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Journal of Minimally Invasive Gynecology Jun 2024Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to...
STUDY OBJECTIVE
Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed.
DESIGN
The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM).
SETTING
Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling.
INTERVENTIONS
The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up.
CONCLUSION
Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.
PubMed: 38866099
DOI: 10.1016/j.jmig.2024.06.003 -
The Journal of Trauma and Acute Care... Nov 2020Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories,...
INTRODUCTION
Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories, even for low-grade injuries.
METHODS
Data sets from two large multicenter prospective observational studies were used to analyze a cohort of children (age, <17 years) with grade I to III SOI following blunt abdominal trauma. Children with hollow viscus injuries were excluded. Patients were divided into (a) those with or without other major injuries (OMIs) (traumatic brain injury, hemothorax or pneumothorax, pelvic fracture, urgent orthopedic or neurosurgical operations) and (b) with grade I or II versus grade III injuries. Outcomes included AIs (transfusion, angiography, abdominal operation) and disposition (admission unit and length of stay).
RESULTS
There were 14,232 children enrolled in the two studies, and 791 patients had a SOI (5.6%). After excluding patients with hollow viscus injuries and higher-grade SOIs, 517 patients with a grade I to III SOI were included, and 262 of these had no OMI. Among patients with no OMI, none of 148 patients with grade I or II SOI underwent AI, while only 3 of 114 patients with grade III injuries underwent AI (3 transfusions/1 angioembolization). All three had hemoperitoneum; two of three had an additional organ with a grade II injury. Among grade I and II SOIs with no OMI, 28 (18.9%) of 148 were admitted to an intensive care unit, 110 (74.3%) of 148 to floor, and 7 (4.7%) of 148 discharged home from emergency department; median length of stay 2 days. Among grade III SOIs with no OMI, 38 (33.3%) of 114 were admitted to an intensive care unit and 61.4% to the floor; median length of stay was 4 days. Among 255 patients with a grade I to III SOI and other major organ system injuries, 31 (12.2%) underwent AI.
CONCLUSION
No patient with a grade I and II SOI and no OMI following blunt abdominal trauma received intervention, suggesting that patients with low-grade SOI without OMIs could be safely observed and discharged from the emergency department.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
Topics: Abdominal Injuries; Adolescent; Child; Child, Preschool; Emergency Service, Hospital; Emergency Treatment; Female; Humans; Injury Severity Score; Length of Stay; Male; Multicenter Studies as Topic; Observational Studies as Topic; Patient Discharge; Practice Guidelines as Topic; Prospective Studies; Risk Assessment; Wounds, Nonpenetrating
PubMed: 32769952
DOI: 10.1097/TA.0000000000002899 -
Clinical Anatomy (New York, N.Y.) May 2020For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial... (Comparative Study)
Comparative Study
For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial structures. It is usually performed vaginally, but it has recently been performed laparoscopically through either an anterior or a posterior approach, with the broad ligament as a landmark to differentiate the two. In the present study, these two laparoscopic approaches were assessed using Thiel-embalmed cadavers. The anterior and posterior approaches were compared in terms of the closest distance to anatomical structures at risk, including pelvic viscera, the obturator nerve, and vascular structures. The posterior approach was more often closer to the investigated vessels and the rectum. The obturator nerve and the ureter were close to both the anterior and posterior approaches. The urinary bladder was closer using the anterior approach. From an anatomical standpoint, therefore, the anterior laparoscopic approach for SSLF is more likely to cause injury to the urinary bladder, whereas the posterior approach is more prone to causing rectal and vessel injuries. This study illustrates, from a basic science perspective, the importance of combining fascia research, novel endoscopic or minimally invasive surgical exposures informed by anatomy, and contemporary trends in gynecology in order to improve patient outcomes. Clin. Anat. 33:522-529, 2020. © 2019 Wiley Periodicals, Inc.
Topics: Aged; Aged, 80 and over; Cadaver; Fascia; Female; Humans; Laparoscopy; Ligaments, Articular; Organs at Risk; Pelvic Organ Prolapse; Pelvis
PubMed: 31087424
DOI: 10.1002/ca.23404 -
Journal of Neurological Surgery Reports Oct 2023CIC-DUX4 sarcoma is a rare, aggressive tumor that is difficult to diagnose. Although it is closely related to Ewing's sarcoma, each is a distinct pathologic entity...
