This document provides information on parotidectomy surgery and the Fundamentals of Laparoscopic Surgery (FLS) program.
It describes the technique for parotidectomy surgery, including identifying and dissecting around the facial nerve. It notes that most parotid tumors are benign and complications are usually temporary facial nerve paralysis.
It then discusses the development of the FLS program to standardize laparoscopic surgery training. The program includes cognitive training and manual skills assessment. Many residency programs and hospitals now require surgeons to complete the FLS. A large grant will help make the program more accessible to residency programs.
The document summarizes the evolution of trauma surgery training and practice in the United States. It discusses how trauma surgery originated in large city hospitals but has since expanded to regional trauma centers. It also notes changes in surgical training away from generalist models towards increased specialization. Trauma surgery is increasingly encompassing broader emergency general surgery duties due to workforce shortages, while training programs emphasize specialized rather than broad skills.
This document summarizes key points about surgical treatment of early rectal cancer and care of elderly surgical patients. It discusses that radical resection for early rectal cancer achieves excellent local control but has risks, while local excision may be preferable but has a higher local recurrence rate. Adjuvant therapy after local excision may help address this. It also notes that the elderly population is growing and physiologic changes with aging, like cardiac function decline, must be considered in surgical planning and risk assessment for elderly patients. Functional status is more important than age alone.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
1) Arthroscopic stabilization of anterior shoulder instability has advantages over open surgery such as better cosmesis, less morbidity, and possibly less loss of external rotation. However, past studies reporting on arthroscopic stabilization have been limited by small sample sizes and variable surgical techniques and patient characteristics.
2) Several arthroscopic techniques have been developed and studied, including stapling, transglenoid suturing, suture anchors, and biodegradable tacks. Recurrence rates vary significantly between studies and depend on patient factors like age and activity level. Improper patient selection and surgical technique also contribute to failed stabilization.
3) Recent studies directly comparing suture anchor and transglenoid fixation techniques found lower recurrence
A 67-year-old female presented with a large unresectable sacral chordoma. Chordomas are rare tumors that arise from notochord remnants in the spine or skull. She received radiotherapy but the tumor recurred. Adjuvant radiation therapy improves local control rates for chordoma compared to surgery alone, but conventional radiation doses were often too low. Modern intensity-modulated radiation therapy allows safer dose escalation and achieves better local control and survival compared to older techniques. Particle therapy may further improve outcomes by concentrating the high radiation dose in the tumor.
This study retrospectively analyzed outcomes of 27 patients who underwent surgery for chondrosarcomas originating in the sacrum between 1992-2014. It found that en bloc resection was associated with longer hospital stays than intralesional surgery. En bloc resection also resulted in greater loss of motor, bowel and bladder function compared to intralesional surgery, though the results were not statistically significant. The 5-year and 10-year overall survival rates for the entire group were 53% and 37.8% respectively, with a higher rate seen for unilateral nerve root resection versus bilateral resection. The study aims to help assess functional outcomes and quality of life for patients with this rare type of cancer.
Spinal cord compression from cancer metastases can cause pain, weakness, and loss of bladder/bowel function. Delayed diagnosis and treatment often leads to patients being unable to walk by the time of diagnosis. Treatment involves steroids, surgery, and radiation. Surgery provides the best chance of regaining mobility and pain relief but radiation is also effective, especially with new techniques like stereotactic radiosurgery. Prognosis depends on cancer type, mobility level at diagnosis, and response to initial treatment.
1. This study compared general anesthesia (GA) and spinal anesthesia (SA) for 100 patients undergoing lumbar disk surgery through a randomized controlled trial.
2. Intraoperatively, mean blood loss was less with GA but not significantly. Surgeon satisfaction was higher with GA. No major complications occurred with either.
3. Postoperatively, hypertension was more common after GA, and nausea/vomiting were more frequent after SA.
4. Contrary to previous studies, the findings revealed SA had no advantages over GA, and GA may reduce risks and complications.
The document summarizes the evolution of trauma surgery training and practice in the United States. It discusses how trauma surgery originated in large city hospitals but has since expanded to regional trauma centers. It also notes changes in surgical training away from generalist models towards increased specialization. Trauma surgery is increasingly encompassing broader emergency general surgery duties due to workforce shortages, while training programs emphasize specialized rather than broad skills.
This document summarizes key points about surgical treatment of early rectal cancer and care of elderly surgical patients. It discusses that radical resection for early rectal cancer achieves excellent local control but has risks, while local excision may be preferable but has a higher local recurrence rate. Adjuvant therapy after local excision may help address this. It also notes that the elderly population is growing and physiologic changes with aging, like cardiac function decline, must be considered in surgical planning and risk assessment for elderly patients. Functional status is more important than age alone.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
1) Arthroscopic stabilization of anterior shoulder instability has advantages over open surgery such as better cosmesis, less morbidity, and possibly less loss of external rotation. However, past studies reporting on arthroscopic stabilization have been limited by small sample sizes and variable surgical techniques and patient characteristics.
2) Several arthroscopic techniques have been developed and studied, including stapling, transglenoid suturing, suture anchors, and biodegradable tacks. Recurrence rates vary significantly between studies and depend on patient factors like age and activity level. Improper patient selection and surgical technique also contribute to failed stabilization.
3) Recent studies directly comparing suture anchor and transglenoid fixation techniques found lower recurrence
A 67-year-old female presented with a large unresectable sacral chordoma. Chordomas are rare tumors that arise from notochord remnants in the spine or skull. She received radiotherapy but the tumor recurred. Adjuvant radiation therapy improves local control rates for chordoma compared to surgery alone, but conventional radiation doses were often too low. Modern intensity-modulated radiation therapy allows safer dose escalation and achieves better local control and survival compared to older techniques. Particle therapy may further improve outcomes by concentrating the high radiation dose in the tumor.
This study retrospectively analyzed outcomes of 27 patients who underwent surgery for chondrosarcomas originating in the sacrum between 1992-2014. It found that en bloc resection was associated with longer hospital stays than intralesional surgery. En bloc resection also resulted in greater loss of motor, bowel and bladder function compared to intralesional surgery, though the results were not statistically significant. The 5-year and 10-year overall survival rates for the entire group were 53% and 37.8% respectively, with a higher rate seen for unilateral nerve root resection versus bilateral resection. The study aims to help assess functional outcomes and quality of life for patients with this rare type of cancer.
Spinal cord compression from cancer metastases can cause pain, weakness, and loss of bladder/bowel function. Delayed diagnosis and treatment often leads to patients being unable to walk by the time of diagnosis. Treatment involves steroids, surgery, and radiation. Surgery provides the best chance of regaining mobility and pain relief but radiation is also effective, especially with new techniques like stereotactic radiosurgery. Prognosis depends on cancer type, mobility level at diagnosis, and response to initial treatment.
1. This study compared general anesthesia (GA) and spinal anesthesia (SA) for 100 patients undergoing lumbar disk surgery through a randomized controlled trial.
2. Intraoperatively, mean blood loss was less with GA but not significantly. Surgeon satisfaction was higher with GA. No major complications occurred with either.
3. Postoperatively, hypertension was more common after GA, and nausea/vomiting were more frequent after SA.
4. Contrary to previous studies, the findings revealed SA had no advantages over GA, and GA may reduce risks and complications.
This case report from Senegal describes a giant cylindroma of the parotid gland in a 27-year-old woman. The tumor had been growing for 10 years and rapidly progressed in the last year. Due to a lack of diagnostic resources, the tumor measured 9x8 cm before surgical removal. A radical parotidectomy and neck dissection were performed, but reconstruction failed due to flap necrosis, requiring a second surgery. Histopathology found a cylindroma, which is a malignant epithelial tumor. The patient died of cerebral metastases four months later, demonstrating the challenges of diagnosing and treating large salivary gland tumors in under-resourced settings.
