<p>Expression levels for BAP1, NF2, TP53, MYH9, MYH6, MYH10, PIK3C2A, RHOA, and TNFRSF1A detected by Affymetrix® Human Gene 1.1 ST Array in 151 MPM</p>
The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.
<p>Schematic representation of the SNVs and/or chromosomal aberrations identified in BAP1, NF2, TP53, MYH9, RHOA, MYH6, MYH10, PIK3C2A, TNFRSF1A, and 22q and 9p in a panel of 147 MPM tumors.</p>
Central MessageRobotic transthoracic repair is a useful approach for diaphragmatic hernia repair in the presence of a hostile abdomen.See Commentaries on pages 581 and 582. Robotic transthoracic repair is a useful approach for diaphragmatic hernia repair in the presence of a hostile abdomen. See Commentaries on pages 581 and 582. Diaphragmatic hernias are rare entities that can be congenital, traumatic, or iatrogenic.1Kim J.K. Desai A. Kunac A. Merchant A.M. Lovoulos C. Robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture.Surg J (N Y). 2020; 6: e164-e166Crossref PubMed Google Scholar Transthoracic hernia repairs are most often performed via open thoracotomy, with few reports of robotic-assisted approaches.1Kim J.K. Desai A. Kunac A. Merchant A.M. Lovoulos C. Robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture.Surg J (N Y). 2020; 6: e164-e166Crossref PubMed Google Scholar, 2Counts S.J. Saffarzadeh A.G. Blasberg J.D. Kim A.W. Robotic transthoracic primary repair of a diaphragmatic hernia and reduction of an intrathoracic liver.Innovations (Phila). 2018; 13: 54-55Crossref PubMed Scopus (3) Google Scholar, 3Campbell S. Kipnis S. Robotic repair of an incarcerated right-sided diaphragmatic hernia after liver resection.https://www.ctsnet.org/article/robotic-repair-incarcerated-right-sided-diaphragmatic-hernia-after-liver-resectionDate accessed: June 9, 2021Google Scholar We report a case that illustrates our technique of transthoracic diaphragmatic hernia repair with mesh using the da Vinci Xi robotic platform in the presence of an extremely hostile abdomen. The Memorial Sloan Kettering Cancer Center institutional review board approved the submission, as this does not constitute human subjects research and the project does not involve identifiable patient information (#16-1631, October 27, 2020). The patient gave informed written consent for the publication of the study data. A 41-year-old woman with stage IV high-grade serous ovarian carcinoma was referred to our clinic. The disease involved bilateral diaphragms, the posterior aspect of the liver, the inferior vena cava, and Morison's pouch. Additional findings were diffuse peritoneal carcinomatosis and large bilateral ovarian masses, disease along the bladder and uterosacral ligaments, and cancerous nodules on the surface of a 4-cm segment of colon. She underwent radical total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, bilateral diaphragmatic stripping, appendectomy, and total peritoneal stripping. On 6-month computed tomography of the chest, abdomen, and pelvis, a new giant left diaphragmatic hernia was noted with distended stomach in the left chest, for which she was referred to thoracic surgery for repair (Figure 1). We used the da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, Calif) with a 0-degree camera to minimize pressure on the intercostal nerve. Before incision, an esophagogastroscopy was performed, and the stomach was decompressed. Placement of an orogastric tube ensured continued gastric decompression and facilitated visualization during the operation. Port placement is shown in Figure 2. The camera was introduced in the sixth intercostal space at the posterior axillary line. Targeting of the platform was performed to the hernia defect. The AirSeal system (CONMED, Utica, NY) was introduced at the eighth intercostal space as anterior as possible for smoke evacuation and insufflation. A monopolar spatula was inserted through an 8-mm port at the sixth interspace at the anterior axillary line, and fenestrated bipolar forceps with bipolar cautery were placed through an 8-mm port at the seventh intercostal space posterior to the tip of the scapula. We used 3 arms and an assistant port for our dissection; however, the addition of a fourth retracting arm posteriorly near the diaphragm can facilitate dissection and exposure. The patient was placed in reverse Trendelenburg position at 30 degrees to facilitate reduction of abdominal contents. The abdominal viscera were mobilized and reduced into the abdomen. Positioning and insufflation can facilitate reduction, which can be challenging if there is loss of domain from a long-standing hernia. A 7-cm × 5-cm central hemidiaphragm defect was noted. A composite bioabsorbable mesh (Phasix ST Mesh; BD, Franklin Lakes, NJ) was tailored, appropriately oriented, and introduced into the abdomen. The defect was closed primarily using interrupted, figure-of-eight 2-0 nonabsorbable suture (ETHIBOND; Ethicon, Sommerville, NJ) buttressing the intraabdominal mesh and reinforced with intrathoracic mesh placement in a "sandwich" fashion (Video 1). A soft chest tube was placed to water-seal drainage, and 0.25% bupivacaine intercostal blocks were performed. Estimated blood loss was 20 mL. Duration of surgery was 181 minutes. The patient reported minimal pain in the immediate postoperative period. The chest tube was removed the morning of postoperative day 1, and the patient was discharged the following morning. At 1 month and 6 months after surgery, no recurrence of hernia was observed (Figure 1). The basic tenet of diaphragmatic hernia repair mandates a tension-free repair with or without reinforcement with prosthetic materials.4Blitz M. Louie B.E. Chronic traumatic diaphragmatic hernia.Thorac Surg Clin. 2009; 19: 491-500Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Traditionally, central diaphragmatic hernias have been repaired transabdominally, owing to surgeon familiarity, quick recovery, and the ability to place mesh intraabdominally to buttress the repair to withstand sudden increases of intraabdominal pressure.4Blitz M. Louie B.E. Chronic traumatic diaphragmatic hernia.Thorac Surg Clin. 2009; 19: 491-500Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,5Liao C.H. Chu C.H. Wu Y.T. Fu C.Y. Hsieh F.J. Wang S.Y. et al.The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literature review.Hernia. 