This document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It indicates that the pedicled TRAM flap has become a common autologous reconstructive procedure due to its ability to create a natural breast mound with limited morbidity. The document describes the indications, techniques, and risks of the pedicled TRAM flap procedure.
This document provides a historical overview of colorectal cancer surgery from ancient times to the modern Total Mesorectal Excision (TME) technique. It describes early attempts at rectal surgery dating back to the 18th century, the development of anesthesia in the 19th century enabling more extensive operations, and advances like the principles of the Miles surgery in the early 20th century based on the anatomy and behavior of rectal cancer. It then covers the classification of rectal cancer stages by Dukes in the 1930s and the introduction of techniques like the Hartmann procedure and availability of antibiotics and blood transfusions, leading up to the current TME approach.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Surgery of Rectal Cancer : Potentials and Limitations - Dimitris P. KorkolisDimitris P. Korkolis
EPIDEMOLOGY
2015 Estimates
New cases: 96,830 (colon); 40,000 (rectal)
Deaths: 50,310 (colon and rectal combined)
Death rate over last 20 years declining
Screening and improvements in treatment
This document discusses the anatomy and patterns of lymph node metastasis in head and neck cancers. It covers the history of neck dissection techniques, anatomy of cervical lymph nodes, levels of lymph node involvement, factors affecting prognosis, and terminology such as occult metastasis and skip metastasis. Select sections discuss findings from studies on patterns of nodal spread in oral cancers and the risk of occult metastases. The conclusion is that lymph node level IV must be included in neck dissections for tongue cancers due to the risk of skip metastases bypassing upper levels.
Cylindrical abdominoperineal resection (APR) provides improved oncologic outcomes for low rectal cancer compared to standard APR. It involves a more extensive dissection in the pelvis during the abdominal phase and an extended perineal resection. This removes more tissue outside the muscularis propria of the rectum, reducing circumferential resection margin involvement and local recurrence rates. However, it may increase risks of perineal wound complications. Tips for the procedure include amputating a fatty sigmoid colon, taking care when reflecting an anteriorly attached tumor, placing an omental pedicle in the pelvis, and remembering to place a drain.
The document discusses different techniques for performing an abdominoperineal resection (APR) for rectal cancer. It outlines problems with the conventional synchronous APR approach and proposes changing to standardized inter-sphincteric, extra-levator, or ischio-anal APR depending on tumor location. Each technique is defined by its relationship to anatomical structures. Indications, advantages, and positioning considerations are provided for each type of APR.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
This document provides a historical overview of colorectal cancer surgery from ancient times to the modern Total Mesorectal Excision (TME) technique. It describes early attempts at rectal surgery dating back to the 18th century, the development of anesthesia in the 19th century enabling more extensive operations, and advances like the principles of the Miles surgery in the early 20th century based on the anatomy and behavior of rectal cancer. It then covers the classification of rectal cancer stages by Dukes in the 1930s and the introduction of techniques like the Hartmann procedure and availability of antibiotics and blood transfusions, leading up to the current TME approach.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Surgery of Rectal Cancer : Potentials and Limitations - Dimitris P. KorkolisDimitris P. Korkolis
EPIDEMOLOGY
2015 Estimates
New cases: 96,830 (colon); 40,000 (rectal)
Deaths: 50,310 (colon and rectal combined)
Death rate over last 20 years declining
Screening and improvements in treatment
This document discusses the anatomy and patterns of lymph node metastasis in head and neck cancers. It covers the history of neck dissection techniques, anatomy of cervical lymph nodes, levels of lymph node involvement, factors affecting prognosis, and terminology such as occult metastasis and skip metastasis. Select sections discuss findings from studies on patterns of nodal spread in oral cancers and the risk of occult metastases. The conclusion is that lymph node level IV must be included in neck dissections for tongue cancers due to the risk of skip metastases bypassing upper levels.
Cylindrical abdominoperineal resection (APR) provides improved oncologic outcomes for low rectal cancer compared to standard APR. It involves a more extensive dissection in the pelvis during the abdominal phase and an extended perineal resection. This removes more tissue outside the muscularis propria of the rectum, reducing circumferential resection margin involvement and local recurrence rates. However, it may increase risks of perineal wound complications. Tips for the procedure include amputating a fatty sigmoid colon, taking care when reflecting an anteriorly attached tumor, placing an omental pedicle in the pelvis, and remembering to place a drain.
The document discusses different techniques for performing an abdominoperineal resection (APR) for rectal cancer. It outlines problems with the conventional synchronous APR approach and proposes changing to standardized inter-sphincteric, extra-levator, or ischio-anal APR depending on tumor location. Each technique is defined by its relationship to anatomical structures. Indications, advantages, and positioning considerations are provided for each type of APR.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document summarizes a study on radical trachelectomy, a surgical procedure used to treat early-stage cervical carcinoma while preserving fertility. The study evaluated 47 patients who underwent laparoscopic vaginal radical trachelectomy between 1987-1996. Key findings include:
- The average durations of the laparoscopic and vaginal portions of the procedure were 62 and 67 minutes respectively. Complications were minor.
- After pathology review, 18 cases were classified as FIGO Stage IA1-IA2. Extrauterine spread occurred in 5 cases.
- With an average follow up of 52 months, 2 recurrences (4%) were observed. 13 normal children were born after the procedure.
- The
Management of the axilla after neoadjuvant chemotherapyDr. Haytham Fayed
This document discusses surgical management of the axilla after neoadjuvant chemotherapy for breast cancer. It provides background on how axillary lymph node dissection was previously the standard approach but is now being reevaluated. Sentinel lymph node biopsy after neoadjuvant chemotherapy may accurately stage the axilla and spare some patients from axillary lymph node dissection if the sentinel nodes are negative, though identification rates are slightly lower than without chemotherapy. The document concludes that current evidence suggests an algorithm involving axillary ultrasound before and sentinel lymph node biopsy after neoadjuvant chemotherapy to guide need for further axillary lymph node dissection.
This document discusses contact radiotherapy (Papillon) as an alternative to surgery for early stage rectal cancer. It notes that surgery is overtreatment for some early cancers and presents morbidity risks, especially in elderly patients. Contact radiotherapy delivers a high dose of localized radiation directly to the tumor and has shown good response rates with few side effects. It may allow some patients to avoid surgery and its risks. The document advocates for considering contact radiotherapy as a non-surgical option for select early stage rectal cancers based on a patient's risk factors and preferences.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
The document discusses recent advances in the management of rectal cancer. It covers:
1. Molecular biology advances like DNA chip technology that help determine prognosis and need for prophylactic surgery based on genes like APC, mismatch repair genes, and markers like p21 and p53.
