Epidural blood patch to treat a postsurgical cerebrospinal fluid leak using central line kit

Epidural blood patches are considered definitive treatment for postdural puncture headache in adult patients. However, they are infrequently used in children or in patients with altered spine anatomy. In patients who have undergone recent spine surgery, the lumbar epidural space can be approached safely via the caudal canal. Our case demonstrates a novel technique to perform an epidural blood patch from a caudal approach using a commonly available central line kit for a 15-year-old patient with severe spinal headache due to cerebrospinal fluid leak following a hemilaminectomy.

Laparoscopic Caudal Approach of the Inferior Vena Cava for Isolated Segment 1 Liver Resection.

Introduction:Isolated segment 1 laparoscopic liver resection is a very challenging procedure. Very few references are available about this laparoscopic technique, so the aim of this article is to show the main technical aspects of laparoscopic caudal approach for segment 1.Material and Methods: A 64 years old woman with a past medical history of a breast cancer previously operated (pT1N0M0, with positive hormonal receptors). Adjuvant treatment was done with radiotherapy and hormone-therapy (Tamoxifen). After 12 months of follow-up, a 18 mm single liver metastasis was detected in the segment 1, suggestive of metastatic disease. A complementary study was done with Magnetic Resonance Image, Computed Tomography and Positron Emission Tomography, without other lesions proven. Result:A laparoscopic resection of isolated liver segment 1 is performed with a caudal approach of the inferior vena cava. All the steps are carefully described. The surgery time was 120 minutes and the blood loss was less than 100 ml. No postoperative complications were registered. The patient was discharged on the third postoperative day.Conclusion:Liver 1 segment resection by laparoscopy with a caudal approach of the inferior vena cava is a secure technique in selected patients and it should be performed in experienced liver surgery and advanced laparoscopy centers, because of its high complexity.

Treatment of Radius Curvus in a Young Dog with Association of Radial Physeal Stapling, Ulnar Ostectomy and Transarticular Dynamic External Fixator Techniques

Background: Radius curvus is a clinical manifestation of the premature closure of the distal ulnar physis and the most common physeal disease in dogs, representing 63% of all physeal injuries. There are few reports indicating the technique of stapling for treatment of radius curvus in squeletically immature dogs. The aim of this study is to report a case of radius curvus in a young dog successfully treated with a combination of 3 surgical tecniques: 1- Stapling the medial and cranial portions of the distal radial physis; 2- Oblique osteotomy of the proximal ulna and ostectomy of the distal ulna, and 3- Dynamic external skeletal fixation in the elbow joint.Case: A 5-month-old female dog was referred to the University Veterinary Hospital with a history of left thoracic limb deformity for 2 weeks. There was a history of possible traumatic event on the front limb, in addition to providing nutritional supplements daily. In the radiographic evaluation the changes were identified in the left thoracic limb: shortening of the ulna, procurvatum and medial angulation of the distal radius, increased joint space and articular incongruity of the elbow joint. The dog was subjected to surgical treatment by the combination of three main surgical techniques. For the stapling of the distal radial physis the surgical approach on the cranial-medial surface of the distal radius was made. Two surgical staples were positioned in the distal radial physis. Thereafter a caudal approach was made to the distal region of the ulnar diaphysis for the distal ostectomy of the ulna. A bone segment of 1 cm in length of the distal ulnar diaphysis was removed. Another caudal approach was made to the proximal region of the ulnar diaphysis and a proximal oblique osteotomy of the ulna was performed. For the dynamic external skeletal fixation in the elbow joint two Steinmann pins were inserted. The first pin was proximal to the supracondilar foramen of the humerus and the second pin was caudal to the trochlear notch of the ulna, both parallel to the joint surface. To create a dynamic system, the pin tips were connected with elastic rubber bands on the medial and lateral sides of the elbow joint. Clinical and radiographic revaluation were made at 15, 30 and 60 days after surgery. Total correction of the limb deviation was achieved at 60 days postoperative. Two years after the surgical procedure, the owner was contacted and reported that the dog was very well and with no change in the operated limb.Discussion: The most common cause of premature closure of the distal ulnar physis is trauma. Due to the proper conical shape of the distal ulnar physis, there is more predisposition to the compression of the germinative cells in traumatic events, leading to radius curvus disease. Another cause of the radius curvus is the nutritional disbalances. In the reported case the patient had both predisponent factors, although unilateral limb involvement suggested trauma with primary causative agent. The treatment included the interruption of the supplementation of the diet associated with surgical techniques. The stapling of the distal radial physis is usually indicated for mild angular valgus deviation. In the current case the technique was applied with success regardless of the higher grade of radial deviation. Generally, the ulnar ostectomy is preferred to the osteotomy, since it reduces the rate of ulnar osteosynthesis, ensuring that the restrictive effect of the ulna upon the radial growth does not restart. In the reported case the ulnar ostectomy was associated with ulnar osteotomy to achieve a more effective result. Furthermore, the proximal ulnar osteotomy is usually indicated when elbow subluxation is present. In the current case the joint congruence was improved with the use of the dynamic external skeletal fixator.