CIC-DUX4 sarcoma is a rare, aggressive tumor that is difficult to diagnose. Although it is closely related to Ewing's sarcoma, each is a distinct pathologic entity and both have been previously reported in the skin, lymph nodes, and viscera. We report the first description of CIC-DUX4 involving the posterior cranial fossa and review the distinctive symptomatology, morphology, immunoprofile, and genetic signature that differentiate this rare tumor. A 32-year-old man presented with an enlarging right lateral neck mass, progressive hoarseness, and orofacial pain. Biopsy revealed a high-grade undifferentiated malignant neoplasm. Imaging demonstrated an 8-cm mass in the right neck extending to the skull base and abutting the carotid sheath, in addition to pulmonary nodules and pelvic lymphadenopathy. Despite initial response to chemotherapy, he experienced disease progression and underwent surgical resection, radical neck dissection, and brachytherapy. Definitive pathologic diagnosis was achieved with next-generation sequencing. Within weeks of treatment, he developed symptoms reflecting progression of disease involving the neck, posterior cranial fossa, and lung. Adjuvant chemotherapy was planned, but the patient succumbed to his disease prior to initiation of further therapy. CIC-DUX4 sarcomas are uncommon and can progress rapidly. Diagnosis requires either fluorescence in situ hybridization or next-generation sequencing. Due to its rarity, there is no standard-of-care treatment for this tumor and further investigations are needed to understand disease behavior and develop targeted therapeutic modalities.
PubMed: 37842548
DOI: 10.1055/a-2166-5688 -
RoFo : Fortschritte Auf Dem Gebiete Der... Apr 2020Development of a fully evidence-based guideline including all aspects of child abuse.
AIM
Development of a fully evidence-based guideline including all aspects of child abuse.
METHODS
In a case-based procedure, 144 primary PICO questions were generated from 476 presented cases of child abuse. Literature research was performed in 5 databases (Pubmed, CINHAL, Embase, PsycInfo, Eric) and in the Cochrane Library. The literature was evaluated according to SIGN and AGREE II.
RESULTS
137 recommendations were developed. Those related to imaging procedures are presented and discussed in this article.
CONCLUSION
The first fully evidence-based German guideline concerning all aspects of child abuse has been established. For imaging, several relevant new approaches have been proposed.
KEY POINTS
· The average radiation exposure is significantly reduced for the whole group of examined children.. · The pelvic view and lateral spine are no longer basic views of the skeletal survey but are only performed additionally in the case of a positive survey.. · Oblique views and a follow-up survey are performed in the case of a negative skeletal survey and ongoing suspicion of child abuse..
CITATION FORMAT
· Born M, Schwier F, Stoever B et al. The German Evidence-Based Child Protection Guideline - Imaging in Suspected Child Abuse. Fortschr Röntgenstr 2020; 192: 343 - 348.
Topics: Algorithms; Child; Child Abuse; Child Protective Services; Child, Preschool; Evidence-Based Medicine; Fractures, Bone; Germany; Humans; Infant; Infant, Newborn; Magnetic Resonance Imaging; Radionuclide Imaging; Siblings; Skull Fractures; Viscera; Whole Body Imaging; Wounds and Injuries
PubMed: 31747703
DOI: 10.1055/a-1019-8018 -
The American Surgeon May 2023The most common cause of pneumoperitoneum in trauma patients is hollow viscus injury; however, in patients with pneumoperitoneum on imaging and normal hollow viscus...
The most common cause of pneumoperitoneum in trauma patients is hollow viscus injury; however, in patients with pneumoperitoneum on imaging and normal hollow viscus during the laparotomy, other rare causes of pneumoperitoneum like intraperitoneal urinary bladder rupture should be ruled out. Urinary bladder can rupture either extraperitoneally or intraperitoneally or both. Rupture of the urinary bladder is commonly seen in patients with abdominal trauma; however, pneumoperitoneum is usually not seen in patients with traumatic bladder rupture. Intraperitoneal bladder rupture is usually due to the sudden rise in intra-abdominal pressure following abdominal or pelvic trauma. However, it is a rare cause of pneumoperitoneum and is managed by surgical repair. We present a case of blunt trauma abdomen with pneumoperitoneum due to isolated intraperitoneal bladder rupture who was managed by exploratory laparotomy and primary repair of the urinary bladder.
Topics: Humans; Urinary Bladder; Pneumoperitoneum; Abdomen; Urinary Bladder Diseases; Abdominal Injuries; Rupture; Wounds, Nonpenetrating; Thoracic Injuries
PubMed: 34111962
DOI: 10.1177/00031348211025765 -
Forensic Science, Medicine, and... Dec 2021Vehicular runover of pedestrians is a commonly reported occurrence in literature. The usual presentations at autopsy are avulsion of the intra-abdominal viscera, solid...