2. Improved staging using endorectal ultrasound, CT, MRI and PET scans to accurately determine tumor depth and node involvement to guide treatment decisions.
3. Advances in surgery including total mesorectal excision, laparoscopic and robotic techniques, and the use of neoadjuvant chemoradiation to improve outcomes.
This document defines the axilla and axillary dissection procedure. The axilla is bounded by the upper chest wall and arm. It contains lymph nodes, blood vessels, and nerves. Axillary dissection is performed during mastectomy or breast-conserving surgery when lymph node biopsy is not suitable. The surgeon makes an incision under the arm and removes at least 10 lymph nodes. Complications can include lymphedema, infection, and limited range of motion. Lymphedema is one of the most morbid complications and can be assessed by measuring both arms.
This document discusses several gray areas in the management of colorectal cancer. It covers topics such as imaging techniques, surgical approaches, use of pre-operative and post-operative radiation, factors determining need for adjuvant therapy, chemotherapy regimens, addition of biologics, and molecular testing. A panel of experts debated issues like circumferential resection margins, short vs long course pre-op radiation, omitting radiation or surgery in select cases, laparoscopy vs open surgery, number of lymph nodes to examine, and sequencing of FOLFOX and FOLFIRI chemotherapy. Neoadjuvant therapy was noted to potentially improve outcomes with similar post-op morbidities compared to upfront surgery.
This document summarizes the management of rectal cancer. It discusses various imaging modalities used for clinical staging such as transrectal ultrasound, CT scan, and MRI. It then covers staging, prognostic factors, principles of pathologic review, and various treatment options including surgery (local excision, transabdominal resection, low anterior resection), total mesorectal excision, laparoscopic resection, and the role of combined modality therapy with chemotherapy and radiotherapy.
The document reviews the anatomical basis for Wilms tumor surgery, focusing on the surgical anatomy of the retroperitoneal space, aorta, vena cava and their branches. It discusses the goals of Wilms tumor surgery as obtaining an exact staging and safe complete resection of the tumor without spillage. The review also covers the types of vascular injuries that can occur during Wilms tumor surgery and their management.
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
Robotic colorectal surgery technique, advantages, disadvantages and its impac...Apollo Hospitals
The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
A History of Natural Orifice Transvaginal Endoscopic Surgery. From Ventroscopy, Culdolaparoscopy, and MANOS to NOTES.
Эндоскопическая транслюминальная хирургия
Ventroscopia.
This document provides information on various types of polyps and benign and malignant tumors of the rectum. It discusses the clinical features, investigations, differential diagnosis, staging, and treatment options for rectal carcinoma. Key points include: colonic polyps are the most common site of polyps in the gastrointestinal tract; adenomas have the potential for malignancy and their removal can prevent cancer; rectal carcinoma spreads locally and can metastasize to distant sites; treatment involves surgery such as local excision, abdominal operations like anterior resection, or palliative procedures.
Rectal cancer By Dr Efrem Ayalew WossenEfremAyalew
Rectal cancer develops in the tissues of the rectum. It is usually diagnosed through symptoms like bleeding, changes in bowel habits, and abdominal pain. Investigation may involve biopsy, imaging, and blood tests. Cancer in the rectum is staged according to how far it has spread locally and whether it has reached lymph nodes or distant sites. Treatment is usually surgery but may also involve chemotherapy and radiation. The type of surgery depends on how far the cancer has spread and includes local excision or removal of part of the rectum. Outcomes are best when cancer is treated with a multidisciplinary approach.
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
This document discusses breast reconstruction using DIEP flaps, which involves using blood vessels and tissue from the lower abdomen. The goals of breast reconstruction are to provide a natural breast contour and shape, avoid the need for external prosthetics, and help patients regain confidence. The document discusses the history of breast reconstruction and why abdominal tissue became popular. It provides details on different types of flaps and considerations for medial versus lateral perforator flaps. Key points discussed are the importance of vessel diameter, central positioning of perforators, and vascular branching patterns. The document also addresses techniques like subfascial dissection and skin-sparing approaches to breast reconstruction.
ABDOMINAL INCISIONS AND LAPAROTOMY-1.pptxAbhijitAzeez
The theoretical advantage of a paramedian over a midline incision is
a diminished risk of wound dehiscence and incisional hernia
In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.
A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision.
In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.
Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia.
This document discusses ventral incisional hernia repair and compares the sublay retromuscular technique using lightweight Vypro mesh versus heavier Prolene mesh. It provides background on incisional hernias, risk factors, techniques for open repair including suture repair, inlay, onlay, and sublay/retromuscular approaches. The study aims to evaluate the challenge of the sublay technique with new technical points to reduce recurrence and compare results of Vypro versus Prolene mesh in postoperative complications, chronic pain, and recurrence rates.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document summarizes a study on radical trachelectomy, a surgical procedure used to treat early-stage cervical carcinoma while preserving fertility. The study evaluated 47 patients who underwent laparoscopic vaginal radical trachelectomy between 1987-1996. Key findings include:
- The average durations of the laparoscopic and vaginal portions of the procedure were 62 and 67 minutes respectively. Complications were minor.
- After pathology review, 18 cases were classified as FIGO Stage IA1-IA2. Extrauterine spread occurred in 5 cases.
- With an average follow up of 52 months, 2 recurrences (4%) were observed. 13 normal children were born after the procedure.
- The
Management of the axilla after neoadjuvant chemotherapyDr. Haytham Fayed
This document discusses surgical management of the axilla after neoadjuvant chemotherapy for breast cancer. It provides background on how axillary lymph node dissection was previously the standard approach but is now being reevaluated. Sentinel lymph node biopsy after neoadjuvant chemotherapy may accurately stage the axilla and spare some patients from axillary lymph node dissection if the sentinel nodes are negative, though identification rates are slightly lower than without chemotherapy. The document concludes that current evidence suggests an algorithm involving axillary ultrasound before and sentinel lymph node biopsy after neoadjuvant chemotherapy to guide need for further axillary lymph node dissection.
This document discusses contact radiotherapy (Papillon) as an alternative to surgery for early stage rectal cancer. It notes that surgery is overtreatment for some early cancers and presents morbidity risks, especially in elderly patients. Contact radiotherapy delivers a high dose of localized radiation directly to the tumor and has shown good response rates with few side effects. It may allow some patients to avoid surgery and its risks. The document advocates for considering contact radiotherapy as a non-surgical option for select early stage rectal cancers based on a patient's risk factors and preferences.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
The document discusses recent advances in the management of rectal cancer. It covers:
1. Molecular biology advances like DNA chip technology that help determine prognosis and need for prophylactic surgery based on genes like APC, mismatch repair genes, and markers like p21 and p53.
2. Improved staging using endorectal ultrasound, CT, MRI and PET scans to accurately determine tumor depth and node involvement to guide treatment decisions.
