Single incision laparoscopic surgery ovarian cystectomy in large benign ovarian cysts using conventional instruments

We describe a technique for the management of large benign ovarian cysts by single incision laparoscopic surgery (SILS) through the umbilicus. The paucity of intra-abdominal working space in large ovarian cysts poses a technical challenge. Moreover, difficult convergence of operating instruments and competition for operating space outside the abdomen during the SILS makes the procedure quite demanding, especially with the conventional instruments. The concept of providing traction by taking sutures from the abdominal wall, as done in SILS laparoscopic cholecystectomy, was applied for SILS cystectomy in large ovarian cysts. Two sutures taken through the abdominal wall and then through the cyst wall provide excellent traction and “hang” the cyst from the abdominal wall, making it convenient to dissect and operate. This technique demonstrates that SILS ovarian cystectomy is feasible, safe and technically unchallenging even in large benign ovarian cysts

Petrous Carotid Exposure with Eustachian Tube Preservation: A Morphometric Elucidation

Inadvertent injury to eustachian tube leading to cerebrospinal fluid rhinorrhea is a known complication associated with drilling of Glasscock's triangle to expose the horizontal petrous internal carotid artery (ICA) for management of difficult tumors (especially malignant) or aneurysms at the cranial base. Contrary to the usual approach, we hypothesize that a “medial-to-lateral” approach to Glasscock's triangle drilling will minimize eustachian tube injury. Four formalin-fixed human cadaveric heads were dissected, and underwent appropriate morphometric analysis; yielding a total of eight datasets. The diameter of the horizontal petrous ICA exposed was 4.7 ± 0.9 mm (range, 3.8 to 5.6 mm).The mean distance from the medial carotid wall midpoint to the medial-most point on the eustachian tube was 6.35 ± 0.58 mm (range, 5.4 to 7.1 mm), yielding a “safety zone” for eustachian tube, ranging 0.2 to 1.9 mm lateral to the lateral carotid wall. With the medial-to-lateral approach, the eustachian tube remained preserved in all the specimens. The results of our study provide a practical, consistent, and safe method of maximizing horizontal petrous carotid artery exposure while minimizing the eustachian tube injury

George Chance and Frank Holdsworth: Understanding Spinal Instability and the Evolution of Modern Spine Injury Classification Systems.

The concept of spinal cord injury has existed since the earliest human civilizations, with the earliest documented cases dating back to 3000 BC under the Egyptian Empire. Howevr, an understanding of this field developed slowly, with real advancements not emerging until the 20th century. Technological advancements including the dawn of modern warfare producing mass human casualties instigated revolutionary advancement in the field of spine injury and its management. Spine surgeons today encounter Chance and Holdsworth fractures commonly; however, neurosurgical literature has not explored the history of these physicians and their groundbreaking contributions to the modern understanding of spine injury. A literature search using a historical database, Cochrane, Google Scholar, and PubMed was performed. As needed, hospitals and native universities were contacted to add their original contributions to the literature. George Quentin Chance, a Manchester-based British physician, is well known to many as an eminent radiologist of his time who described the eponymous fracture in 1948. Sir Frank Wild Holdsworth (1904-1969), a renowned British orthopedic surgeon who laid a solid foundation for rehabilitation of spinal injuries under the aegis of the Miners\u27 Welfare Commission, described in detail the management of thoraco-lumbar junctional rotational fracture. The work of these 2 men laid the foundation for today\u27s understanding of spinal instability, which is central to modern spine injury classification and management algorithms. This historical vignette will explore the academic legacies of Sir Frank Wild Holdsworth and George Quentin Chance, and the evolution of spinal instability and spine injury classification systems that ensued from their work

Extra-Axial Hematoma and Trimethoprim-Sulfamethoxazole Induced Aplastic Anemia: The Role of Hematological Diseases in Subdural and Epidural Hemorrhage

Objective and Importance. To illustrate the development of spontaneous subdural hematoma secondary to aplastic anemia resulting from the administration of trimethoprim-sulfamethoxazole. This is the first report of trimethoprim-sulfamethoxazole potentiating coagulopathy leading to any form of intracranial hematoma. Clinical Presentation. A 62-year-old female developed a bone marrow biopsy confirmed diagnosis of aplastic anemia secondary to administration of trimethoprim-sulfamethoxazole following a canine bite. She then developed a course of waxing and waning mental status combined with headache and balance related falls. CT imaging of the head illustrated a 3.7 cm × 6.6 mm left frontal subdural hematoma combined with a 7.0 mm × 1.7 cm left temporal epidural hematoma. Conclusion. Aplastic anemia is a rare complication of the administration of trimethoprim-sulfamethoxazole. Thrombocytopenia, regardless of cause, is a risk factor for the development of spontaneous subdural hematoma. Given the lack of a significant traumatic mechanism, this subset of subdural hematoma is more suitable to conservative management

Tuberculum Sellae Meningiomas in Pregnancy: 3 Cases Treated in the Second Trimester and Literature Review.