Vehicular runover of pedestrians is a commonly reported occurrence in literature. The usual presentations at autopsy are avulsion of the intra-abdominal viscera, solid organ crushing, hemorrhage, fracture of pelvic bone and vertebra, and herniation of the abdominal contents. There are reports of many cases where the abdominal and thoracic viscera have herniated out of their respective compartment following rupture of the diaphragm. Herniation of the intestine through natural orifices or other anatomical openings of the body has also been reported. This herniation occurs following a reduction in the anteroposterior diameter and acute increase in intra-abdominal pressure, displacing the abdominal contents out of their normal position through some natural anatomical openings inside the body following the path of least resistance. We report an interesting case of vehicular runover where the intestinal coils have come out of the body at the ankle. The authors describe the plausible mechanism and the route through which the intestine could have traversed.
Topics: Abdominal Injuries; Accidents, Traffic; Ankle; Hernia; Humans; Intestines; Rupture
PubMed: 34241757
DOI: 10.1007/s12024-021-00399-5 -
Urology Mar 2021To understand the structures around the vesicourethral junction and to improve functional outcomes after nerve-sparing radical cystectomy with orthotopic urinary...
OBJECTIVE
To understand the structures around the vesicourethral junction and to improve functional outcomes after nerve-sparing radical cystectomy with orthotopic urinary diversion for female patients, we histologically elucidated the fibromuscular construction and nerve distribution around the vesicourethral junction.
METHODS
Pelvic specimens containing all the pelvic viscera were obtained from 33 donated female cadavers. Macroslices that included the urethra, the anterior wall of the vagina, and the inferomedial edge of the levator ani muscle were made and performed elastica Masson and immunohistochemical staining. The intraoperative findings were collected in 3 female patients undergoing nerve-sparing radical cystectomy.
RESULTS
In 18 out of the 33 cadavers, smooth muscle mass occupied a space between the urethra and the inferomedial edge of the levator ani muscle and covered the inferior margin of the bladder detrusor. We termed this mass the hiatal smooth muscle. The detrusor nerves entered the bladder, and the cavernous and sphincter nerves ran between the hiatal smooth muscle and vesicourethral junction. The boundary between hiatal smooth muscle and urethral smooth muscle was easily distinguished intraoperatively during dissection of the vesicourethral junction.
CONCLUSION
We found that more than half of elderly women have hiatal smooth muscle between the urethra and inferior edge of the levator ani. Autonomic nerve fibers innervating the urethral sphincter, run between the hiatal smooth muscle and vesicourethral junction in female cadavers with hiatal smooth muscle. When performing female radical cystectomy before neobladder reconstruction, nerve sparing can be reliably performed using the hiatal smooth muscle as a landmark.
Topics: Aged; Aged, 80 and over; Autonomic Pathways; Cadaver; Cystectomy; Female; Humans; Muscle, Smooth; Urethra; Urinary Bladder; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 33309709
DOI: 10.1016/j.urology.2020.12.001 -
Animals : An Open Access Journal From... Jul 2020The present study was designed to evaluate the relationship between the body measurements (BMs) and carcass characteristics of hair sheep lambs. Twenty hours before...
The present study was designed to evaluate the relationship between the body measurements (BMs) and carcass characteristics of hair sheep lambs. Twenty hours before slaughter, the shrunk body weight (SBW) and BMs were recorded. The BMs involved were height at withers (HW), rib depth (RD), body diagonal length (BDL), body length (BL), pelvic girdle length (PGL), rump depth (RuD), rump height (RH), pin-bone width (PBW), hook-bone width (HBW), abdomen width (AW), girth (GC), and abdomen circumference (AC). After slaughter, the carcasses were weighed and chilled for 24 h at 1 °C, and then were split by the dorsal midline. The left-half was dissected into total soft tissues (muscle + fat; TST) and bone (BON), which were weighed separately. The weights of viscera and organs (VIS), internal fat (IF), and offals (OFF-skin, head, feet, tail, and blood) were also recorded. The equations obtained for predicting SBW, HCW, and CCW had an ranging from 0.89 to 0.99, and those for predicting the TST and BON had an ranging from 0.74 to 0.91, demonstrating satisfactory accuracy. Our results indicated that use of BMs could accurately and precisely be used as a useful tool for predicting carcass characteristics of hair sheep lambs.
PubMed: 32727056
DOI: 10.3390/ani10081276 -
Annals of Vascular Surgery Nov 2020"Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may... (Review)
Review
BACKGROUND
"Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries.
METHODS
-approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded.
RESULTS
We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation.
CONCLUSIONS
Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.
Topics: Abdominal Injuries; Accidents, Traffic; Adolescent; Age Factors; Aorta, Abdominal; Bioprosthesis; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Child; Child, Preschool; Humans; Myocardial Contusions; Retrospective Studies; Seat Belts; Treatment Outcome; Vascular System Injuries
PubMed: 32768538
DOI: 10.1016/j.avsg.2020.07.024