3. Advances in surgery including total mesorectal excision, laparoscopic and robotic techniques, and the use of neoadjuvant chemoradiation to improve outcomes.
This document defines the axilla and axillary dissection procedure. The axilla is bounded by the upper chest wall and arm. It contains lymph nodes, blood vessels, and nerves. Axillary dissection is performed during mastectomy or breast-conserving surgery when lymph node biopsy is not suitable. The surgeon makes an incision under the arm and removes at least 10 lymph nodes. Complications can include lymphedema, infection, and limited range of motion. Lymphedema is one of the most morbid complications and can be assessed by measuring both arms.
This document discusses several gray areas in the management of colorectal cancer. It covers topics such as imaging techniques, surgical approaches, use of pre-operative and post-operative radiation, factors determining need for adjuvant therapy, chemotherapy regimens, addition of biologics, and molecular testing. A panel of experts debated issues like circumferential resection margins, short vs long course pre-op radiation, omitting radiation or surgery in select cases, laparoscopy vs open surgery, number of lymph nodes to examine, and sequencing of FOLFOX and FOLFIRI chemotherapy. Neoadjuvant therapy was noted to potentially improve outcomes with similar post-op morbidities compared to upfront surgery.
This document summarizes the management of rectal cancer. It discusses various imaging modalities used for clinical staging such as transrectal ultrasound, CT scan, and MRI. It then covers staging, prognostic factors, principles of pathologic review, and various treatment options including surgery (local excision, transabdominal resection, low anterior resection), total mesorectal excision, laparoscopic resection, and the role of combined modality therapy with chemotherapy and radiotherapy.
The document reviews the anatomical basis for Wilms tumor surgery, focusing on the surgical anatomy of the retroperitoneal space, aorta, vena cava and their branches. It discusses the goals of Wilms tumor surgery as obtaining an exact staging and safe complete resection of the tumor without spillage. The review also covers the types of vascular injuries that can occur during Wilms tumor surgery and their management.
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
Robotic colorectal surgery technique, advantages, disadvantages and its impac...Apollo Hospitals
The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
A History of Natural Orifice Transvaginal Endoscopic Surgery. From Ventroscopy, Culdolaparoscopy, and MANOS to NOTES.
Эндоскопическая транслюминальная хирургия
Ventroscopia.
This document provides information on various types of polyps and benign and malignant tumors of the rectum. It discusses the clinical features, investigations, differential diagnosis, staging, and treatment options for rectal carcinoma. Key points include: colonic polyps are the most common site of polyps in the gastrointestinal tract; adenomas have the potential for malignancy and their removal can prevent cancer; rectal carcinoma spreads locally and can metastasize to distant sites; treatment involves surgery such as local excision, abdominal operations like anterior resection, or palliative procedures.
Rectal cancer By Dr Efrem Ayalew WossenEfremAyalew
Rectal cancer develops in the tissues of the rectum. It is usually diagnosed through symptoms like bleeding, changes in bowel habits, and abdominal pain. Investigation may involve biopsy, imaging, and blood tests. Cancer in the rectum is staged according to how far it has spread locally and whether it has reached lymph nodes or distant sites. Treatment is usually surgery but may also involve chemotherapy and radiation. The type of surgery depends on how far the cancer has spread and includes local excision or removal of part of the rectum. Outcomes are best when cancer is treated with a multidisciplinary approach.
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
This document discusses breast reconstruction using DIEP flaps, which involves using blood vessels and tissue from the lower abdomen. The goals of breast reconstruction are to provide a natural breast contour and shape, avoid the need for external prosthetics, and help patients regain confidence. The document discusses the history of breast reconstruction and why abdominal tissue became popular. It provides details on different types of flaps and considerations for medial versus lateral perforator flaps. Key points discussed are the importance of vessel diameter, central positioning of perforators, and vascular branching patterns. The document also addresses techniques like subfascial dissection and skin-sparing approaches to breast reconstruction.
ABDOMINAL INCISIONS AND LAPAROTOMY-1.pptxAbhijitAzeez
The theoretical advantage of a paramedian over a midline incision is
a diminished risk of wound dehiscence and incisional hernia
In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.
A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision.
In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.
Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia.
This document discusses ventral incisional hernia repair and compares the sublay retromuscular technique using lightweight Vypro mesh versus heavier Prolene mesh. It provides background on incisional hernias, risk factors, techniques for open repair including suture repair, inlay, onlay, and sublay/retromuscular approaches. The study aims to evaluate the challenge of the sublay technique with new technical points to reduce recurrence and compare results of Vypro versus Prolene mesh in postoperative complications, chronic pain, and recurrence rates.
This document discusses techniques for reconstructing chest wall defects following resection of damaged tissue. It presents the author's experience with 28 patients who underwent chest wall resection and reconstruction. Three main techniques are described: rigid reconstruction using polypropylene mesh and methylmethacrylate, non-rigid reconstruction with polypropylene mesh alone, and soft tissue reconstruction with myocutaneous flaps. Postoperative complications occurred in 17.9% of patients and were associated with older patient age, larger chest wall defects, and combined lung resection. The author concludes that chest wall resection and reconstruction can be performed safely and effectively in a single stage.
1) The document reviews various incision and closure techniques used in obstetrics and gynecology, including transverse (e.g. Pfannenstiel), vertical (e.g. midline), and laparoscopic incisions.
2) It discusses factors to consider when selecting an incision such as patient characteristics, pathology, and risk of adhesions or malignancy. It also reviews various suturing and closure methods like continuous versus interrupted sutures.
3) The ideal closure method provides good approximation with minimal risk of complications like infection, hemorrhage or wound dehiscence while allowing for the best cosmetic outcome. Layered versus mass closure techniques are evaluated.
This document discusses recent refinements in implant-based breast reconstruction. It notes that 80% of breast reconstructions are now immediate implant-based procedures. However, radiation therapy can increase complications, and autologous reconstruction may have better outcomes in terms of morbidity. The document also discusses the benefits of acellular dermal matrices like AlloDerm which can improve implant placement and symmetry outcomes compared to total muscle coverage techniques. Fat grafting is also discussed as a method to further improve reconstruction outcomes, even in patients who have received radiation therapy.
Breast reconstruction has become an important part of breast cancer treatment to help restore a woman's body image and self-esteem after mastectomy. There are several options for reconstruction, including implants, flaps of tissue from the abdomen, back, or buttocks, or a combination of procedures. Immediate reconstruction at the time of mastectomy has advantages over delayed reconstruction in terms of cosmetic results and psychological impact. Proper patient selection considering health factors and goals is important to achieve a successful surgical outcome and recovery.