A comprehensive presentation on the epidemiology, pathophysiology, clinical presentation, decision making and treatment options of spinal metastases. Supported with the best available evidence as of October 6, 2008
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
Spinal cord compression bhf aos study day mar 2014 finalfondas vakalis
This document provides an overview of malignant spinal cord compression (MSCC). It begins with a clinical case of a 56-year-old man initially diagnosed with back pain who is later found to have prostate cancer with MSCC. The talk then covers the anatomy of the spinal cord, definition and incidence of MSCC, typical symptoms, investigations including MRI, and treatment options like surgery, radiotherapy, and steroids. Outcomes are discussed, with the median survival being 6 months. The document concludes by outlining the key priorities for implementing NICE guidance on MSCC, including early detection and treatment of suspected cases as emergencies.
The document discusses chondrosarcoma, a rare form of bone cancer. It begins by explaining how cancer was once a dreaded word that caused shame and fear. It then defines chondrosarcoma and explains that it arises from cartilage tissue found between bones. Common symptoms include pain, and it is most often diagnosed in adults aged 30-70 through various scans and biopsies. Current treatments include surgery, radiation therapy, and cryosurgery. Survival rates vary depending on the grade of the cancer. While cancer remains difficult to hear, advances in treatment and awareness have improved quality of life and given hope.
This document discusses principles of surgical approaches to central nervous system (CNS) lesions. It covers brain and spine lesions and various surgical techniques. For the brain, it describes common lesion types and goals of surgery. It then explains different surgical approaches like craniotomy, craniectomy, endoscopy, and stereotactic procedures. For the spine, it outlines common lesion locations and types of tumors. It also discusses posterior and anterior surgical approaches to access different spinal regions. The document provides examples of various patients who underwent these procedures.
The document evaluates stabilization failure in the thoracolumbar spine. It analyzes 93 patients who underwent spinal stabilization surgery. 9 patients (8.37%) experienced implant failure, mostly screw breakage. Failure was likely due to inadequate bone grafting, poor surgical technique, use of undersized screws, low-quality implants, and inadequate rest after surgery. To prevent failure, the study recommends limiting stabilization to appropriate cases, improving surgical methods, using adequate bone grafts, proper implant selection, and considering spinal biomechanics.
This document discusses the management of duodenal injuries. It notes that while duodenal injuries are uncommon, accounting for about 4% of abdominal injuries, they can have high morbidity and mortality rates of 65% and 20% respectively due to difficulties in diagnosis and management. It outlines the history of treatment for duodenal injuries and factors that influence incidence rates. It then discusses techniques for diagnosis, including physical exam, imaging studies, and exploratory laparotomy. Finally, it reviews surgical management strategies and repairs that can be used to treat duodenal injuries.
Primary bone tumors of the spine are rare, accounting for only 4.2% of spinal tumors. This study summarizes the experience of treating 18 cases of primary bone tumors of the spine over 10 years at two hospitals in Bangladesh. The most common tumors were malignant (61%), with the dorsal and lumbar spine being most commonly involved. Pain was the primary presenting symptom in most cases. Surgical treatment with the aim of complete resection when possible combined with preservation of neurological function and spinal stabilization was performed. Adjuvant chemotherapy and radiation were also used. Outcomes were improved pain and function, though malignant tumors often had poorer outcomes and higher mortality. Early diagnosis and multidisciplinary treatment were concluded to be important for managing these rare tumors
Chondrosarcoma is the second most common primary bone tumor that occurs mostly in middle-aged and older adults. It is associated with cartilage matrix production and lacks osteoid. Risk factors include malignant transformation of osteochondromas or enchondromas. Diagnosis involves imaging like CT or MRI followed by biopsy. Treatment depends on histologic grade and location. Surgical excision is the primary treatment, while radiotherapy may be used for intermediate to high grade or unresectable tumors. Several studies have shown good local control rates with combined surgery and radiotherapy for chondrosarcoma.
Ewing sarcoma is the second most common bone tumor in children. Radiotherapy plays an important role in the treatment of both localized and metastatic Ewing sarcoma. For localized disease, radiotherapy is recommended for patients who cannot undergo surgery or have unresectable tumors. It is also used post-operatively if there is residual disease. For metastatic disease, radiotherapy can help control the primary tumor and reduce pulmonary metastases when combined with chemotherapy. Advances in radiotherapy planning and techniques have improved outcomes while reducing long-term side effects.
Presentation on Spinal Metastases Scorng system and Decision making
By
Dr.SHASHIDHAR B K
Bangalore Spine Specialist Clinic
www.spinesurgeonbangalore.com
drshashidharbk@gmail.com
This document discusses the treatment of Ewing's sarcoma. It begins with an introduction to Ewing's sarcoma, describing its identification in 1921 and its characteristics. It then discusses the pathology, genetics, clinical presentation, routes of spread, diagnostic workup, staging, and prognostic factors. The bulk of the document focuses on treatment options, including induction chemotherapy, local therapy options of surgery or radiation, maintenance chemotherapy, and surveillance. It also covers treatment of metastatic and recurrent disease. The document provides detailed information on chemotherapy regimens, radiation techniques, and ongoing research directions.
Case reports treatment of ameloblastoma of the jaws in childrenQuách Bảo Toàn
This document summarizes a study of 6 children treated for ameloblastoma, a jaw tumor. Three cases treated with enucleation (removal of tumor without removing bone) showed early recurrence and required repeated surgery. One case was treated with partial mandibular resection and two with marginal resection (removing bone at tumor margins), with no recurrences. The author concludes that while enucleation may be used initially in children to allow jaw growth, marginal resection has better long-term results for completely removing the tumor.
Identified in 1921 by James Ewing
2nd most common bone tumor in children
Ewing’s Sarcoma Family of tumors:
Ewing’s sarcoma (Bone –87%)
Extraosseous Ewing’s sarcoma (8%)
Peripheral PNET(5%)
Askin’s tumor
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
Rhinoplasty post nasal trauma often requires an open approach to achieve precise anatomic fracture reduction and stabilization of the disrupted skeletal framework. For complex nasal fractures involving severe comminution and skeletal instability, early open septorhinoplasty may have lower failure and revision rates compared to closed reduction. While closed reduction can be effective for localized bony fractures with modest displacement, open rhinoplasty techniques provide unparalleled accuracy that may lead to better long-term outcomes despite the need for more surgical experience and the procedure being more costly initially.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
Squamous cell carcinoma in the native kidney of a renal transplant recipient ...Apollo Hospitals
A 54-year-old man who received a kidney transplant 3 years prior presented with flank pain. Imaging showed a large mass in his native left kidney. He underwent a nephrectomy and the mass was found to be a squamous cell carcinoma. He later developed a squamous cell carcinoma in his urethra, which was excised. The patient received adjuvant radiation therapy to the tumor bed to reduce the risk of recurrence, while avoiding damage to surrounding structures like the transplanted kidney. This case report discusses the rare occurrence of squamous cell carcinoma in the native kidney of a transplant recipient and the challenges of postoperative management.
Este documento describe varios servicios de las tecnologías de la información y la comunicación (TIC), incluyendo el correo electrónico, búsqueda en internet, banca en línea, podcasts, televisión por internet, comercio electrónico, servicios públicos en línea, telemedicina, educación en línea, videojuegos, y telefonía móvil. Estos servicios han cambiado las formas en que las personas interactúan y acceden a información, entretenimiento, banca, atención médica y educación.
Acs0702 Injuries To The Central Nervous Systemmedbookonline
The document discusses injuries to the central nervous system, including head injuries and spinal cord injuries. It provides guidelines for initial management of severe head injuries, including resuscitation to stabilize airway, breathing, and circulation. It recommends intubation for patients with a Glasgow Coma Scale score of 8 or lower. Computed tomography is used to identify surgical lesions like subdural hematomas, which require urgent evacuation. For critically injured patients, treatment in a neurosurgical intensive care unit is indicated to prevent secondary injuries through monitoring of intracranial pressure, cerebral blood flow, oxygenation and other parameters. Outcomes are correlated with the duration and degree of jugular desaturation.
