. We present the sixth set of identical twins with multiple aneurysms. These cases represent the first report in the literature of multiple mirror aneurysms in identical twins. One twin presented with subarachnoid hemorrhage. Her sister, who was asymptomatic, had elective angiography which demonstrated multiple aneurysms in locations identical to her sister's aneurysms. In families in which a twin presents with subarachnoid hemorrhage, it is appropriate to recommend angiography to the asymptomatic twin.

Epidural lipomatosis and renal transplantation

A 34-year-old man presented with progressive myelopathy 4 months after cadaveric renal transplant for endstage renal disease. Radiographic evaluation gave findings consistent with epidural lipomatosis and compression of the thoracic thecal sac. Decompressive laminectomy resulted in dramatic improvement of his neurologic deficit. This case is unusual in the brevity of steroid treatment prior to onset of the myelopathy, as well as the relatively small dose. The 10 previous cases of epidural lipomatosis are also reviewed.

Chronic posttraumatic lumbar intradural arachnoid cyst with cauda equina compression: case report

An unusual case of a chronic posttraumatic lumbar intradural arachnoid cyst causing compression of the cauda equina is reported. The etiological, pathological, and clinical features are discussed. Emphasis is placed on the importance of a correct interpretation of radiological findings.

Successful laser-assisted excision of a metastatic midbrain tumor

Metastatic lesions to the midbrain are rare. They are found in 1 to 3% of autopsy series of solitary brain metastases. The consensus of opinion in the current literature is that they are inoperable lesions and should be treated by radiation therapy alone. This is the first case report of a completely excised metastatic adenocarcinoma to the midbrain. The patient's clinical course has been stable, and there is no computed tomographic evidence of recurrence at 18 months follow-up.

Improved outcome in the treatment of trigeminal neuralgia by percutaneous stereotactic rhizotomy with a new, curved tip electrode

Percutaneous stereotactic rhizotomy (PSR) as a method of treatment of trigeminal neuralgia has gained popularity in recent years as techniques of electrode placement and lesion production have improved. However, undesirable side effects including major and minor paresthesias, trigeminal motor root weakness, diplopia, and keratitis continue to occur even in cases where the neuralgia is treated successfully. In an attempt to improve treatment further, we have developed an electrode with a flexible curved tip for PSR of the trigeminal nerve. Once the electrode and the cannula are positioned in the retrogasserian portion of the trigeminal nerve with a standardized technique, manipulation of the electrode about its 360° axis readily enables an infinite variety of position adjustments of the electrode tip. This capability enables easier and more precise electrode placement and lesion production. Undesirable lesions of the motor root may be avoided. A curved electrode has been used in 150 patients. The incidence of masseter weakness is 7.3% in this series, compared to 24% in our series of 700 patients treated with a straight electrode. The incidence of undesirable paresthesias has decreased from 27% to 10.6%. The immediate results obtained in patients with the curved electrode have improved. Excellent results (no pain, no side effects) have been achieved in 88% of patients, in contrast to 76% treated with the straight electrode. Application of stereotactic principles and the use of the curved electrode have enhanced the appeal of PSR for the treatment of trigeminal neuralgia.