This document describes a study evaluating the use of internal uterine balloon tamponade as a diagnostic test for postpartum hemorrhage. 13 patients experiencing critical postpartum hemorrhage were treated with intrauterine balloon tamponade. The tamponade was successful in immediately arresting hemorrhaging in 12 of the 13 cases. Only 1 case failed to respond to the tamponade. This suggests internal uterine balloon tamponade may be an effective first-line treatment for postpartum hemorrhage that can identify those needing surgery and avoid more invasive procedures for most patients.
The Obstetric Gynaecologis - 2013 - Stavroulis - Methods for specimen remov...Amer Raza
This document discusses different methods for removing specimens from the peritoneal cavity after laparoscopic excision. It describes using mini laparotomy, transumbilical or ancillary port-site incisions, or posterior colpotomy. Recently, using morcellators and endoscopic bags to remove specimens laparoscopically has grown in popularity. The size, whether cystic or solid, and risk of malignancy influence the retrieval method. There is a risk of spillage, especially with suspected early malignancy, so this must be considered during excision and retrieval. In the future, natural orifice transluminal endoscopy may be an operative and retrieval route.
This document summarizes a study of 100 consecutive lipoabdominoplasty procedures performed between 2007-2010. Key findings include:
- Lipoabdominoplasty combines aggressive liposuction, excision of redundant skin/tissue, and plication of the rectus muscles without extensive undermining of the abdominal flap.
- There were no cases of DVT or death. Minor complications included 1 small bowel injury during liposuction and 5 hematomas, 2 of which became infected.
- The incidence of seroma, wound dehiscence, hematoma, and DVT was found to be lower using this technique compared to traditional abdominoplasty.
- The authors conclude lipo
Surgical management of the failed airway a guide to percutaneous cricothyrotomyEmergency Live
Surgical Management Of the Failed Airway: A guide to precutaneous cricothyrotomy
Guidelines from Hoan E. Spiegel, MD
Assistant Professor
Beth Israel Ddeaconess Medical Center
Harvard medical School Boston, MS
Vipul Shah, MD
Western Washington Medical Group
Everett, Washington
The first-known mention of an attempted surgical airway, a tracheostomy, was depicted on Egyptian tablets as early as 3600 BCE. History has condemned the emergent surgical airway when it has failed, but when successful, the physicians who performed it have risen in esteem to become "on a footing with the gods".
Il 100 BCE, the Persian physician Asclepiades described in detail a tracheal incision for improving the airway. Yet most who advocated surgical approaches to the airway, including Asclepiades, were severely criticized. Vicq d'Azyr, a French surgeon and anatomist, first described cricothyrotomy in 1805. Emergent cricothyroidotomy /also known as cricothyrotomy, minitracheostomy, and high tracheostomy) became widely acknowledged and accepted in 1976 when Brantigan and Grow confirmed the relative safety of the procedure. A decade later, the Seldinger technique, a wire-over-needle procedure commonly used for intra-vascular cannulation, was adapted for use in obtaining both emergent and nonemergent surgical airways.
This document provides information on breast oncoplastic surgery techniques:
- Oncoplastic surgery (OPS) integrates plastic surgery with breast-conserving cancer surgery to allow for wider excisions without compromising breast shape. It ranges from simple reshaping to advanced mammoplasty techniques.
- Key factors in determining the appropriate OPS approach are excision volume, tumor location, breast density, and glandular composition. Excisions over 20% of breast volume or from certain locations risk deformity. OPS allows excision of up to 1000g compared to 80g for standard surgery.
- OPS techniques are classified into Level I involving reshaping and Level II involving skin excision and reshaping using
Chest wall defects and their reconstructionVivek Gs
This document discusses chest wall anatomy, functions, and various defects that can occur. It covers the history of chest wall reconstruction and describes defects that can result from trauma, tumors, infections, radiation, and congenital causes. For each type of defect, the document outlines treatment approaches such as debridement, skeletal reconstruction, flap coverage, and correction of congenital defects. Key reconstruction methods mentioned include muscle flaps, omentum, methylmethacrylate sandwiched between mesh, and transposition of regional flaps.
Free nipple grafting is proposed as an alternative for patients ineligible for nipple-sparing mastectomy due to anatomical limitations. A retrospective review was conducted of 36 breasts that underwent nipple-sparing mastectomy with immediate reconstruction using free nipple grafting. Average graft take was 93.6% with no complete graft losses. Four nipples lost all projection and 4 experienced hypopigmentation requiring tattooing. For patients ineligible for nipple-sparing mastectomy due to anatomical factors, free nipple grafting in a single stage is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties.
The document discusses high-vacuum wound drainage systems for post-operative drainage from pfm medical ag. It offers a variety of drainage systems for all clinical applications using high-vacuum drainage. The systems provide concise summaries in 3 sentences or less that provide the high level and essential information from the document. It discusses the goals and advantages of using high-vacuum wound drainage systems, including preventing fluid accumulation, relieving surrounding tissue, improving wound contact, faster patient mobilization, and removing abscesses. It also provides a general product description of high-vacuum drainage system components.
The document discusses guidelines for the prevention and treatment of parastomal hernias. It finds that the incidence of parastomal hernias is 30-50% depending on follow up time, with terminal colostomies having a higher risk than lateral colostomies or ileostomies. Risk factors include age, obesity, infection and surgical technique. Mesh repair during hernia surgery results in lower recurrence rates of 7-17% compared to 69.4% for primary suture repair. Laparoscopic and open intraperitoneal mesh techniques have recurrence rates of around 10%. Prophylactic mesh placement during stoma creation may decrease hernia rates.
Surgery plays an important role in the treatment of breast cancer. The main goals of surgical treatment are complete removal of the primary tumor and determination of lymph node involvement. Mastectomy is recommended for large or multicentric tumors while breast-conserving surgery such as lumpectomy is preferred when possible. Sentinel lymph node biopsy is the standard method for staging axillary lymph nodes in clinically node-negative patients. Reconstruction options after mastectomy include implants, TRAM flaps, and latissimus dorsi flaps. Overall, mastectomy and breast-conserving surgery have been shown to have equivalent survival outcomes when combined with radiation or chemotherapy.
The document provides information on surgical procedures for the oral cavity, including preoperative evaluation and planning, operative techniques, and postoperative care. Key points include:
- Wide surgical margins of 1-2 cm are needed to adequately treat oral cavity cancers. Reconstruction aims to close defects primarily when possible to maintain tongue mobility, sensation, and oral competence.
- For anterior glossectomy, either orotracheal or nasotracheal intubation may be used depending on the approach and resection extent. A tracheostomy is recommended for significant postoperative swelling risk.