This case report from Senegal describes a giant cylindroma of the parotid gland in a 27-year-old woman. The tumor had been growing for 10 years and rapidly progressed in the last year. Due to a lack of diagnostic resources, the tumor measured 9x8 cm before surgical removal. A radical parotidectomy and neck dissection were performed, but reconstruction failed due to flap necrosis, requiring a second surgery. Histopathology found a cylindroma, which is a malignant epithelial tumor. The patient died of cerebral metastases four months later, demonstrating the challenges of diagnosing and treating large salivary gland tumors in under-resourced settings.
A comprehensive presentation on the epidemiology, pathophysiology, clinical presentation, decision making and treatment options of spinal metastases. Supported with the best available evidence as of October 6, 2008
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
Spinal cord compression bhf aos study day mar 2014 finalfondas vakalis
This document provides an overview of malignant spinal cord compression (MSCC). It begins with a clinical case of a 56-year-old man initially diagnosed with back pain who is later found to have prostate cancer with MSCC. The talk then covers the anatomy of the spinal cord, definition and incidence of MSCC, typical symptoms, investigations including MRI, and treatment options like surgery, radiotherapy, and steroids. Outcomes are discussed, with the median survival being 6 months. The document concludes by outlining the key priorities for implementing NICE guidance on MSCC, including early detection and treatment of suspected cases as emergencies.
The document discusses chondrosarcoma, a rare form of bone cancer. It begins by explaining how cancer was once a dreaded word that caused shame and fear. It then defines chondrosarcoma and explains that it arises from cartilage tissue found between bones. Common symptoms include pain, and it is most often diagnosed in adults aged 30-70 through various scans and biopsies. Current treatments include surgery, radiation therapy, and cryosurgery. Survival rates vary depending on the grade of the cancer. While cancer remains difficult to hear, advances in treatment and awareness have improved quality of life and given hope.
This document discusses principles of surgical approaches to central nervous system (CNS) lesions. It covers brain and spine lesions and various surgical techniques. For the brain, it describes common lesion types and goals of surgery. It then explains different surgical approaches like craniotomy, craniectomy, endoscopy, and stereotactic procedures. For the spine, it outlines common lesion locations and types of tumors. It also discusses posterior and anterior surgical approaches to access different spinal regions. The document provides examples of various patients who underwent these procedures.
The document evaluates stabilization failure in the thoracolumbar spine. It analyzes 93 patients who underwent spinal stabilization surgery. 9 patients (8.37%) experienced implant failure, mostly screw breakage. Failure was likely due to inadequate bone grafting, poor surgical technique, use of undersized screws, low-quality implants, and inadequate rest after surgery. To prevent failure, the study recommends limiting stabilization to appropriate cases, improving surgical methods, using adequate bone grafts, proper implant selection, and considering spinal biomechanics.
This document discusses the management of duodenal injuries. It notes that while duodenal injuries are uncommon, accounting for about 4% of abdominal injuries, they can have high morbidity and mortality rates of 65% and 20% respectively due to difficulties in diagnosis and management. It outlines the history of treatment for duodenal injuries and factors that influence incidence rates. It then discusses techniques for diagnosis, including physical exam, imaging studies, and exploratory laparotomy. Finally, it reviews surgical management strategies and repairs that can be used to treat duodenal injuries.
Primary bone tumors of the spine are rare, accounting for only 4.2% of spinal tumors. This study summarizes the experience of treating 18 cases of primary bone tumors of the spine over 10 years at two hospitals in Bangladesh. The most common tumors were malignant (61%), with the dorsal and lumbar spine being most commonly involved. Pain was the primary presenting symptom in most cases. Surgical treatment with the aim of complete resection when possible combined with preservation of neurological function and spinal stabilization was performed. Adjuvant chemotherapy and radiation were also used. Outcomes were improved pain and function, though malignant tumors often had poorer outcomes and higher mortality. Early diagnosis and multidisciplinary treatment were concluded to be important for managing these rare tumors
Chondrosarcoma is the second most common primary bone tumor that occurs mostly in middle-aged and older adults. It is associated with cartilage matrix production and lacks osteoid. Risk factors include malignant transformation of osteochondromas or enchondromas. Diagnosis involves imaging like CT or MRI followed by biopsy. Treatment depends on histologic grade and location. Surgical excision is the primary treatment, while radiotherapy may be used for intermediate to high grade or unresectable tumors. Several studies have shown good local control rates with combined surgery and radiotherapy for chondrosarcoma.
Ewing sarcoma is the second most common bone tumor in children. Radiotherapy plays an important role in the treatment of both localized and metastatic Ewing sarcoma. For localized disease, radiotherapy is recommended for patients who cannot undergo surgery or have unresectable tumors. It is also used post-operatively if there is residual disease. For metastatic disease, radiotherapy can help control the primary tumor and reduce pulmonary metastases when combined with chemotherapy. Advances in radiotherapy planning and techniques have improved outcomes while reducing long-term side effects.
Presentation on Spinal Metastases Scorng system and Decision making
By
Dr.SHASHIDHAR B K
Bangalore Spine Specialist Clinic
www.spinesurgeonbangalore.com
drshashidharbk@gmail.com
This document discusses the treatment of Ewing's sarcoma. It begins with an introduction to Ewing's sarcoma, describing its identification in 1921 and its characteristics. It then discusses the pathology, genetics, clinical presentation, routes of spread, diagnostic workup, staging, and prognostic factors. The bulk of the document focuses on treatment options, including induction chemotherapy, local therapy options of surgery or radiation, maintenance chemotherapy, and surveillance. It also covers treatment of metastatic and recurrent disease. The document provides detailed information on chemotherapy regimens, radiation techniques, and ongoing research directions.
Case reports treatment of ameloblastoma of the jaws in childrenQuách Bảo Toàn
This document summarizes a study of 6 children treated for ameloblastoma, a jaw tumor. Three cases treated with enucleation (removal of tumor without removing bone) showed early recurrence and required repeated surgery. One case was treated with partial mandibular resection and two with marginal resection (removing bone at tumor margins), with no recurrences. The author concludes that while enucleation may be used initially in children to allow jaw growth, marginal resection has better long-term results for completely removing the tumor.
Identified in 1921 by James Ewing
2nd most common bone tumor in children
Ewing’s Sarcoma Family of tumors:
Ewing’s sarcoma (Bone –87%)
Extraosseous Ewing’s sarcoma (8%)
Peripheral PNET(5%)
Askin’s tumor
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
Rhinoplasty post nasal trauma often requires an open approach to achieve precise anatomic fracture reduction and stabilization of the disrupted skeletal framework. For complex nasal fractures involving severe comminution and skeletal instability, early open septorhinoplasty may have lower failure and revision rates compared to closed reduction. While closed reduction can be effective for localized bony fractures with modest displacement, open rhinoplasty techniques provide unparalleled accuracy that may lead to better long-term outcomes despite the need for more surgical experience and the procedure being more costly initially.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
Squamous cell carcinoma in the native kidney of a renal transplant recipient ...Apollo Hospitals
A 54-year-old man who received a kidney transplant 3 years prior presented with flank pain. Imaging showed a large mass in his native left kidney. He underwent a nephrectomy and the mass was found to be a squamous cell carcinoma. He later developed a squamous cell carcinoma in his urethra, which was excised. The patient received adjuvant radiation therapy to the tumor bed to reduce the risk of recurrence, while avoiding damage to surrounding structures like the transplanted kidney. This case report discusses the rare occurrence of squamous cell carcinoma in the native kidney of a transplant recipient and the challenges of postoperative management.
Este documento describe varios servicios de las tecnologías de la información y la comunicación (TIC), incluyendo el correo electrónico, búsqueda en internet, banca en línea, podcasts, televisión por internet, comercio electrónico, servicios públicos en línea, telemedicina, educación en línea, videojuegos, y telefonía móvil. Estos servicios han cambiado las formas en que las personas interactúan y acceden a información, entretenimiento, banca, atención médica y educación.