BACKGROUND: Tuberculum sella meningiomas typically present with progressive visual loss. It is also known that meningiomas can become symptomatic during pregnancy. Herein we report on 3 patients who presented with progressive visual decline during pregnancy, prompting urgent surgical removal of their meningiomas. CASE DESCRIPTIONS: From our prospectively collected brain tumor database, all women surgically treated for tuberculum sella meningioma since 2006 were retrospectively reviewed. Clinical presentation, surgical approach, perioperative management, and pathology of pregnant patients were reviewed and compared with those of the nonpregnant cohort. Of 43 women with newly diagnosed tuberculum sella meningioma, 3 (7%) presented in pregnancy with progressive visual loss, 1 in the late first trimester and 2 in the early second trimester. One woman pregnant with twins had a broad-based meningioma and underwent a supraorbital craniotomy and gross total tumor removal in her second trimester. Two women with singleton pregnancies both underwent endoscopic endonasal gross total tumor removal during their second trimesters. All 3 patients had visual recovery, 2 of which were complete, and all went on to have successful uncomplicated deliveries of their children and maintain normal pituitary gland function. CONCLUSIONS: Presentation of tuberculum sella meningioma during pregnancy is uncommon but not rare, accounting for 7% of women in our series. Ideally, surgery is performed in the second trimester, ensuring fetal safety while restoring maternal vision and maintaining pituitary gland function are essential. Depending on tumor size and sellar anatomy, endoscopic endonasal or supraorbital keyhole craniotomy approaches are both viable options

Diagnostic pitfalls in Cushing\u27s disease impacting surgical remission rates; test thresholds and lessons learned in 105 patients.

CONTEXT: Confirming a diagnosis of Cushing\u27s disease (CD) remains challenging yet is critically important before recommending transsphenoidal surgery for adenoma resection. OBJECTIVE: To describe predictive performance of preoperative biochemical and imaging data relative to post-operative remission and clinical characteristics in patients with presumed CD. DESIGN, SETTING, PATIENTS, INTERVENTIONS: Patients (n=105; 86% female) who underwent surgery from 2007-2020 were classified into 3 groups: Group A (n=84) pathology-proven ACTH adenoma; Group B (n=6) pathology-unproven but with postoperative hypocortisolemia consistent with CD, and Group C (n=15) pathology-unproven, without postoperative hypocortisolemia. Group A+B were combined as Confirmed CD and Group C as Unconfirmed CD. MAIN OUTCOMES: Group A+B was compared to Group C regarding predictive performance of preoperative 24-hour urinary free cortisol (UFC), late night salivary cortisol (LNSC), 1mg dexamethasone suppression test (DST), plasma ACTH, and pituitary MRI. RESULTS: All groups had a similar clinical phenotype. Compared to Group C, Group A+B had higher mean UFC (p CONCLUSIONS: Use of strict biochemical thresholds may help avoid offering transsphenoidal surgery to presumed CD patients with equivocal data and improve surgical remission rates. Patients with Cushingoid phenotype but equivocal biochemical data warrant additional rigorous testing

Minimally invasive surgical treatment of intracranial meningiomas in elderly patients (≥ 65 years): outcomes, readmissions, and tumor control.

OBJECTIVE: Increased lifespan has led to more elderly patients being diagnosed with meningiomas. In this study, the authors sought to analyze and compare patients ≥ 65 years old with those \u3c 65 years old who underwent minimally invasive surgery for meningioma. To address surgical selection criteria, the authors also assessed a cohort of patients managed without surgery. METHODS: In a retrospective analysis, consecutive patients with meningiomas who underwent minimally invasive (endonasal, supraorbital, minipterional, transfalcine, or retromastoid) and conventional surgical treatment approaches during the period from 2008 to 2019 were dichotomized into those ≥ 65 and those \u3c 65 years old to compare resection rates, endoscopy use, complications, and length of hospital stay (LOS). A comparator meningioma cohort of patients ≥ 65 years old who were observed without surgery during the period from 2015 to 2019 was also analyzed. RESULTS: Of 291 patients (median age 60 years, 71.5% females, mean follow-up 36 months) undergoing meningioma resection, 118 (40.5%) were aged ≥ 65 years and underwent 126 surgeries, including 20% redo operations, as follows: age 65-69 years, 46 operations; 70-74 years, 40 operations; 75-79 years, 17 operations; and ≥ 80 years, 23 operations. During 2015-2019, of 98 patients referred for meningioma, 67 (68%) had surgery, 1 (1%) had radiosurgery, and 31 (32%) were observed. In the 11-year surgical cohort, comparing 173 patients \u3c 65 years versus 118 patients ≥ 65 years old, there were no significant differences in tumor location, size, or outcomes. Of 126 cases of surgery in 118 elderly patients, the approach was a minimally invasive approach to skull base meningioma (SBM) in 64 cases (51%) as follows: endonasal 18, supraorbital 28, minipterional 6, and retrosigmoid 12. Endoscope-assisted surgery was performed in 59.5% of patients. A conventional approach to SBM was performed in 15 cases (12%) (endoscope-assisted 13.3%), and convexity craniotomy for non-skull base meningioma (NSBM) in 47 cases (37%) (endoscope-assisted 17%). In these three cohorts (minimally invasive SBM, conventional SBM, and NSBM), the gross-total/near-total resection rates were 59.5%, 60%, and 91.5%, respectively, and an improved or stable Karnofsky Performance Status score occurred in 88.6%, 86.7%, and 87.2% of cases, respectively. For these 118 elderly patients, the median LOS was 3 days, and major complications occurred in 10 patients (8%) as follows: stroke 4%, vision decline 3%, systemic complications 0.7%, and wound infection or death 0. Eighty-three percent of patients were discharged home, and readmissions occurred in 5 patients (4%). Meningioma recurrence occurred in 4 patients (3%) and progression in 11 (9%). Multivariate regression analysis showed no significance of American Society of Anesthesiologists physical status score, comorbidities, or age subgroups on outcomes; patients aged ≥ 80 years showed a trend of longer hospitalization. CONCLUSIONS: This analysis suggests that elderly patients with meningiomas, when carefully selected, generally have excellent surgical outcomes and tumor control. When applied appropriately, use of minimally invasive approaches and endoscopy may be helpful in achieving maximal safe resection, reducing complications, and promoting short hospitalizations. Notably, one-third of our elderly meningioma patients referred for possible surgery from 2015 to 2019 were managed nonoperatively