- Anterior glossectomy exposure is achieved transorally or through a lip-splitting mandibulotomy incision. Re
Similar to Formacion De Especialistas Responsabilidad Compartida (20)
Este documento describe la hemicorporectomía, que implica la amputación de la mitad inferior del cuerpo por debajo de la columna lumbar. Las indicaciones incluyen cáncer confinado a la pelvis, traumatismos severos de la pelvis y extremidades inferiores, y osteomielitis pélvica terminal. La técnica quirúrgica ha evolucionado de un solo tiempo quirúrgico a un enfoque de múltiples etapas que incluye una colostomía terminal y el cierre de la herida con un colgajo mi
Este documento resume la anatomía del hígado y las vías biliares. Describe que el hígado pesa alrededor de 1.5 kg y se encuentra en el cuadrante superior derecho del abdomen. Explica sus ligamentos de soporte y relaciones con otros órganos. También describe la irrigación sanguínea del hígado, incluida la vena porta y las arterias hepáticas. Finalmente, resume brevemente la histología del hígado, incluida la organización de los hepatocitos en lobulillos hepátic
Este documento resume los conceptos básicos, técnicas quirúrgicas, niveles, complicaciones y resultados funcionales de las amputaciones de las extremidades inferiores. La amputación es un procedimiento común para eliminar tejidos no viables, principalmente debido a causas vasculares o traumáticas. Existen diferentes tipos de amputaciones según el nivel anatómico, desde dedos del pie hasta la rodilla o muslo. El éxito depende de una adecuada selección preoperatoria y rehabilitación posterior para lograr la
Hastened Attachment Of A Superficial Inf Epigastric Flapguest1c9ac82
This case report describes using the vacuum-assisted closure (VAC) device to hasten the attachment of a superficial inferior-epigastric artery flap used to reconstruct a third-degree burn injury on the hand of a 33-year-old patient. The VAC system was applied in a glove-like shape beneath the flap. After 4 days, hastened attachment of the flap to the exposed fingers was observed. The author reports that using the VAC system may decrease the typical 2-3 week attachment period for such flaps by promoting wound granulation and vascularization.
The document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It describes the indications, techniques, and outcomes of the procedure. The pedicled TRAM flap provides natural breast reconstruction with limited morbidity and good patient satisfaction. The document outlines the surgical steps including flap harvest, tunneling, and abdominal closure to properly perform the procedure and minimize complications.
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1) N-acetylcysteine (NAC) was used as a mucolytic agent to treat peripancreatic collections in a patient with severe acute pancreatitis after necrosectomy.
2) Administration of NAC into drainage tubes increased daily drain output from 50-120 mL to over 500 mL, indicating it helped break down the highly viscous fluid.
3) A follow up CT scan after treatment with NAC for 4.5 weeks showed reduction in size of the peripancreatic collection, and the patient made a full recovery with NAC treatment continued for 7 months.
Formacion De Especialistas Responsabilidad Compartidaguest1c9ac82
The document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It describes the indications, techniques, and outcomes of the procedure. The pedicled TRAM flap provides natural breast reconstruction with limited morbidity and good patient satisfaction. The document outlines the surgical steps including flap harvest, tunneling, and abdominal closure to properly perform the procedure and minimize complications.
Formacion De Especialistas Responsabilidad Compartidaguest1c9ac82
El documento discute la necesidad de mejorar la formación de médicos especialistas en México a través de un enfoque basado en competencias. Actualmente, los médicos reciben formación en instituciones diferentes con planes de estudio no unificados, lo que resulta en calidades y habilidades desiguales entre los egresados. Se propone la creación de un modelo educativo nacional estandarizado para garantizar una formación de alta calidad y uniforme. También es necesario mejorar la integración entre la educación teórica y la práctica clínica para
El documento discute la necesidad de mejorar la formación de médicos especialistas en México a través de un enfoque basado en competencias. Actualmente, los planes de estudio varían entre universidades y no garantizan la calidad uniforme de los egresados. Se propone integrar mejor la educación teórica con la práctica clínica y coordinar al sector salud y educación para establecer modelos educativos alineados a las necesidades de la población.
This study retrospectively reviewed 29 patients over 10 years with penetrating duodenal or pancreaticoduodenal injuries to compare outcomes of repairs with or without pyloric exclusion. It found that the two groups were similar in demographics and injury severity. There was a non-significant trend toward higher complication rates, pancreatic fistulas, and longer hospital stays with pyloric exclusion. Neither group experienced duodenal fistulas. The study concludes pyloric exclusion did not improve outcomes for these injuries and simple repair may be adequate and safer.
El documento describe los elementos clave de una investigación y la elaboración de un informe de investigación. Explica que un informe de investigación describe el estudio realizado, incluyendo el objetivo, la metodología, los resultados y las conclusiones. También destaca que el formato del informe depende del usuario final, ya sea en un contexto académico donde se enfatiza la metodología científica, o en un contexto no académico donde se enfatizan las conclusiones y su aplicabilidad. Además, enumera los elementos típicos de
Este documento trata sobre conceptos estadísticos fundamentales como distribuciones muestrales, estadística inferencial y nivel de significancia. Explica que una distribución muestral es un conjunto de valores sobre una estadística calculada de todas las muestras posibles de determinado tamaño, y que la estadística inferencial permite generalizar los resultados obtenidos en una muestra a la población completa. También presenta un esquema del procedimiento de la estadística inferencial que involucra la recolección de datos, cál
Este documento describe diferentes diseños de investigación, incluyendo diseños experimentales como preexperimentos, experimentos puros y cuasiexperimentales, y diseños no experimentales como transeccionales descriptivos y correlacionales/causales, y longitudinales de tendencia, evolución de grupo y panel. Explica que el diseño es el plan para encontrar respuestas a las preguntas de investigación y que la elección de diseño depende de los objetivos, preguntas y hipótesis del estudio.
Este documento resume los pasos para formular hipótesis en una investigación. Explica que las hipótesis son explicaciones tentativas del fenómeno investigado y que deben definir las variables conceptual y operacionalmente. También describe las características que deben tener las hipótesis, como referirse a situaciones reales y tener términos comprensibles, precisos y concretos con una relación clara entre las variables.
Este documento describe los cuatro tipos principales de estudios de investigación: estudios exploratorios, estudios descriptivos, estudios correlacionales y estudios explicativos. Explica la naturaleza y propósito de cada tipo de estudio, y proporciona ejemplos para ilustrar las diferencias entre ellos. También señala que un estudio puede incluir elementos de más de un tipo de estudio dependiendo del enfoque y los objetivos planteados.