Acs0702 Injuries To The Central Nervous Systemmedbookonline
The document discusses injuries to the central nervous system, including head injuries and spinal cord injuries. It provides guidelines for initial management of severe head injuries, including resuscitation to stabilize airway, breathing, and circulation. It recommends intubation for patients with a Glasgow Coma Scale score of 8 or lower. Computed tomography is used to identify surgical lesions like subdural hematomas, which require urgent evacuation. For critically injured patients, treatment in a neurosurgical intensive care unit is indicated to prevent secondary injuries through monitoring of intracranial pressure, cerebral blood flow, oxygenation and other parameters. Outcomes are correlated with the duration and degree of jugular desaturation.
This document discusses the management of fulminant ulcerative colitis, a potentially life-threatening condition. It describes:
1) Initial evaluation involves a thorough history, physical exam, and tests like bloodwork and imaging to assess severity and rule out complications.
2) Medical management begins with IV corticosteroids, and if that fails within 5-7 days, cyclosporine therapy is considered.
3) Surgery is indicated if medical therapies are not effective or complications develop. The staged or "all-at-once" surgical approach depends on the patient's condition and experience of the surgical team.
The author wakes up at 8am, has breakfast at 9am and organizes their room at 10am. They practice skateboarding for an hour between 11am and midday, then have lunch and get ready to study at the Sena institute from 1pm to 6pm, with classes starting at 1:15pm and a break at 3pm. After returning home at 6pm, they do homework between 7pm and 8pm before having dinner, watching TV and going to bed at 10pm.
ОСОБЛИВОСТІ ФОРМУВАННЯ СТРАТЕГІЇ ПІДПРИЄМСТВА НА РИНКУ ЕКОЛОГІЧНИХ ІННОВАЦІЙAlex Grebeshkov
Кириченко Валентин,
ФЕтаУ, 4 курс, ЕЕП-405, valentin-kirichenko@ukr.net
(науковий керівник: Прохорова Є. В., к. е. н., доцент каф. стратегії підприємств)
ОСОБЛИВОСТІ ФОРМУВАННЯ СТРАТЕГІЇ ПІДПРИЄМСТВА НА РИНКУ ЕКОЛОГІЧНИХ ІННОВАЦІЙ
Кириченко Валентин
ОСОБЕННОСТИ ФОРМИРОВАНИЯ СТРАТЕГИИ ПРЕДПРИЯТИЯ НА РЫНКЕ ЭКОЛОГИЧЕСКИХ ИННОВАЦИЙ
Kyrychenko Valentyn
FEATURES OF ENTERPRISE’S STRATEGY FORMATION IN THE MARKET OF ECOLOGICAL INNOVATIONS
http://conference.spkneu.org/2015/12/osoblivosti-formuvannya-strategiyi-pidpriyemstva-na-rinku-ekologichnih-innovatsij/
This document provides guidance on treating a perforated ulcer or subphrenic abscess. It describes:
1) Preparing patients preoperatively by administering IV fluids/antibiotics and gastric suction.
2) Closing perforations by suturing the ulcer and reinforcing it with omentum, or sealing it if too indurated.
3) Draining subphrenic abscesses extraperitoneally by making incisions below the costal margin or through the 12th rib bed and inserting drains into the abscess cavity.
Acs0824 Disorders Of Water And Sodium Balancemedbookonline
The document discusses disorders of water and sodium balance in the body, explaining how water and electrolytes are distributed and regulated through fluid compartments and kidney function. Precise control systems work to maintain stability of the internal environment through balancing fluid intake and output each day. Disruptions to fluid homeostasis can cause excess water retention or loss of water from cells.
This document outlines a proposed research study to examine the effect of vinegar in degrading solanine, a glycoalkaloid toxin commonly found in potatoes. The study will investigate how different concentrations of vinegar, cooking temperatures, and cooking times impact solanine levels when potatoes are boiled. Samples will be extracted using an ethyl alcohol-acetic acid method and analyzed using HPLC to measure solanine concentration. The goal is to determine conditions that can degrade half the solanine content in potatoes.
This document provides guidance on expressing sympathy and care for others who are experiencing difficulties. It discusses conveying sympathy through various media like letters, emails, or in person. The purpose is to comfort those in trouble and let them know you care. Examples are given for formal, informal, and normal situations with appropriate expressions of sympathy and potential responses. Sample sympathy letters for illness and condolences are also included. The document concludes with information on complimenting others to encourage good performance and appreciation.
This document summarizes Mike Jetten's work discovering previously unknown anaerobic microorganisms through his research at the Soehngen Institute of Anaerobic Microbiology. It discusses two major findings: (1) the discovery of anaerobic ammonium oxidation (anammox) bacteria that convert ammonium and nitrite to dinitrogen gas, and (2) the discovery of bacteria capable of the complete oxidation of ammonia without oxygen (comammox). It also outlines Jetten's career, research approach, and the importance of microbial life in biogeochemical cycles and sustainability of the planet.
This document discusses the anatomy and surgical procedure of splenectomy. It describes:
- The spleen's highly variable arterial blood supply, which can take bundled or distributed patterns. This variability impacts the difficulty of surgery.
- The splenic artery typically branches off the celiac axis but can originate from other nearby arteries in rare cases.
- In addition to main branches, the splenic artery also forms transverse anastomoses with collateral vessels at 90 degree angles, complicating efforts to occlude branches.
- A brief history of splenectomy, from its first reported use in the 16th century to modern adoption of laparoscopic techniques. Splenectomy became more common with automobile use and
Acs0825 Metabolic Response To Critical Illnessmedbookonline
The document discusses the metabolic response to critical illness in surgical patients. It notes that critical illness can cause debility through specific biochemical and physiological alterations. Some key factors that can contribute to debility include wounds, pain, inflammation, anorexia, and immunosuppression. The metabolic response involves an initial "ebb phase" characterized by cardiovascular instability and impaired oxygen transport. This is followed by a "flow phase" of hyperdynamic circulatory changes, inflammation, and glucose intolerance. Managing these issues appropriately can help minimize patient debility.
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1) Parotidectomy involves surgically removing all or part of the parotid gland located in front of and below the ear.
2) The procedure begins by making incisions and developing skin flaps to expose the gland. The facial nerve is then identified, either at its main trunk or branches.
3) Dissection then proceeds along the plane of the facial nerve to remove portions of the gland while preserving the nerve branches. Hemostasis is achieved and any duct divisions are managed. Deep lobe tumors require additional care near the nerve.
This document discusses diaphragmatic procedures. It begins with an overview of diaphragmatic anatomy and physiology. The main procedures described for treating congenital diseases include repair of Bochdalek hernias, the most common form of congenital diaphragmatic hernia (CDH). Repair of Morgagni hernias is also covered. For acquired conditions, diaphragmatic plication is described to treat unilateral diaphragmatic paralysis by suturing the paralyzed hemidiaphragm. Overall causes and diagnosis of diaphragmatic paralysis are reviewed.
The document discusses various radiographic techniques used in orthodontic diagnosis. It begins with a brief history of x-rays and their discovery by Roentgen. It then summarizes several intraoral and extraoral radiographs used in orthodontics including panoramic radiographs, lateral cephalograms, posterior anterior views, and temporomandibular joint tomograms. It highlights the structures visualized and diagnostic information provided by each technique. The document also discusses digital radiography and its advantages over conventional radiography.
This document provides information on evaluating a parotid mass. It begins by classifying parotid masses as nonneoplastic, lymphoepithelial, or neoplastic. The evaluation involves obtaining a clinical history focusing on duration and symptoms. On physical examination, the examiner evaluates the extent of the mass, effects on surrounding areas, and facial nerve function. Imaging may be used to further characterize indeterminate masses. Fine needle aspiration is sometimes used but is controversial. Treatment depends on whether the mass is benign or malignant.
The document discusses the anatomy relevant to periodontal surgery. It describes the goals of periodontal surgery as restoring health and function to the periodontium. The maxilla and mandible contain important anatomical landmarks like the maxillary sinus, zygomaticoalveolar crest, and mental foramen. Periodontal surgery must consider the vascular supply from branches of the external carotid artery and avoid damaging structures like the lingual nerve. Anatomic factors can limit the scope of periodontal procedures.
