Surgical management of post-surgical intercostal thoracic-abdominal nerve neuroma

Background Formation of post-operative neuroma formation after laparoscopic surgery is not common. Its diagnosis is often missed because pain often mimics intra-abdominal pathology. In this paper, the authors report a case in which the severe pain resulting from the abovementioned neuroma was successfully treated by excision of neuroma and implant of the proximal stump into the adjacent muscle. Case presentation The patient is a 20-year-old female who had laparoscopic surgery on her left kidney. Immediately after surgery, she started experiencing severe pain at the operative site that continued for 5 years. A recent nerve block of the thoracic-abdominal intercostal nerve deep in the abdominal wall immediately beneath the incision gave her temporary relief for a couple of weeks. The patient was operated on. The neuroma was identified in the scar tissue of the transversalis muscle. The neuroma was excised, and the proximal stump was buried in the adjacent muscle. After the operation, she was free of pain and continues to be free of pain at 6 months follow-up. Conclusion Formation of neuroma with severe chronic abdominal pain can occur after laparoscopic surgery. Nerve block is a diagnostic study for this condition. Neuroma resection with burying the covering of the stump can result in the cure of the pain.

Regulation of UNC-40/DCC and UNC-6/Netrin by DAF-16 promotes functional rewiring of the injured axon

ABSTRACT The adult nervous system has a limited capacity to regenerate after accidental damage. Post-injury functional restoration requires proper targeting of the injured axon to its postsynaptic cell. Although the initial response to axonal injury has been studied in great detail, it is rather unclear what controls the re-establishment of a functional connection. Using the posterior lateral microtubule neuron in Caenorhabditis elegans, we found that after axotomy, the regrowth from the proximal stump towards the ventral side and accumulation of presynaptic machinery along the ventral nerve cord correlated to the functional recovery. We found that the loss of insulin receptor DAF-2 promoted ‘ventral targeting’ in a DAF-16-dependent manner. We further showed that coordinated activities of DAF-16 in neuron and muscle promoted ‘ventral targeting’. In response to axotomy, expression of the Netrin receptor UNC-40 was upregulated in the injured neuron in a DAF-16-dependent manner. In contrast, the DAF-2-DAF-16 axis contributed to the age-related decline in Netrin expression in muscle. Therefore, our study revealed an important role for insulin signaling in regulating the axon guidance molecules during the functional rewiring process.

Post salpingectomy intraluminal endometriosis in a premenopausal lady - an incidental finding often paid less attention to

Endometriosis of the fallopian tube is often incidentally picked up in hysterectomy specimens that are sent for histopathological examination for other obvious pathological conditions. Post-salpingectomy endometriosis is one such entity that is known to occur in the tip of the proximal stump of the fallopian tube years after tubal ligation. As mere visualization of the endometriotic lesions is inadequate for an accurate diagnosis, histopathologic analysis of the biopsy samples becomes mandatory for confirmation. We report a case of post salpingectomy endometriosis which was incidentally discovered in a peri menopausal lady who was operated for multiple fibroids of the uterus. This case not only highlights an entity which is challenging to visualize radiologically and suspect clinically, but is also underrecognized, as very little attention is given to the fallopian tube during routine grossing.

“Wings of a Butterfly” Technique in Modified Bentall's Procedure

Many surgeons have modified the technique to reduce bleeding from anastomosis line since Bentall and De Bono introduced aortic root replacement using a composite graft. We present a new composite, butterfly wing–shaped, valve graft fixated using hand-made double sewing cuff. The “wings of a butterfly” technique is a method of reinforcement suturing between an added sewing cuff and residual aortic wall at the proximal stump and helps to reduce bleeding after the modified Bentall's procedure.

Major cellular events in peripheral nerve regeneration: A brief overview

Injury to a peripheral nerve leads to degeneration of the segment distal to the site of lesion, a process referred to as Wallerian degeneration. During Wallerian degeneration, axons and myelin sheaths undergo degeneration and are phagocytosed by macrophages and Schwann cells. The Schwann cells proliferate and the endoneurial tubes persist, together the whole structure is known as the band of Büngner. Within few hours, the damaged axons in the proximal stump initiate a regeneration response, with formation of new growth cones. During Wallerian degeneration, neurotrophins, neural cell adhesion molecules, cytokines and other soluble factors are upregulated to facilitate regeneration. The recovery of the target in mammals is often variable, but almost never complete. In humans, scar tissue forms at the site of lesion and this often results in poor recovery of the target. The major events underlying this regenerative process is highlighted and discussed in this review.

Morton Neuroma Surgery: Relation Clinical Results to Excised Sample Length

Background:Morton’s neuroma (MN) is mechanical neuropathy of plantar interdigital nerve. It is one of the most common causes of forefoot pain. One of the most undesirable complications of MN surgery is recurrent neuroma. Excision level of MN is important to prevent recurrence. In this study, we aimed to find the relation resection lenght of MN to clinical results of MN surgery cases. Methods:76 samples sent with the diagnosis of Morton neuroma to the pathology department of our hospital between years 2010-2019. 66 patients whose clinical results were available were included in the study. Mean age was 41,5 (between 21 to 70). All of 66 patients were primary diagnosed 22 of them was left foot and the other 170 were right foot. 50 of them were female, and 16 were male. Recurrent neuromas, pathological sample more than one piece from one surgical site were excluded from the study. 72 of them were evaluated as a clinically and compare the sample lenght.Results:76 pathological specimens were prepared and examined by the same pathologist. Gross pathological appearance and histopathology findings were recorded. Mean sample length was 2,05 cm (between 0,7cm and 3,5 cm). 68 samples was smaller (89.5%) than 3 cm and only 8 sample (10.5%) was bigger than 3 cm. Average interdigital neuroma score improved from 20 to 62 points following the surgery (p<0.05).Conclusion:We recommend that, the common digital nerve should be cut from the proximal as much as possible to bury the proximal stump into the lumbrical muscles regardless of the sample size and using loupe magnification, careful and sharp dissection can be prevent injury to the PDNB.Level of Evidence: 2

A non-conventional proximal inflow for the radial artery coronary graft

Despite good outcomes, the use of the radial artery as a coronary graft is not widespread. Concerns regarding its low versatility and the risk of hand ischaemia, as well as the lack of reliable information regarding the best storage solution of the graft, and regarding the treatment for preventing spasms have limited its use. In this manuscript, the (numerous) benefits and (few) drawbacks of the proximal inflow for the radial artery from the in situ right internal thoracic artery proximal stump are discussed. Outcomes are reported from a limited series of patients undergoing totally arterial myocardial revascularization using this composite graft and both internal thoracic arteries.