Este documento describe el marco teórico como una etapa importante en el proceso de investigación. Explica que el marco teórico sustenta teóricamente el estudio mediante la revisión de literatura y la identificación de teorías y conceptos relevantes. También destaca seis funciones principales del marco teórico como prevenir errores, orientar el estudio, ampliar el horizonte del problema, establecer hipótesis, inspirar nuevas líneas de investigación e interpretar resultados. Además, ofrece detalles sobre cómo registrar referencias
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How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
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Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
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Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
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Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
2. Plastic and Reconstructive Surgery • October 2009
Despite an inherent increased risk, patients with recommendations regarding complication rates
the above risk factors may still choose to have a cannot be made at this time.18 –21
pedicled TRAM flap reconstruction. In this in-
stance, any effort to increase flap blood supply TECHNIQUES
should be considered to improve overall flap re- The pedicled TRAM flap procedure can be
liability. Commonly used techniques, which are initiated concurrently with the mastectomy pro-
discussed below, include flap “supercharging” and cedure to reduce overall operative time. The pa-
surgical delay. tient is generally marked, either preoperatively or
The increased risk associated with smoking intraoperatively, with a tapering transverse ellipse
and obesity can be greatly reduced by performing with superior extensions above the umbilicus.
a free TRAM flap rather than a pedicled flap.15–17 These extensions capture the superior perfora-
The choice between free and pedicled TRAM flaps tors, which emanate from the superior epigastric
is most commonly made by experience and com- vessels. The position of the ellipse is an important
fort with microsurgical techniques and the avail- aspect in overall flap design. If the superior skin
ability of instrumentation and postoperative mon- incision is placed at or below the umbilicus, there
itoring facilities. More specialized microsurgical is a risk of missing direct perforators from the
flaps, such as perforator flaps and superficial in- superior epigastric vessels. Using a higher supe-
ferior epigastric artery flaps require even greater rior incision results in a more reliable pedicled
familiarity with microsurgical technique and close flap. A woman with a high costal margin may be
postoperative observation, with the ability to offered a “midabdominal” TRAM flap, centering
quickly return to the operating room for correc- the ellipse about the umbilicus. The result is a
tion of acute microvascular complications. Using more robust vascularity but a higher midabdomi-
the pedicled flap will limit the vascularity as com- nal scar.
pared with a free TRAM flap but may have as much The operation begins by using the superior
vascularity as a perforator flap or an inferior epi- incision to elevate the upper abdominal wall off of
gastric artery flap if those vessels are not unusually the rectus fascia to the level of the xiphoid and
costal margins laterally. The patient is then flexed
large. Thus, the surgeon who chooses a pedicled
and the upper flap pulled taught over the pro-
TRAM flap is providing an autologous abdominal
posed TRAM flap to check the location of the
reconstruction with reduced technical and facility
inferior incision. This ensures that the abdominal
demands and a decreased risk of total flap loss as
closure will not be too tight. After verification of
compared with free flap techniques. Most would appropriate positioning, the inferior incision is
agree that in return there is an increased risk of fat then made and the subcutaneous fat is elevated,
necrosis and a longer or more difficult early (first from lateral to medial, until reaching the lateral
few months) convalescence for the patient; the rectus perforators. In a unilateral reconstruction,
long-term outcome is still being debated, with the perforators are then divided on the side that
many believing that there is no long-term (1 year will not be used, the umbilicus is cut free, and the
or more) difference in abdominal recovery. dissection proceeds to the medial row of rectus
Not all women are candidates for pedicled perforators. It is usually possible to perform either
TRAM flap reconstruction, and there are a few an ipsilateral or a contralateral flap. At our insti-
absolute contraindications for this procedure: the tution, an ipsilateral flap is usually preferred for
presence of an old upper abdominal incision with immediate reconstruction, whereas a contralat-
previous division of the rectus abdominis muscles eral flap may be best for a delayed reconstruction
precludes a flap based on the superior pedicle if a wide skin paddle is needed. This is an expe-
from that side. A history of prior abdominoplasty riential bias. Surgeons who become familiar and
likely indicates disruption of the perforating ves- adept at a contralateral flap most commonly will
sels to the abdominal skin and soft tissue, and a use that technique, whereas those who are more
pedicled TRAM flap should not be performed.18 familiar with an ipsilateral flap will use that tech-
In addition, there are few studies investigating the nique predominantly. Also, based on pedicle po-
effects of prior TRAM flap reconstruction on the sitioning, we often choose the contralateral muscle
expected abdominal changes related to preg- when greater than 50 percent of the abdominal
nancy. A few case reports and small case series skin paddle is to be used. Using the contralateral
suggest that a successful pregnancy can occur after muscle in this situation will result in less twisting
the TRAM flap procedure; however, because of of the pedicle during tunneling. If 50 percent or
the limited number of overall cases, meaningful less of the abdominal skin is needed, we prefer an
1048
3. Volume 124, Number 4 • Pedicled TRAM Flap
ipsilaterally based flap. The ipsilaterally based flap long-term effects.24 –26 With regard to surgical delay,
will also place the deep inferior epigastric vessels it is important to remember that ligation of the deep
in good position for supercharging to the thora- inferior epigastric perforators will preclude the po-
codorsal vessels, when necessary. tential for free-tissue transfer, supercharging,
At this point, various accepted techniques and/or microvascular salvage on that side in the
emerge, depending on the degree of rectus mus- event that the pedicled procedure is unsuccessful.
cle harvest and/or preservation. In our experi- This consideration should be contemplated in pa-
ence, we believe that there is no advantage to tients who have prior upper abdominal incisions, or
leaving a medial or lateral strip of muscle; thus, we if there is concern over the reliability of the super-
generally raise the entire muscle with both the ficial epigastric vasculature.25
medial and lateral row of perforators intact. After the TRAM flap is elevated completely, it
At the inferior, lateral edge of the rectus mus- may be deepithelialized partly to assess blood flow
cle, the deep inferior epigastric vessels are iden- and speed up the inset process. Next, it is passed
tified, dissected to their origin, ligated, and trans- through a subcutaneous tunnel and into the mas-
ferred with the flap. The deep inferior epigastric tectomy defect. It is important during the tunnel-
vessels provide a backup blood supply in the event ing process to pay particular attention to the ori-
that the superior pedicle is inadequate in perfus- entation of the pedicle, as excessive twisting,
ing the flap. This may only be evident after the flap kinking, and/or tension can result in flap isch-
is tunneled, folded, and inset within the mastec- emia. In its final resting state within the mastec-
tomy defect. If flap perfusion is in question, or the tomy defect, the abdominal skin island is typically
flap appears threatened, the harvested deep infe- rotated 180 degrees, such that the inferior abdom-
rior epigastric vessels can then be anastomosed to inal soft tissue provides the superior tissue within
the thoracodorsal system through the use of mi- the new breast mound and vice versa. The flap is
crosurgical techniques. This technique is referred trimmed and contoured to match the opposite
to as supercharging the flap.22 breast mound (Fig. 1). During the inset, it is im-
In addition to supercharging, a surgical delay
perative to find and divide the most superior in-
can also be used to increase flap reliability when
tercostal nerve supplying the rectus muscle. Fail-
perfusion is a concern. In the surgical delay tech-
ure to do so will result in an epigastric bulge
nique, the deep inferior epigastric artery and
because of persistent rectus muscle volume. Di-
veins, on the flap side, are exposed and ligated
before the final reconstruction. A small transverse viding the upper nerve causes muscle atrophy,
incision is typically made just superior and lateral thus avoiding the telltale epigastric bulge.