Capital Punishment For And Against Essay.pdfAnna Holmes
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This document discusses dysphagia and aspiration risk structures (DARS) after chemoradiation treatment for head and neck cancers. It identifies the pharyngeal constrictor muscles, glottis, and supraglottic larynx as key structures involved in swallowing whose damage can cause dysphagia. Intensity-modulated radiation therapy (IMRT) allows for sparing of these structures and has been shown to improve swallowing outcomes and quality of life without increasing cancer recurrence risks. An ongoing randomized controlled trial called DARS is evaluating whether IMRT plans that explicitly aim to reduce dose to the pharyngeal constrictor muscles can further improve long-term swallowing function.
Acs0108 Preparation Of The Operating Roommedbookonline
This document discusses the preparation of the operating room. It provides details on:
1) General principles of operating room design including patient positioning for common procedures like laparotomy, thoracotomy, and thyroidectomy.
2) Considerations for operating room design such as standards, physical layout, equipment needs, and integrating new technologies.
3) Ensuring patient safety, operating room efficiency, and quality improvement through proper patient positioning, communication systems, and disciplined introduction of new technologies.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Congenital anomalies of head,neck and face(Radiology) including USG and fetal...Shaurya Agarwal
Congenital anomalies of head,neck and face(Radiology) including USG ,fetal mri including conditions of cleft lip ,palate, branchial cleft abn ormalities,nasofrontal masses ,down syndrome,turner syndrome,
Position of the Mental Foramen in a Northern Regional Palestinian PopulationAbu-Hussein Muhamad
Background: The mental foramen is one of important anatomical features frequently encountered
in maxillofacial surgical procedures in premolars area. Its position has been shown to vary according to
race. In this study researchers aim to study the position, shape, and appearance of the mental foramen,
as seen on panoramic radiographs of Palestinians, and to compare our findings with international
values.
Materials and methods: A randomly selected panoramic radiographs (368 with 736 sides)
from the records of dental patients attending three dental services in north of Palestine, the mental
foramina’s anterior–posterior position, shape, and radiologic appearance were subjected to analysis.
Results: The most frequent anterior–posterior position was in the area between the long axes of
first and second mandibular premolar teeth. The most frequent appearance was the continuous type
and majority of foramina were rounded in shape.
Conclusion: The position of the mental foramen on panoramic radiographs in this selected group
of Palestinians was most commonly between the mandibular premolars. The continuous type and
rounded shape of the mental foramen was founded in majority of cases. These results are similar to
previous findings in Caucasian populations.
This document summarizes a study of 25 cases of parapharyngeal tumors over a 2 year period. The key findings are:
1) There was a male preponderance (52%) and highest incidence in the 3rd and 5th decades.
2) The most common presenting symptoms were difficulty swallowing (36%) and neck swelling (28%).
3) Fine needle aspiration was performed in 21 cases and correlated with biopsy in 13 cases.
4) CT scan was required for all cases to delineate the size, extent and relationship to surrounding structures.
5) The most common tumor types were neurogenic (44%), salivary origin pleomorphic adenoma (24%), and parag
NECK anatomy muscles with clinical anatomy.pdfsiddhimeena3
The document discusses the clinical anatomy of the neck. It begins by describing the structures located in the neck that allow for thinking, speaking, seeing, hearing, tasting, and smelling. It then discusses the cervical spine, fascial compartments of the neck including the carotid sheath, tissue spaces of the neck including the prevertebral space, and triangles of the neck including the anterior and posterior triangles. It also summarizes key structures in the neck including the thyroid gland, larynx, pharynx, trachea, great vessels, and cervical sympathetic trunk.
This document provides information about parotidectomy, which is the surgical removal of the parotid gland. It discusses the different types of parotidectomy including superficial and total parotidectomy. Superficial parotidectomy involves removing the superficial lobe of the parotid gland while preserving the facial nerve. The procedure is described in detail, including identifying landmarks to locate the facial nerve and carefully dissecting the gland superficial to the nerve. Complications involving the facial nerve are also addressed.
Theories of growth /certified fixed orthodontic courses by Indian dental acad...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
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Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Identifying a safe zone for midface augmentation using anatomic landmarks for...Nhat Nguyen
The study identifies a safe zone for dissection during midface augmentation to avoid injury to the infraorbital nerve. Measurements were taken on 44 CT scans of adult faces to determine the average distance between the infraorbital foramen and nearby bony landmarks. For men, the average distances were 8.61 mm from the infraorbital rim, 17.43 mm from the piriform aperture, 41.81 mm from the second premolar tip, and 25.93 mm from the lateral orbital rim. For women, the averages were 8.25 mm, 15.69 mm, 37.33 mm, and 24.21 mm, respectively. Defining this safe zone can help clinicians locate the infraorbital for
A 60-year-old male presented with a large intraoral mass on the floor of the tongue. Excision biopsy revealed the mass to be a lipoma, a benign tumor composed of adipose tissue that most commonly develops in subcutaneous tissues but can also occur in deeper tissues like the oral cavity. Lipomas typically occur in patients over 40 years of age and can cause interference with functions if allowed to grow large. Complete surgical excision is the recommended treatment and provides good long-term outcomes without recurrence, as was the case for this patient.
Published annually, the Progress Report describes the top findings in brain research during the previous year as selected by executive members of the Dana Alliance for Brain Initiatives. The 2009 report features in-depth articles on substance abuse, Alzheimer's disease, obesity, schizophrenia, brain-machine interface, and post-traumatic stress disorder, as well as a roundup chapter on other areas of advancement. The Progress Report is the signature publication of the Dana Alliance for Brain Initiatives.
Acs0522 procedures for benign and malignant biliary tract disease-2005medbookonline
This document discusses procedures for benign and malignant biliary tract diseases. It provides guidance on preoperative evaluation and management of biliary obstruction. Specific considerations are given to infection, renal dysfunction, impaired immunity, malnutrition, and coagulation issues. The document outlines operative planning details such as patient positioning, exposure techniques, and guidelines for biliary anastomoses including suture placement and techniques for difficult access situations.
This document discusses the anatomy and surgical procedure of splenectomy. It describes:
- The spleen's highly variable arterial blood supply, which can take bundled or distributed patterns. This variability impacts the difficulty of surgery.
- The splenic artery typically branches off the celiac axis but can originate from other nearby arteries in rare cases.
- Additional branches of the splenic artery before it enters the spleen, including short gastric and pancreatic arteries.
- A history of splenectomy beginning in the 16th century and its increasing use through the 20th century for trauma and hematologic disorders.
- The development of laparoscopic splenectomy in the early 1990s and ongoing refinement of minim
Gastrostomy is commonly used as a temporary procedure to avoid discomfort from prolonged nasogastric suction after major abdominal surgery. It can also be used permanently when the esophagus is obstructed to nonresectable cancer. The Stamm gastrostomy is most common temporary procedure where a catheter is placed through the stomach wall and anchored to the skin. The Janeway gastrostomy is a permanent alternative where a flap of stomach is brought through the abdominal wall and attached to form a mucosal lined tube to prevent regurgitation. Postoperative care involves gradual advancement to oral intake as the stomach heals and functions return to normal.
This document describes the Billroth I gastric resection procedure, which involves removing part of the stomach and reattaching it to the duodenum. Key steps include transecting the stomach, attaching it to the duodenum using a circular stapler, and closing the gastrotomy site. The procedure aims to control peptic ulcers by combining hemigastrectomy with vagotomy while restoring normal gastrointestinal continuity. Postoperative care focuses on gradual advancement of oral intake and monitoring for complications.
This document describes the Billroth I procedure for gastroduodenostomy. It involves extensive mobilization of the stomach and duodenum to allow for an end-to-end anastomosis between the stomach and duodenum, restoring normal continuity of the gastrointestinal tract. The stomach is divided and sutured closed, then sutured to the duodenum in layers to create the gastroduodenal connection. Postoperative care focuses on gradual advancement of diet and monitoring for gastric retention to support healing and prevent complications.
