Devirgilio Surgery Case Based Pd
DOWNLOAD ->>->>->> https://cinurl.com/2sZH8C
Abstract: Traditional removal of the submandibular gland is done through a transcervical approach; new proposals have come into the scientific limelight such as endoscopy-assisted transcervical sialadenectomy or (robot-assisted) submandibular sialadenectomy through a postauricular facelift transcervical approach. Transoral submandibular sialadenectomy has been described in the past, but with the advent of transoral robotic surgery, the proposal of removing the submandibular gland from the oral floor is gaining strength. A transoral robotic submandibular sialadenectomy by the Si Da Vinci Surgical Robot was performed in a 68-years-old female patient under general anaesthesia. The transoral robotic procedure was successful with no major postoperative complications. A mild tingling of the tip of the tongue was described by the patient 3 months after. The surgical time took 110 minutes. No residual gland was observed at ultrasonography. The transoral robotic submandibular sialadenectomy seems to be, with selective indication based on clinical and radiological assessment, a viable and safe alternative to traditional management in patients who refuse a cervical scar and the risk of paralysis of the facial nerve.
Traditional surgical management of the submandibular gland is based on the transcervical approach with known complications such as nerve injuries, unaesthetic scars, inflammatory residual glands, or duct stones with remnant inflammatory ducts (1-3). The development of conservative salivary techniques such as sialendoscopy (4-6) and sialendoscopy-assisted surgical transoral procedures (7-9) have provided a minimally invasive way of curing residual obstructing symptoms as a consequence of transcervical sialadenectomy (10). The risk of a residual unaesthetic scar has been partially solved by the so-called modified facelift or retroauricular approach; robotic surgery via modified facelift or the retroauricular route has been recently proposed for the transcervical removal of the submandibular gland (11-14). Following the transoral pathway, the risk of facial nerve injury is reduced. The transoral removal of the submandibular gland was proposed by Downtown and Quist in 1960 (15), but abandoned until the 2000s when it was newly proposed by means of traditional surgical approach (16-18), of an endoscopically-assisted surgical approach (19), and, more recently, by means of robot-assisted glandular surgery (20-22). Terris et al. (23) described the endo-robotic resection of the submandibular gland in a cadaveric model through a transcervical approach in 2005. Only two case reports dealing with transoral robotic submandibular sialadenectomy (TORSS) have been described (20,22). In 2003, we began our experience with sialendoscopy-assisted transoral surgery for the removal of hiloparenchymal stones that nowadays represents the preferred alternative to transcervical submandibular sialadenectomy (24); we showed that up to 90% of these stones could be effectively removed through a conservative transoral approach (8,9).
Another crucial anatomical point is the facial artery. Authors have simply described the coagulation of branches of the facial artery (36), others (22) have converted the robotic procedure to traditional transoral surgery to clamp and ligate the facial artery, and some have not found the facial artery during robotic surgery. Accordingly, we did not find the main trunk of the facial artery but simply coagulated small vessels in the posterior part of the gland. Our initial experience is concordant with that of other authors (20), who have assured of the minimal risks of the involvement of the facial vessel package during TORS. The robot-assisted excision of the submandibular gland through a postauricular facelift approach has become a viable option to cure benign salivary disorders (including benign neoplasms) with better cosmetic outcomes (11-14) as well as for the TORS for the removal of the submandibular gland (20,22). There is no mention in the literature about the postoperative occurrence of any case of facial nerve deficit, and in this regard, the facelift procedure can be considered safe with a very low risk of complications (facelift). Further experience with the transoral robotic approach is necessary to confirm the safety of this procedure as has been observed for the facelift approach. We observed that blunt dissection with the spatula supported by the delicate grip of the Maryland forceps guaranteed a clear and bloodless surgical field, thus achieving a better view of the deep surgical plane, also facilitated by an adequate docking of the robot (26,27). The robotic scopes and arms should be positioned behind the head of the patient and on the opposite side with respect to the involved gland at an angle of 30°; moreover, a better view of the posterior part of the oral floor can be realized with a 30° downward-facing endoscope. Unless used for the transoral robotic removal of parenchymal submandibular stones where the presence of the main surgeon and one assistant surgeon is sufficient (the assistant surgeon can simultaneously suction the oral field and push up the submandibular gland from the neck to better expose the parenchyma), the TORSS can be performed with the help of an assistant (useful for gland pushing up) as the second surgeon is involved in the suction and tracking of the parenchyma of the gland from the oral floor. Finally, the robotic surgical time was shorter than previously reported (22) (100 minutes for the robotic procedure including docking). In our opinion, by increasing the number of robotic procedures, the surgical time will be further reduced according to the robotic learning curves (37).