Caudal Epidural Anesthesia

Caudal epidural anesthesia in pediatric patients was first described in 1933 as a replacement for general anesthesia in 83 children undergoing transurethral surgery, and since that time it has been shown to be useful in a variety of surgeries. The popularity of this block stems from its efficacy, simplicity, speed, and relative safety. The caudal approach to the epidural space can be used for the administration of local anesthetic and adjunct medications for either surgical anesthesia or postoperative analgesia. This technique is most commonly applied to surgical procedures occurring below the umbilicus and is frequently used as a single injection technique to be performed after induction of general anesthesia and before surgical incision for augmentation of general anesthesia and postoperative pain control. For longer procedures, a catheter can be placed to facilitate repeat dosing at the conclusion of surgery. Alternatively, more cephalad dermatomes can be anesthetized with an epidural catheter threaded to the desired level. The benefits of caudal epidural anesthesia extend beyond postoperative analgesia and include decreased intraoperative anesthetic requirements and a reduction in the neuroendocrine stress response to surgery.

Lateral ultrasound-guided axillary RUMM block in cats: a pilot cadaveric study

Objectives This study aimed to describe the prominent landmarks for an in-plane ultrasound-guided lateral approach to an axillary RUMM block in cats and document the anatomical distribution of injected solution in cadavers. Methods Eleven mixed breed, frozen-thawed cat cadavers were used. The ultrasound probe was placed on the lateral aspect of the forelimb. A spinal needle was used to inject either methylene blue 5 mg/ml or permanent tissue dye 1:10 within the focal clustering point of the radial (R), ulna (U), median (M) and musculocutaneous (Mc) nerves. The block was approached from either a cranial or caudal direction. Specimens were immediately dissected. A successful block was defined as ⩾20 mm of continuous stain on all nerves (R, U, M and Mc), a partial block as one or more nerves stained ⩾20 mm continuously and a negative block failed to stain any nerve ⩾20 mm. Results The cranial approach stained the R 8/9, U 6/9, M 6/9 and Mc 8/9 nerves successfully, while the caudal approach stained the R 7/9, U 8/9, M 7/9 and Mc 5/9 nerves successfully. There were no statistical differences on staining rates between approaches or limbs used. Conclusions and relevance The lateral approach to an axillary RUMM block is feasible in cats and may be a useful alternative to current approaches used for brachial and antebrachial desensitisation. Both cranial and caudal approaches produced similar results; however, further research in live animals will determine the clinical applicability.

Laparoscopic Right Hepatectomy

Laparoscopic right hepatectomy (LRH) is an important technique in a modern hepatobiliary surgeon’s arsenal. It’s application extends to many different disease processes including both malignant and benign tumors as well as infections and in trauma. The procedure involves using minimally invasive methods to remove Couinaud segments 5-8 delineated by the portion of the liver right and lateral to Cantlie’s line. In this chapter, we explain the approach to performing this operation by delving into preoperative considerations with a focus on high quality imaging, 3D reconstruction, and virtual hepatectomy, optimizing the future liver remnant (FLR) with PVE and use of parenchymal sparing methods, and detailed intraoperative steps emphasizing caudal view, Glissonian approach, MHV roadmap, and communication with anesthesia. We also give context to LRH by discussing the two most common diseases addressed by it, namely colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC), as well as historical perspectives and how LRH use has evolved. We also address complication management such as post-operative liver failure and intra-operative bleeding accidents, variants on exposure with hand assist and transthoracic view, and comparing the advantages and disadvantages between open and laparoscopic right hepatectomy. This review contains 12 figures, 4 tables, and 111 references. Keywords: augmented reality, laparoscopic right hepatectomy, laparoscopic PVE and ALPPS, low CVP anesthesia, MHV roadmap, minimally invasive liver resection, parenchymal sparing right hepatectomy, Takasaki caudal approach, virtual hepatectomy,