Gastrostomy is commonly used as a temporary procedure to avoid discomfort from prolonged nasogastric suction after major abdominal surgery. It can also be used permanently when the esophagus is obstructed to nonresectable cancer. The Stamm gastrostomy is most common temporary procedure where a catheter is placed through the stomach wall and anchored to prevent leakage. The Janeway gastrostomy is a permanent alternative where a flap of stomach is brought through the abdominal wall and lined with mucosa to form a permanent opening, preventing regurgitation. Postoperative care involves gradual advancement to oral intake as the stomach and bowel recover function.
Gastrojejunostomy is a surgical procedure that connects the stomach directly to the jejunum. It is indicated for patients with duodenal ulcers complicated by pyloric obstruction or nonresectable stomach or pancreatic cancers causing obstruction. The procedure involves opening the stomach and jejunum, suturing them together to form a stoma, then closing in multiple layers. Postoperatively, gastric emptying is monitored and diet advanced gradually to ensure proper healing.
A C S0103 Perioperative Considerations For Anesthesiamedbookonline
This document discusses perioperative considerations for anesthesia. It notes advancements in modern surgical care and alterations in anesthetic management to maximize patient benefit. A preoperative evaluation is important to assess medical history and current medications. Certain medications may need to be adjusted or discontinued before surgery, such as MAOIs, oral anticoagulants, and some herbal supplements, to reduce risks of adverse reactions or bleeding complications during the procedure. The risks and options for anesthesia should be discussed with the patient.
Postoperative pain is a complex experience involving sensory, emotional, and mental components. Effective pain management is important for patient comfort and recovery. Guidelines for postoperative pain treatment have been developed for specific procedures. Multimodal analgesic regimens targeting multiple pathways are recommended over reliance on opioids alone to prevent tolerance and hyperalgesia. Nonpharmacological complementary therapies can be combined with drug treatments to enhance pain control.
The document discusses the approach to a patient experiencing ongoing bleeding. It outlines the following key steps:
1. First consider the possibility of a technical cause like an unligated vessel and examine for injuries.
2. If no technical cause is found, check the patient's temperature and perform laboratory tests. Hypothermia can cause coagulopathy.
3. Evaluate test results along with the patient's history for clues to underlying causes like platelet dysfunction, coagulation factor deficiencies, or inherited bleeding disorders. Treat the specific condition while continuing evaluation.
A C S0812 Brain Failure And Brain Deathmedbookonline
This document discusses brain failure and brain death. It defines different levels of impaired consciousness from cloudy consciousness to coma. It describes how brain failure results from cardiac arrest and the challenges of restarting the brain after lack of oxygen. It outlines the criteria for diagnosing brain death, including absence of brain stem reflexes and apnea testing. It also discusses the evolution of determining death as technology has allowed life support to prolong vital signs indefinitely.
1. The document discusses various sources of data for benchmarking surgical outcomes, including public reporting programs, public use administrative databases, and clinical registries. It notes limitations of using administrative data including problems with accuracy, completeness, and clinical precision of coding.
2. Clinical registries like the National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons database are described as better sources of benchmarking data as they provide risk-adjusted outcomes while protecting individual hospital and surgeon confidentiality.
3. Limitations of all surgical benchmarking sources include small sample sizes, lack of generalizability between databases, and lack of external auditing to ensure accuracy and completeness of submitted data.
This document discusses organ procurement from cadaveric donors. It describes the coordination between donor and recipient activities, including matching organs to recipients based on factors like blood type, medical urgency, and waiting time. The evaluation of donor organs is outlined for different organs. Careful donor management aims to optimize organs while respecting donor dignity.
Hand-assisted laparoscopic surgery (HALS) is a hybrid technique that provides many of the advantages of traditional open surgery and laparoscopic colectomy. HALS employs a special access device that allows the surgeon to place a hand in the abdomen to assist with retraction, dissection, and visualization while maintaining pneumoperitoneum and laparoscopic instrumentation through trocars. Studies have shown HALS results in shorter operative times and lower conversion rates to open surgery compared to traditional laparoscopic colectomy while preserving similar short-term clinical outcomes. HALS may help expand the use of minimally invasive approaches for complex colectomies by providing an easier transition from open surgery than traditional laparoscopic techniques.
This document provides reference values for many common clinical chemistry analytes measured in various specimens like plasma, serum, urine, and whole blood. The analytes include metabolic panels, lipids, proteins, electrolytes, vitamins, and more. Reference ranges are given in conventional and SI units for each analyte. The purpose is to provide clinicians with the normal expected ranges to interpret laboratory results at the Massachusetts General Hospital.
Acs0905 Gynecologic Considerations For The General Surgeonmedbookonline
This document discusses several gynecologic conditions and considerations for general surgeons:
- Gynecologic emergencies like bleeding from ovarian cysts, adnexal torsion, pelvic inflammatory disease, and ectopic pregnancy. Diagnosis and treatment approaches are outlined.
- Outpatient gynecologic problems including evaluating pelvic masses and abnormal uterine bleeding.
- Gynecologic malignancies like ovarian and cervical cancer that some general surgeons may encounter.
- Most conditions can be initially managed conservatively but may require surgery depending on patient stability or response to treatment. Diagnostic tools like ultrasound, CT, and laparoscopy are discussed.
Acs0904 Urologic Considerations For The General Surgeonmedbookonline
This document discusses urologic considerations for general surgeons. It begins with an overview of genitourinary anatomy, including the kidneys, ureters, bladder, prostate, seminal vesicles, penis, and urethra. It then discusses common urologic injuries general surgeons may encounter, such as those resulting from multiple trauma or iatrogenic injuries during other operations. Urologic malignancies and benign prostatic hyperplasia are also briefly mentioned.
1) The document discusses the management of pregnant patients requiring surgery or experiencing trauma. It notes special considerations for pregnant patients, including physiological changes and the need to care for both mother and fetus.
2) In trauma situations, the initial focus is stabilizing the mother to benefit both patients. Penetrating injuries often directly threaten the fetus while blunt trauma poses less direct risk, usually resulting in placental abruption or preterm labor.
3) Surgical decisions must weigh fetal viability against maternal stability, with non-urgent cases delayed if possible. Monitoring includes fetal heart monitoring and ultrasound to detect issues like abruption.
This document discusses considerations for pediatric surgical patients. Some key points:
- Pediatric physiology differs significantly from adults, with higher fluid needs and electrolyte requirements. Careful fluid and electrolyte management is important.
- Nutritional needs are also higher in pediatric patients, especially infants, due to rapid growth. Enteral nutrition is preferred when possible, otherwise total parenteral nutrition may be needed. Close monitoring of nutrition and growth parameters is important.
- Vital signs and fluid intake/output norms differ for pediatric patients compared to adults. Recognizing what is normal for different pediatric age groups is essential for surgical care.
The document discusses considerations for elderly surgical patients. Older patients represent a growing demographic undergoing more procedures. While age alone is a poor indicator of health, the aging process involves physiological changes that reduce cardiac, pulmonary, renal and other organ reserves. Careful preoperative evaluation of functional status is important to assess risks. Perioperative strategies aim to support compromised systems and avoid stressors that can precipitate complications in elderly patients.
1. www.acssurgery.com
WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor July 2008
THE BEST THIS MONTH’S UPDATES
SURGICAL 2 Head and Neck the earlobe), and finally turns
downward to descend along the
THINKING 6 Parotidectomy
LEONARD R. HENRY, MD, AND JOHN A.
sternocleidomastoid muscle. Skin
flaps are then created to expose the
parotid gland. The posterior-inferior
The Fundamentals of RIDGE, MD, PHD, FACS skin flap is then elevated in a similar
manner.