Patients are usually referred to our outpatient department by their general practitioner with symptomatic gallbladder stones and subsequently planned for an elective laparoscopic cholecystectomy. Other indications for surgery include referral from our gastroenterologists because of a biliary pancreatitis or bile duct stones. When patients present with an acute cholecystitis they are preferably operated on in an acute setting or sometimes electively planned for a laparoscopic cholecystectomy à froid based on patient characteristics, durations of symptoms in accordance with the current national guidelines . For the purpose of the current study, we defined out of hours as during weekends, national holidays, and daily between 5PM and 8AM.
145 patients (9.3%) underwent an out-of-hours procedure. Notably, all of these procedures were nonelective (n=145; 9.3%) and in most cases the indication for surgery was an acute cholecystitis (n=111; 7.1%). Table 2 further specifies the details of patients who underwent an out-of-hours procedure. Importantly, upon comparing the characteristics of these two groups, the included patients were very heterogeneous, as major base-line differences were observed.
To gain more insight into the possible differences between patients operated on during daytime and after-hours, we explored the subgroup of patients undergoing a laparoscopic cholecystectomy as an emergency case. These results are displayed in Table 3. Interestingly, upon comparing patients who underwent their emergency procedure during daytime to those whose procedure was performed at night, there were no differences regarding gender, age, previous abdominal surgery, or indication for surgery (all p>0.05). Furthermore, there were no differences regarding bile spill, operative time, nor estimated blood loss (all p>0.05). The only difference during the procedure was the seniority of the surgeon performing the operation, as emergency cases during business hours were more often performed by a surgical resident rather than by a surgical staff member compared with out-of-hours procedures (p
In the case of major pelvic injury, it is nevertheless agreed that damage-control interventional radiology and urgent resuscitative surgery should be initiated early and simultaneously . Adjunct techniques can be combined with a consecutive laparotomy if deemed necessary . This may decrease the high mortality rate observed in patients with major pelvic injuries who have undergone laparotomy as the primary intervention. However, non-therapeutic laparotomy should be avoided . Time to pelvic embolisation for haemodynamically unstable pelvic fractures may impact survival [439, 458].
Gelatine-based products can be used alone or in combination with a procoagulant substance . Swelling of the gelatine in contact with blood reduces the blood flow and, in combination with a thrombin-based component, enhances haemostasis [476, 477, 482]. These products have been successfully used for local bleeding control in brain or thyroid surgery when electrocautery may cause damage to nerves  or to control bleeding from irregular surfaces such as during post-sinus surgery .
Absorbable cellulose-based haemostatic agents have been widely used to treat bleeding for many years, and case reports as well as a prospective observational human study support their effectiveness . The oxidised cellulose-based product can be impregnated with polyethylene glycol and other salts and achieve comparable and more rapid haemostasis compared to the combined products described below .
Many previous reports have indicated that pulsatile tinnitus caused by an aberrant internal carotid artery (ICA) should not be treated surgically because of the risk of infection or aneurysm formation. We herein describe a case of aberrant ICA treated by middle ear surgery for which we introduced a novel approach. An 84-year-old man was presented with a one-year history of tinnitus in his right ear. Otoscopic examination demonstrated a whitish mass in the antero-inferior quadrant of the tympanic membrane associated with rhythmic pulsation. Images obtained by CT, MRI and MRA revealed protrusion of the ICA into the tympanic cavity, making contact with the tympanic membrane. Surgery to separate the tympanic membrane from the ICA was performed in order to relieve the pulsatile tinnitus. After the operation, the patient's aural activity was preserved and the tinnitus did not recur within a follow-up period of one year. In the present case, delicate middle ear surgery was effective for relief of the tinnitus. When treating patients with aberrant IAC showing features similar to the present case, the surgical approach we have described is worth attempting. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved. 2b1af7f3a8