Gasless, endoscopic trans-axillary thyroid surgery: our series of the first 51 human cases

Background The safety of gasless endoscopic trans-axillary thyroid surgery is still undetermined. Methods Clinical findings and postoperative complications of patients who had undergone trans-axillary thyroid surgery due to thyroid cancer and thyroid nodules were retrospectively studied. The sensory change and paralysis results from this technique and patients’ satisfaction with the cosmesis were also studied. Results Fifty-one patients (49 females and 2 males) received operations by gasless, endoscopic trans-axillary approaches with one patient whose operation was converted to open surgery because of internal jugular vein injury. Only two patients developed temporary vocal cord paralysis and no patients developed other severe complications. The alleviation of the discomfort in the anterior neck area and sternocleidomastoid, and the cosmetic effect of gasless endoscopic trans-axillary thyroid surgery were acceptable. No evidence of recurrence was found during the follow-up period. Conclusions Gasless, endoscopic trans-axillary thyroid surgery is a feasible procedure with acceptable safety and better cosmetic results in strictly selected patients.

An Anatomical Clue for Minimizing Iliac Vein Injury During the Anterolateral Approach at L5–S1 Level: A Cadaveric Study

Objective: The injury to the common iliac vein (CIV) seems to be the most important concern during the anterior approach to the spine at L5–S1 level. We investigated the anatomy of the L5–S1 vertebral structures related to the CIV through a cadaveric study to find an anatomical clue for safe dissection of CIV.Methods: Ten cadavers were prepared for this study. After removing the peritoneum and the presacral fascia, the section from the lower part of the L5 to the upper part of the S1 vertebral body was removed with the CIV attached. After decalcification, 2 sections in the vertical and horizontal directions were made for histological study.Results: An adipose tissue layer was present between the intervertebral disc and CIV. The adipose tissue layer in 6 cadavers was thin, and in 3 of these cadavers, the CIV was attached to the vertebral body and the disc. In the other 4 cadavers, the CIV was clearly separated from the vertebral body and the disc by the intervening adipose tissue layer (IATL). Under the microscope, a thin layer surrounding the anterior longitudinal ligament, periosteum, and disc was observed, and we named this structure the ‘perivertebral membrane’. The perivertebral membrane was attached to the CIV when there was no IATL, but a potential space was detected under the membrane.Conclusion: There was a thin membrane, perivertebral membrane, between the CIV and L5–S1 disc. In cases with CIV adhesion to the disc due to the absence of IATL, the CIV may be mobilized indirectly through the perivertebral membrane.

Hypofibrinogenemia with preserved hemostasis and protection from thrombosis in mice with a Fga truncation mutation

Genetic variants within the fibrinogen Aa-chain encoding the aC-region commonly result in hypodysfibrinogenemia in patients. However, the (patho)physiological consequences and underlying mechanisms of such mutations remain undefined. Here, we generated Fga270 mice carrying a premature termination codon within the Fga gene at residue 271. The Fga270 mutation was compatible with Mendelian inheritance for offspring of heterozygous crosses. Adult Fga270/270 mice were hypofibrinogenemic with ~10% plasma fibrinogen levels relative to FgaWT/WTmice, linked to 90% reduction in hepatic Fga mRNA due to nonsense-mediated decay of the mutant mRNA. Fga270/270 mice had preserved hemostatic potential in vitro and in vivo in models of tail bleeding and laser-induced saphenous vein injury, while Fga-/- mice had continuous bleeding. Platelets from FgaWT/WTandFga270/270 mice displayed comparable initial aggregation following ADP stimulation, but Fga270/270 platelets quickly disaggregated. Despite ~10% plasma fibrinogen, the fibrinogen level in Fga270/270 platelets was ~30% of FgaWT/WT platelets with a compensatory increase in fibronectin. Notably, Fga270/270 mice showed complete protection from thrombosis in the inferior vena cava stasis model. In a model of Staphylococcus aureus peritonitis, Fga270/270 mice supported local, fibrinogen-mediated bacterial clearance and host survival comparable to FgaWT/WT, unlike Fga-/- mice. Decreasing the normal fibrinogen levels to ~10% with siRNA in mice also provided significant protection from venous thrombosis without compromising hemostatic potential and antimicrobial function. These findings both reveal novel molecular mechanisms underpinning fibrinogen aC-region truncation mutations and highlight the concept that selective fibrinogen reduction may be efficacious for limiting thrombosis while preserving hemostatic and immune protective functions.

Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures

Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.

A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure

Background Strayer’s gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically. Methods Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques. Results There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829). Conclusions Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them. Level of Evidence Level II, randomized controlled trial.

Case Report: How an Iliac Vein Lesion During Totally Endoscopic Preperitoneal Repair of an Inguinal Hernia Can Be Safely Managed

Inguinal hernia repair is a common surgical procedure with an acceptably low complication rate. However, complications with potentially life-threating consequences may occur in rare cases. These complications might be very challenging to manage, even more in laparo-endoscopic interventions compared to open repair. One of these challenges can be the treatment of an intraoperative injury to the iliac vein. To the best of our knowledge, a lesion of the iliac vein during TEP (totally endoscopic preperitoneal) for inguinal hernia repair, and a safe technique for its management have not been reported yet. We report the case of a 75-year-old male patient with previous abdominal surgery scheduled for TEP repair of an inguinal hernia. During surgery, the iliac vein was damaged. If we had performed a laparotomy in this situation, the potentially life-threatening condition of the patient could have deteriorated further. Instead, to avoid a potential CO2 associated embolism, the preperitoneal pressure was gradually reduced, and the positive end expiratory pressure (PEEP) was increased in the manner that a balance between excessive bleeding and potential development of a CO2 embolism was achieved. The injured vein was sutured endoscopically, and in addition a hemostatic patch was applied. We then continued with the planned surgical procedure. Thrombosis of the sutured vein was prevented by prophylactic administration of low molecular weight heparin until the 14th postoperative day. We conclude that in case of major vein injury during TEP, which might happen irrespective of prior abdominal surgery, the preperitoneal pressure and PEEP adjustment can be used to handle the complication.