Laparoscopic Surgery (FLS) National Naval Medical Center, Once the skin flaps have been
Program: Its Time Has Come! Uniformed Services University of the developed and retracted, the next
Health Sciences; Fox Chase Cancer step is to identify the facial nerve.
NATHANIEL J. SOPER, MD
Center, Temple University School of Usually, the nerve may be identified
Department of Surgery, Medicine either at its main trunk (the ante-
Northwestern University Feinberg DOI 10.2310/7800.S02C06 grade approach) or at one of the
School of Medicine distal branches, with subsequent
Most parotid tumors are benign, dissection back toward the main
DOI 10.2310/7800.2008.NCjul necessitating only superficial trunk (the retrograde approach). For
he incorporation of laparoscopic parotidectomy.
T surgery into the armamentarium he parotid gland, the largest of
a lateral parotidectomy, our
preference is to identify the main
of general surgeons occurred rapidly
in the early 1990s. There was a
T the salivary glands, occupies the
space immediately anterior to the
trunk first (unless it is thoroughly
obscured by tumor or scar), keeping
distinct “learning curve” during the ear, overlying the angle of the in mind that the nerve typically lies
uptake of laparoscopic cholecystec- mandible. The portion of the deeper than one might expect.
tomy, with an increase in bile duct parotid gland lateral to the facial Once identified, the plane of the
injuries.1 Much of the education nerve (about 80% of the gland) is facial nerve remains uniform
offered on laparoscopic techniques designated as the superficial lobe; throughout the gland (unless the
for established surgeons was the portion medial to the facial nerve is displaced by a tumor) and
provided by industry, and many nerve (the remaining 20%) is serves to guide the parenchymal
surgeons learned “one-handed” designated as the deep lobe. dissection, which proceeds directly
operating techniques, whereas the Deep lobe tumors often present over the facial nerve. We do not
underpinning cognitive aspects clinically as retromandibular or
continued on page 3
unique to laparoscopy were given parapharyngeal masses, with
short shrift. In the late 1990s, the displacement of the tonsil or the soft
Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES)
palate appreciated in the throat. The
overwhelming majority of parotid In This Issue
began developing the Fundamentals tumors, however, are benign and
The Best Surgical Thinking
of Laparoscopic Surgery (FLS), a lateral to the facial nerve. This The Fundamentals of Laparoscopic
program designed to cover the chapter focuses primarily on Surgery (FLS) Program: Its Time Has
cognitive and psychomotor aspects superficial parotidectomy. Come! 1
unique to laparoscopic surgery, 2 Head and Neck
associated with a mechanism for Operative Technique for 6 Parotidectomy 1
assessment. It was not SAGES’ Parotidectomy 2 Head and Neck
he incision begins immediately 9 Thyroid and Parathyroid Operations 4
intent to develop a certifying
examination but rather to provide T anterior to the ear, continues
downward past the tragus, curves
4 Thorax
8 Minimally Invasive Esophageal
continued on page 2 back under the ear (staying close to Procedures 4
3. www.acssurgery.com What’s New in ACS Surgery 3
This Month’s CME
THIS MONTH’S UPDATES
continued from page 1 Chapters
regularly resect the entire lateral mandible and may reach a signifi- ACS Surgery offers CME in
lobe of the parotid gland unless the cant size in patients with large or convenient online format. As
tumor is large and such resection is recurrent tumors. Strictly speaking, many as 60 AMA PRA Category
required on oncologic grounds. this cosmetic change is a necessary 1 credits can be earned at
Complete superficial parotidec- feature of the procedure, not a any time during the year. The
tomy with full dissection of all facial complication. following chapters are available
nerve branches is seldom necessary, for CME credit this month:
although, in some cases, it is
mandated by tumor size or histo-
Outcome Evaluation of 2 Head and Neck
6 Parotidectomy
logic findings. The question of Parotidectomy
2 Head and Neck
whether to sacrifice the facial nerve ith proper surgical technique,
almost invariably arises in the
setting of malignancy. In our view,
W superficial or partial superficial
parotidectomy can be performed
9 Thyroid and Parathyroid Operations
4 Thorax
8 Minimally Invasive Esophageal
this measure is seldom necessary. safely and within a reasonable Procedures
Benign tumors tend to displace the operating time.
nerve, not invade it. Sacrifice of the
nerve probably does not enhance
survival.
Before closure, absolute hemosta-
sis is confirmed. Facial nerve
function is evaluated in the recovery
room, with particular attention paid
THE BEST SURGICAL THINKING
continued from page 2
to whether the patient is able to
close the eyelid. general surgery resident training surgery trainees, the FLS program
program in the United States and should achieve wide dissemination
Canada to obtain one of the FLS and improve the safety of patients
Complications of video training boxes as part of their undergoing laparoscopic surgery.
Parotidectomy Residency Review Committee-
mandated simulation effort. Fur-
tudies have found that transient References
S paralysis of all or part of the
facial nerve occurs in 17 to 100% of
thermore, vouchers for completing
the testing component of FLS will be 1. Strasberg SM, Hertl M, Soper
supplied for each graduating chief NJ. An analysis of the problem
patients undergoing parotidectomy, resident in general surgery and to of biliary injury during laparo-
depending on the extent of the fellows in gastrointestinal surgery scopic cholecystectomy. J Am
resection and the location of the fellowships. Notices have gone out Coll Surg 1995;180:101–25.
tumor. Fortunately, permanent to all program directors informing 2. Peters JH, Fried GM, Swanstrom
paralysis is uncommon, occurring in them of the ability to obtain these LL, et al. Development and
fewer than 5% of cases. The resources. It thus seems likely that validation of a comprehensive
primary complications are gustatory FLS will be incorporated in virtually program of education and
sweating, sialocele, and cosmetic all North American training assessment of the basic funda-
changes. programs. mentals of laparoscopic surgery.
Gustatory sweating, or Frey In summary, the FLS program was Surgery 2004;135:21–7.
syndrome, occurs in most patients developed because of an identified 3. Swanstrom LL, Fried GM,
after parotidectomy; it has been seen need to educate surgeons in the Hoffman KI, Soper NJ. Beta test
after submandibular gland resection underlying principles and basic skills results of a new system assessing
of laparoscopic surgery and because competence in laparoscopic
as well. The symptom complex
of the growing demand to document surgery. J Am Coll Surg
includes sweating, skin warmth, and
competency in surgical practice. The 2006;202:62–9.
flushing after chewing food and is 4. Derossis AM, Fried GM, Abra-
program has been extensively vetted
caused by cross-innervation of the by experts and validated in beta hamowicz M, et al. Development
parasympathetic and sympathetic testing. The inclusion of a testing of a model for training and
fibers supplying the parotid gland component ensures that competency evaluation of laparoscopic skills.
and the overlying skin. Sialocele, or in laparoscopy is both taught and Am J Surg 1998;15:482–7.
salivary fistula, has been reported evaluated. Given the partnership 5. Fried GM, Feldman LS, Vassiliou
to occur after 1 to 15% of paroti- with the ACS, the growing recogni- MC, et al. Proving the value of
dectomies. Parotidectomy creates a tion of FLS internationally, and the simulation in laparoscopic
hollow anterior and inferior to the recent Covidien grant allowing surgery. Ann Surg
ear, which may extend behind the widespread adoption by general 2004;240:518–28.
4. 4 What’s New in ACS Surgery • July 2008 www.acssurgery.com
THIS MONTH’S UPDATES
continued from page 3
2 Head and Neck mobilization of the lower thyroid Complications of
pole. The carotid sheath is retracted
laterally, and the thyroid gland is Thyroidectomy
9 Thyroid and Parathyroid he most significant complications
Operations
retracted anteriorly and medially.
This retraction puts tension on the
inferior thyroid artery and conse-
T of thyroidectomy are injury to the
recurrent laryngeal nerve, hypopara-
WEN T. SHEN, MD, GREGG H. JOSSART, quently on the recurrent laryngeal thyroidism, bleeding, injury to the
MD, FACS, AND ORLO H. CLARK, MD, nerve, thereby facilitating identifica- external branch of the superior
FACS tion of the nerve. The right and left laryngeal nerve, infection, seroma,
University of California, San recurrent laryngeal nerves must be or keloid.