2016; 20: 303Crossref PubMed Scopus (11) Google Scholar However, an extremely hostile abdomen conveys substantial risk of inadvertent injuries to the abdominal viscera. Debulking gynecologic surgery obliterates the peritoneal cavity and adds to the risk of intraoperative injury. Giant hernia with near-complete filling of the pleural cavity with abdominal viscera has also been traditionally regarded as a relative contraindication to transabdominal repair. Transthoracic repairs have mostly been performed via open thoracotomy, with few reports of robotic-assisted repairs.1Kim J.K. Desai A. Kunac A. Merchant A.M. Lovoulos C. Robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture.Surg J (N Y). 2020; 6: e164-e166Crossref PubMed Google Scholar, 2Counts S.J. Saffarzadeh A.G. Blasberg J.D. Kim A.W. Robotic transthoracic primary repair of a diaphragmatic hernia and reduction of an intrathoracic liver.Innovations (Phila). 2018; 13: 54-55Crossref PubMed Scopus (3) Google Scholar, 3Campbell S. Kipnis S. Robotic repair of an incarcerated right-sided diaphragmatic hernia after liver resection.https://www.ctsnet.org/article/robotic-repair-incarcerated-right-sided-diaphragmatic-hernia-after-liver-resectionDate accessed: June 9, 2021Google Scholar No randomized controlled trials exist exploring the benefit of mesh reinforcement of diaphragmatic hernia repairs. Unlike hiatal hernias, where the use of mesh has been shown to reduce short-term recurrences,6Abdelmoaty W.F. Dunst C.M. Filicori F. Zihni A.M. Davila-Bradley D. Reavis K.M. et al.Combination of surgical technique and bioresorbable mesh reinforcement of the crural repair leads to low early hernia recurrence rates with laparoscopic paraesophageal hernia repair.J Gastrointest Surg. 2020; 24: 1477-1481Crossref PubMed Scopus (11) Google Scholar there are no definitive data suggesting improved short-term or long-term protection from recurrence with the addition of mesh. If there is enough muscle redundancy, it is our preference to primarily close the defect to restore the normal anatomy of the diaphragm and to preserve the domain of the peritoneal and thoracic cavities. It is our preference to reinforce the repair with composite mesh, as the muscle is often weakened after stripping of the peritoneum and multiple abdominal surgeries. We prefer a composite mesh with an antiadhesion film coating to minimize adhesions to nearby viscera,7Deeken C.R. Matthews B.D. Characterization of the mechanical strength, resorption properties, and histologic characteristics of a fully absorbable material (poly-4-hydroxybutyrate-PHASIX mesh) in a porcine model of hernia repair.ISRN Surg. 2013; 2013: 238067Crossref PubMed Google Scholar which may make future intraabdominal or intrathoracic operations challenging. Although this was a left diaphragmatic hernia, conceivably the technique is applicable for right-sided repairs. The presence of the liver on the right side makes herniation of abdominal contents less likely. In the presence of liver herniation, meticulous attention to avoid bleeding while staying in the correct plane of dissection is paramount. Proponents of robotic-assisted surgery cite superior visualization and improved ergonomics; drawbacks include perceived greater cost and longer duration of surgery.8Ricciardi S. Zirafa C.C. Davini F. Melfi F. How to get the best from robotic thoracic surgery.J Thorac Dis. 2018; 10: S947-S950Crossref PubMed Scopus (6) Google Scholar The case described here demonstrates that robotic-assisted repair is feasible and may be appropriate in select patients with diaphragmatic hernias, regardless of the size of the hernia. Furthermore, placement of intraabdominal mesh is feasible, and the repair can be reinforced with intrathoracic mesh. Robotic diaphragmatic hernia repair allows for minimal postoperative pain and hastened recovery. https://www.jtcvstechniques.org/cms/asset/42b90510-6a93-4554-98fb-6782ad3710f9/mmc1.mp4Loading ... Download .mp4 (108.41 MB) Help with .mp4 files Video 1Robotic transthoracic diaphragmatic hernia repair. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00585-X/fulltext. Commentary: Robotic repair of diaphragmatic herniaJTCVS TechniquesVol. 10PreviewRepair of traumatic diaphragmatic hernias can be complex.1 Traditionally, surgeons fixed these hernias either through an open thoracotomy or via the abdomen with laparoscopy. Often, intrathoracic adhesions make the repair from the abdomen difficult. Very large diaphragmatic hernias occupying most of the chest can also make a transabdominal repair difficult. Finally, reentering the abdominal cavity to repair the hernia in patients with a hostile abdomen may increase the risk of complication and is often avoided. Full-Text PDF Open AccessCommentary: Do. Share. Discuss. Improve. Repeat.JTCVS TechniquesVol. 10PreviewIn this issue of JTCVS Techniques, Sideris and Molena1 describe their robotic-assisted transthoracic repair of a giant left diaphragmatic hernia after the radical resection of metastatic ovarian cancer requiring bilateral diaphragm stripping. Their included video shows the important steps of the operation: port placement, reducing the contents of the hernia, lysis of adhesions from the diaphragm to abdominal viscera, partial primary closure of the defect, placement of intra-abdominal mesh and closure of the defect, and placement of intrathoracic mesh. Full-Text PDF Open Access
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