to the symphysis pubis. Dissection is carried Once the flap is inset, attention is turned to the
through the subcutaneous tissue and down to the abdominal wall. When closing the abdominal fas-
level of the rectus fascia. The vessels are typically cia, particular attention should be paid to incor-
encountered at the lateral margin of the rectus porating the internal and external oblique fascia
sheath, where they are cauterized using conven- within the anterior rectus closure (Fig. 1, above,
tional bipolar electrocautery. The major perium- right). Failure to visualize the internal oblique fas-
bilical perforators on the side for which the pedi- cia may mean missing it in the closure and result
cle is not planned should also be divided. These in lower abdominal bulge formation. In our in-
perforators are exposed by means of a small pe- stitution, we often reinforce the closure with fas-
riumbilical incision. The vessels are identified and cial staples (Autosuture DFS Fascial stapler; Covi-
cauterized using bipolar electrocautery. Surgical dien, Mansfield, Mass.). If a tension-free fascial
delay will allow the recruitment, or opening, of repair cannot be achieved or abdominal wall in-
choke vessels within the superior epigastric sys- tegrity is in question, inlay and/or onlay soft Pro-
tem, optimizing perfusion by means of the re- lene mesh (Ethicon, Inc., Somerville, N.J.) can be
maining superior pedicle.23 Traditionally, the li- used. At our institution, we prefer the inlay tech-
gation procedure occurs 1 to 2 weeks before the nique. The mesh is secured in the subfacial plane
planned TRAM flap procedure. The timing of the by means of interrupted 0 Prolene sutures. If there
delay is generally surgeon dependent, and no rec- is considerable laxity in the anterior rectus sheath,
ommendation for an “optimal time” has been re- it can be closed over the mesh to act as an addi-
ported. Regardless of whether the delay takes tional layer of closure. Successful abdominal clo-
place 1 or more weeks before the TRAM flap re- sure has also been achieved using acellular dermal
construction, animal studies have proven that this matrix; however, this technique is rarely used at
technique improves flap survival, with beneficial, our institution.
1049
4. Plastic and Reconstructive Surgery • October 2009
Fig. 1. (Above, left) Intraoperative image of the abdomen immediately after TRAM flap harvest and tunneling. (Below,
left ) TRAM flap within the mastectomy defect before contouring for symmetry. (Below, right) TRAM flap inset within
mastectomy defect after trimming and contouring for symmetry, before skin closure. (Above, right) Intraoperative
image of the fascial closure after TRAM flap harvest and tunneling. The running suture incorporates the oblique fascia
within the rectus fascial closure.
It is imperative to be meticulous with the ab- muscles are sacrificed during these procedures,
dominal wall closure, as technical errors can result trunk function during activities such as perform-
in contour abnormalities, such as bulging and/or ing sit-ups or rising from a low chair may be
hernia. The fascia should be palpated for “soft” impaired. Although this risk may be worrisome,
areas at the inferior aspect of the fascial closure. proponents of the bipedicled TRAM flap, or
This represents a fascial dog-ear which, if not ad- bilateral pedicled TRAM flaps, argue that the
dressed, will become a bulge when the patient majority of these patients will eventually regain
stands upright. sufficient trunk function, and those who do not
In patients requiring a large volume of ab- will adapt and are not affected in the majority of
dominal soft tissue for unilateral reconstruction daily activities.27,28 The bipedicled TRAM flap
or seeking bilateral reconstruction, bipedicled technique is similar to that of the unipedicled
or bilateral TRAM flaps can be used. The bi- procedure. This technique often requires more
pedicled TRAM flap uses both rectus muscles, complex inset techniques, such as a “stacked”
providing increased blood flow at the expense of inset. When performing bilateral pedicled
rectus muscle function. Because both rectus TRAM flaps or the bipedicled TRAM flap for
1050
5. Volume 124, Number 4 • Pedicled TRAM Flap
unilateral reconstruction, abdominal wall clo-
sure nearly always requires mesh.
OUTCOMES
As the standard for autologous breast recon-
struction, the pedicled TRAM flap has been
heavily scrutinized in the academic literature.
There are multiple large-volume series detailing
institutional outcomes, concerns, and technical
considerations.2– 4,13,27–29 In addition, the pedicled
TRAM flap has served as the standard method and
historical control against which other novel re-
constructive techniques are measured. This has
resulted in a plethora of comparative studies, fur-
ther documenting outcome measures.30 –33
Overall, autologous abdominal tissue flaps
are unrivaled in their ability to create a natural
appearing breast mound2 (Figs. 2 and 3). These
flaps age naturally with time, maintain a soft and
ptotic appearance, and rarely require surgical Fig. 3. Follow-up image of the same patient after pedicled TRAM
revision.2,3,34 Aside from surgeon-judged aes- flap reconstruction detailing excellent symmetry and the cre-
thetic and anatomical results, pedicled TRAM ation of a natural appearing breast mound.