Francisco; California Pacific Medical preserved during every thyroid
Center, San Francisco; University of operation. In identifying the
recurrent laryngeal nerves, it is Parathyroidectomy
California, San Francisco
he preparation for
DOI 10.2310/7800.S02C09
helpful to remember that they are
supplied by a small vascular plexus
and that a tiny vasa nervorum runs
T parathyroidectomy is similar to
that for thyroidectomy. The gold
The operative techniques for
parallel to and directly on each standard operation for primary
thyroidectomy and parathyroidec-
nerve. hyperparathyroidism remains bilateral
tomy are similar, and avoiding The pyramidal lobe (found in about neck exploration; however, the
injury of the laryngeal nerves is 80% of patients) is mobilized by excellent results of preoperative
paramount. retracting it caudally and by dissect- imaging with sestamibi scanning and
ing immediately adjacent to it in a ultrasonography, coupled with the
Operative Technique for cephalad direction. Once the availability of rapid intraoperative
parathyroid glands have been
Thyroidectomy carefully swept or dissected from the
parathyroid hormone assays, have
efore thyroidectomy, laryngoscopy made unilateral focused exploration
B is essential to determine whether
the vocal cords are functioning
thyroid gland and the recurrent
nerve has been identified, the
thyroid lobe can be quickly resected.
feasible for well-localized parathyroid
adenomas. The complications of
normally. Thereafter, as a rule, parathyroidectomy are similar to
dissection should always begin on those of thyroidectomy but occur
Special Concerns of less often.
the side of the suspected tumor; if
there is a problem with the dissec- Thyroidectomy
tion on this side, a less than total n rare occasions, thyroid or
thyroidectomy can be performed on
the contralateral side to prevent
O parathyroid cancers may invade
the trachea or the esophagus. As
4 Thorax
complications. The thyroid gland is much as 5 cm of the trachea can be 8 Minimally Invasive
exposed via a midline incision resected safely without impairment Esophageal Procedures
through the superficial layer of deep of the patient’s voice. If the invasion
cervical fascia between the strap is not extensive and is confined to FRANCESCO PALAZZO, MD, PIERO M.
muscles. However, if they are the anterior portion of the trachea, a FISICHELLA, MD, AND MARCO G. PATTI,
adherent to the underlying thyroid small section of the trachea that MD, FACS
tumor, the portion of the muscle contains the tumor should be
adhering to the tumor should be excised, and a tracheostomy may be University of California, San
sacrificed and removed en bloc with placed at the site of resection. Francisco; Loyola University
the specimen. Lymph nodes in the central neck Medical Center, Chicago; University
When a thyroid lobectomy is (medial to the carotid sheath) are
performed, the isthmus of the frequently involved in patients with continued on page 5
thyroid gland is usually divided papillary, medullary, and Hürthle
lateral to the midline, taking care
not to cut across the tumor. Once
cell cancer. These nodes should be
removed without injury to the Coming in August
the isthmus has been divided, parathyroid glands or the recurrent Elements of Contemporary Practice
dissection is continued superiorly, laryngeal nerves. A median sternoto- 8 Health Care Economics:
laterally, and posteriorly. It is my is rarely necessary for removal of The Broader Context
essential to avoid injuring the the thyroid gland, but if one proves
1 Basic Surgical and Perioperative
external branch of the superior necessary, the sternum should be Considerations
laryngeal nerve (responsible for divided to the level of the third 9 Ambulatory and Fast-Track Surgery
tensing the vocal cords). intercostal space and then laterally
8 Critical Care
The lower parathyroid gland is on one side at the space between the 22 Nutritional Support
usually encountered during lateral third and fourth ribs.
5. www.acssurgery.com What’s New in ACS Surgery 5
of Chicago Pritzker School of fundoplication as for Nissen generally comparable to those
Medicine fundoplication, and many of the obtained with corresponding open
surgical steps are the same. Over the surgical procedures. Delayed
DOI 10.2310/7800.S04C08
years, however, it has become esophageal leakage is a common
Treating benign esophageal evident that a partial fundoplication postoperative complication.
disorders with minimally invasive is not as durable as a total fundopli-
laparoscopic procedures yields cation. As a result, total fundoplica-
results comparable to those of
Reoperation for GERD
tion is currently considered the urrently, an increasing number of
treatment with traditional
operations.
procedure of choice for patients
with GERD, regardless of the
C patients are being seen for
evaluation and treatment of foregut
he development of laparoscopic strength of their esophageal
T surgery over the past 20 years has
caused a significant shift in the
peristalsis.
symptoms after laparoscopic
antireflux surgery. If the symptoms
persist or heartburn and regurgita-
treatment of benign esophageal Laparoscopic Heller tion occur, a thorough evaluation
diseases. Consequently, minimally (with barium swallow, endoscopy,
invasive surgery is increasingly Myotomy with Partial esophageal manometry, and pH
considered first-line treatment for Fundoplication monitoring) is carried out.
achalasia, and laparoscopic fundopli- oday, laparoscopic Heller We do not routinely attempt a
cation is considered more readily and
at an earlier stage to manage gastro-
T myotomy with partial fundoplica-
tion has supplanted left thoraco-
second antireflux operation laparo-
scopically, and the optimal proce-
esophageal reflux disease (GERD). scopic myotomy as the procedure of dure depends on the original
Here we focus on the operative choice for esophageal achalasia. approach (open versus laparoscop-
procedures for the most common Candidates should undergo a ic), the severity of the adhesions,
minimally invasive approaches. and the specific technique used for
thorough and careful evaluation to
establish the diagnosis and charac- the first operation (total or partial
Laparoscopic Nissen terize the disease. Many of the steps fundoplication). Because the risk of
gastric or esophageal perforation or
Fundoplication in a laparoscopic Heller myotomy
damage to the vagus nerves is much
ll candidates for laparoscopic are the same as the corresponding
A fundoplication should undergo
(1) symptomatic evaluation, with
steps in a laparoscopic fundoplica-
tion; intraoperative endoscopy is
higher during a second antireflux
operation, the surgeon must proceed
with extreme care, making sure to
symptoms graded with respect to where the operative technique
identify structures completely before
their intensity both before and after differs, and great care must be taken
dividing them. The success rate falls
the operation; (2) an upper gastroin- not to perforate the esophagus. The
to 70 to 80% for a second such
testinal series, to diagnose an results obtained to date with operation.
existing hiatal hernia; (3) endos- laparoscopic Heller myotomy and
copy, to confirm a symptom-based partial fundoplication are excellent
diagnosis of GERD; (4) esophageal and are generally comparable Reoperation for Esophageal
manometry, which provides useful to those obtained with the Achalasia
information about the motor corresponding open surgical aparoscopic Heller myotomy
function of the esophagus; and (5)
ambulatory pH monitoring, the
procedure. L improves swallowing in more
than 90% of patients. What causes
most reliable test for the diagnosis Left Thoracoscopic the relatively few failures reported is
of GERD. Once the operation is still incompletely understood.
complete, the greatest complication
Myotomy Typically, a failed Heller myotomy
urrently, we consider a left
is esophageal or gastric perforation.
Optimal management consists of C thoracoscopic myotomy for
patients in whom multiple previous
is signaled either by persistent
dysphagia or by recurrent dysphagia
laparotomy and direct repair. that develops after a variable
abdominal procedures (done to treat symptom-free interval following the
other diseases) would preclude a original operation. There are two
Laparoscopic Partial laparoscopic approach. Preoperative treatment options for persistent or
(Guarner) Fundoplication evaluation is essentially the same recurrent dysphagia after Heller
reoperative evaluation and as that for laparoscopic Heller
P operative planning are essentially
the same for partial (Guarner)
myotomy. The results obtained
with thoracoscopic myotomy are
myotomy: pneumatic dilatation and
a second operation tailored to the
results of preoperative evaluation.