flap reconstruction also leads to excellent over-
all long-term patient satisfaction, which one
could argue is a more important marker of a for developing fat necrosis. These factors include
successful reconstruction.5,35 active smoking, obesity, and a history of prior chest
Pedicled TRAM flap reconstruction is gen- wall irradiation.29 The most feared flap complica-
erally a well-tolerated procedure. Complications tion, total flap loss, is fortunately a rare occur-
are typically related to either donor-site or flap- rence, with a reported incidence of less than 1
related problems, with flap complications being percent.2,15 Likewise, partial flap loss occurs rarely
the most frequent.13 Nonspecific postsurgical and, when present, can generally be managed with
complications, such as hematoma and infection, conservative measures.2
occur rarely.2,13 The effect of postoperative radiation on au-
Fat necrosis is the most common flap-related tologous flaps is an additional concern. Currently,
complication, with a reported incidence of 10 to there is no definitive consensus on whether flaps
18 percent.13,19,28 –29,36 Several risk factors have should be delayed until after irradiation. Some
been identified that place patients at greater risk reports indicate that post–TRAM flap radiother-
apy is tolerated with few complications and ac-
ceptable cosmetic results.37 A recent study by
Spear and colleagues reported that neither pre-
operative nor postoperative radiotherapy in-
creased the risk of most serious flap or donor-site
complications but that there was an effect on over-
all aesthetic results. Given this concern, they rec-
ommend that pedicled TRAM flap procedures be
delayed until after radiotherapy when possible.12
Presently, the decision to delay autologous re-
construction until after adjuvant therapy is insti-
tution dependent. At our institution, we generally
elect to delay our TRAM flap procedure until after
the patient has completed her course of radiation
therapy. Immediately after mastectomy, tissue ex-
panders are placed as a first step, providing the
Fig. 2. Preoperative image of a patient before left mastectomy advantages of immediate reconstruction without
and pedicled TRAM flap reconstruction. subjecting autologous tissue to possible radiation
1051
6. Plastic and Reconstructive Surgery • October 2009
effects. Several studies have reported successful TRAM flap reconstruction results in an initial in-
staged breast reconstruction using tissue expand- sult to abdominal wall integrity and overall trunk
ers during adjuvant radiotherapy treatments. function, several reports suggest that the long-
These reports indicate that expanders can with- term clinical effect of rectus muscle harvest is min-
stand radiation therapy and provide an effective imal and well tolerated.43,44 Secondary surgical in-
bridge to definitive reconstruction using implants tervention for abdominal wall complications is
or autologous tissue.38 – 40 Although some centers warranted only when severe aesthetic concerns
may postpone expansion until after radiotherapy and/or pain are present.
is completed, at our institution, the expander is There have been numerous studies devoted to
generally left inflated during the course of radia- pedicled TRAM flap–related abdominal wall com-
tion treatment. Careful attention is paid to pre- plications, and multiple attempts to minimize this
vent overexpansion. In addition, we work closely morbidity have been described.22,30,43– 46 These
with our radiation oncologists and will decrease measures include fascial reinforcement using
expander volume as needed if it is believed to mesh, rectus muscle preservation, layered closure
interfere with treatment efficacy. After comple- of the rectus sheath and oblique fascia, and pli-
tion of irradiation, the expander is removed, the cation of the rectus fascia above and below the
pectoralis muscle is separated from the mastec- muscle harvest site.45 In their extensive analysis of
tomy skin flap, and the TRAM flap is placed into contour abnormalities after TRAM flap recon-
the original mastectomy defect. This staging tech- struction, Nahabedian and Manson established
nique gives the benefit of immediate reconstruc- several important principles related to the pres-
tion without risking radiation changes in the ervation of abdominal wall integrity: first, muscle-
TRAM flap. The possibility of expander discom- sparing techniques do not significantly reduce the
fort or complication is balanced against the ad- probability of contour abnormality. Second, mesh
vantages of immediate reconstruction; these issues reinforcement is not necessary unless tension-free
should be discussed fully, and women should be closure cannot be obtained. Third, the use of fas-
allowed to choose which they prefer. cial plication superior and inferior to the harvest
Donor-site morbidity following pedicled site, and incorporation of the oblique fascia within
TRAM flap reconstruction can be divided into the anterior rectus sheath closure, can reduce the
early and late complications. Early complications risk of contour abnormalities.45,47
can include delayed wound healing, hematoma, It is important to note that postoperative con-
and/or seroma formation. The incidence of se- tour abnormalities are not isolated to pedicled
roma formation is reportedly between 2 and 7 TRAM flap procedures. Within the general sur-
percent of cases.41,42 The risk of seroma formation gery literature, the incidence of incisional hernia
can be limited through the use of closed-suction after primary fascial closure is nearly 10 to 20
drains. The drain output should be monitored percent, regardless of technique.42 Popular autol-
closely, and removal of the drains should not oc- ogous alternatives to pedicled TRAM flaps, includ-
cur until the output is minimal (typically 30 ml ing the deep inferior epigastric perforator (DIEP)
per 24 hours). If a seroma develops, it can gen- flap and free TRAM flap, are also not immune to
erally be treated with serial aspiration.2 Delayed the development of abdominal bulging, hernias,
healing is often related to tension on the abdominal and flap-related complications.42– 45,48 In fact, ab-
closure and can usually be treated with local wound dominal contour abnormalities do not appear to
care. Large skin flap loss is exceedingly rare, al- correlate with degree of muscle preservation.47
though the risk is increased in active smokers. There are several reports in the literature suggest-
Late donor-site complications following pedi- ing that there is no significant difference between
cled TRAM flap reconstruction are related pri- pedicled TRAM, free TRAM, and/or DIEP flaps
marily to abdominal wall integrity. These compli- with regard to abdominal wall morbidity.44 – 46,49 In
cations can include contour abnormalities, such as 1997, Blondeel and colleagues published a case
abdominal bulging and hernia formation, and re- series comparison of donor-site morbidity be-
duced trunk function. Abdominal bulging is the tween DIEP flaps and free TRAM flaps. Although
most common late complication following pedi- their data suggested that DIEP flap patients suf-
cled TRAM flap reconstruction, with some series fered from less trunk dysfunction than their
reporting an incidence of nearly 44 percent.43 For- TRAM flap counterparts, it is unclear whether this
tunately, the incidence of true hernia is much difference persists long term.48
lower, approximately 1 to 3 percent of cases.13,43 It is also worth noting that almost all of the
Although rectus muscle harvest for pedicled reports detailing significant complications and/or
1052
7. Volume 124, Number 4 • Pedicled TRAM Flap
CONCLUSIONS
CODING PERSPECTIVE As the incidence of breast cancer continues to
This information prepared by Dr. Raymond rise, an increasing number of patients will be seek-
Janevicius is intended to provide coding guid- ing plastic surgery consultation for breast recon-
ance. struction. Given its long history of success and
reputation as the workhorse in autologous breast
19367 TRAM flap, single pedicle reconstruction, the pedicled TRAM flap will con-
19368 TRAM flap, with microvascular tinue to be a viable option in most patients. In a
“supercharging” nonobese, nonsmoking patient with sufficient ab-
19369 TRAM flap, double pedicle dominal tissue, the pedicled TRAM flap is a rea-
19367 and sonable and time-tested choice for the creation of
19367-50 TRAM flap, bilateral (two a natural and symmetric breast mound, with lim-
unipedicle TRAM flaps) ited morbidity and excellent patient satisfaction.
• Three separate Current Procedural Ter- Neil A. Fine, M.D.
minology codes are available to report Division of Plastic and Reconstructive Surgery
TRAM flaps: unipedicle, unipedicle with Northwestern University
“supercharging,” and bipedicle. Feinberg School of Medicine
675 North St. Clair Street
• A bilateral TRAM flap is reported as two Galter 19-250
unipedicle TRAM flaps: 19367 and Chicago, Ill. 60611
19367-50. nfine@nmh.org
• The three TRAM flap breast reconstruc-
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