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Challenging Procedure (challenging + procedure)
Selected AbstractsReconstruction of the columella using the prefabricated reverse flow submental flap: A case reportHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 7 2006Onder Tan MD Abstract Background. The reconstruction of columellar defects is still a challenging procedure because of limited local and regional flap options and the characteristics of the anatomy of this site. Although a number of methods are available to repair nasal columella defects, no treatment of choice ensuring an excellent texture- and color-matched tissue in one stage has been determined to date. Method. In this case, we used a reverse-flow submental island flap prefabricated with the costal cartilage for the reconstruction of a complex columellar defect. Result. The flap survived completely with reversible venous congestion. The cosmetic result and nasal respiratory function were acceptable during the follow-up time of 6 months. Conclusion. We propose that the prefabricated reverse submental flap may be an alternative among the surgical options for columellar defects. This flap may also be considered in the reconstructive repertoire of other composite defects of the head and neck region. © 2006 Wiley Periodicals, Inc. Head Neck, 2006 [source] Atrial Anatomy and Imaging in Atrial Fibrillation AblationJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 2006ANDREW D. McGAVIGAN M.B.Ch.B., M.D. Catheter ablation of atrial fibrillation (AF) can be a technically challenging procedure, requiring detailed knowledge of the anatomy of the atria and thoracic veins to achieve successful cure of AF with a low complication rate. In this article, we review the anatomy relevant to AF ablation: the intraatrial septum, the pulmonary veins and left atrial antral region, the left atrial vestibule, the right atrium and related veins, and the esophagus. We focus on normal variations of anatomy and the role of the available imaging modalities in facilitating safe and effective ablation of this common and complex arrhythmia. [source] Penile resurfacing with vascularized fascia lataMICROSURGERY, Issue 6 2005Andreas I. Gravvanis M.D., Ph.D. Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10,13 cm in width and 15,30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing. © 2005 Wiley-Liss, Inc. Microsurgery 25:462,468, 2005 [source] Ultrasound-guided central venous cannulation in infants and childrenACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2002P. Åsheim Background: Percutaneous central venous cannulation in infants and children is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. An ultrasound-guided technique is now available and we wanted to evaluate this method in children and infants, looking specifically at the ease of use, success rate and complications. Methods: Forty-two consecutive infants and children (median 16.5 [0,177] months and 10 [3,45] kg) scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding puncture of vessels was used. After locating the puncture site, a sterile procedure was performed using an accompanying kit to aid puncture of the vessel. Results: Cannulation was successful in all patients and we had no complications during insertion of the catheters. The right internal jugular vein was preferred in most patients, and in 95% of the patients the vein was punctured at the first attempt. The median time from start of puncture to aspiration of blood was 12 (3,180) seconds. Conclusion: The ultrasound-guided technique for placement of central venous catheters was easy to apply in infants and children. It is our impression that it increased the precision and safety of the procedure in this group of patients. [source] Ultrasound-guided central venous cannulation in a very small preterm neonatePEDIATRIC ANESTHESIA, Issue 4 2005ANDREAS MACHOTTA MD Summary Percutaneous central venous cannulation of small infants is a challenging procedure. The use of ultrasound guidance has been shown to increase the success rate generally in children and to decrease the incidence of associated complications. To demonstrate that this technique is also suitable in very small infants we describe the case of a preterm neonate of 850 g body weight (BW), in which percutaneous central venous cannulation was performed successfully using ultrasound imaging for guidance. [source] Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: A multi-institutional studyCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 2 2007Thomas J. Forbes MD Abstract Background: We report a multi-institutional experience with intravascular stenting (IS) for treatment of coarctation of the aorta. Methods and Results: Data was collected retrospectively by review of medical records from 17 institutions. The data was broken down to prior to 2002 and after 2002 for further analysis. A total of 565 procedures were performed with a median age of 15 years (mean = 18.1 years). Successful reduction in the post stent gradient (<20 mm Hg) or increase in post stent coarctation to descending aorta (DAo) ratio of >0.8 was achieved in 97.9% of procedures. There was significant improvement (P < 0.01) in pre versus post stent coarctation dimensions (7.4 mm ± 3.0 mm vs. 14.3 ± 3.2mm), systolic gradient (31.6 mm Hg ± 16.0 mm Hg vs. 2.7 mm Hg ± 4.2 mm Hg) and ratio of the coarctation segment to the DAo (0.43 ± 0.17 vs. 0.85 ± 0.15). Acute complications were encountered in 81/565 (14.3%) procedures. There were two procedure related deaths. Aortic wall complications included: aneurysm formation (n = 6), intimal tears (n = 8), and dissections (n = 9). The risk of aortic dissection increased significantly in patients over the age of 40 years. Technical complications included stent migration (n = 28), and balloon rupture (n = 13). Peripheral vascular complications included cerebral vascular accidents (CVA) (n = 4), peripheral emboli (n = 1), and significant access arterial injury (n = 13). Older age was significantly associated with occurrence of CVAs. A significant decrease in the technical complication rate from 16.3% to 6.1% (P < 0.001) was observed in procedures performed after January 2002. Conclusions: Stent placement for coarctation of aorta is an effective treatment option, though it remains a technically challenging procedure. Technical and aortic complications have decreased over the past 3 years due to, in part, improvement in balloon and stent design. Improvement in our ability to assess aortic wall compliance is essential prior to placement of ISs in older patients with coarctation of the aorta. © 2007 Wiley-Liss, Inc. [source] Identification of post-transplant lymphocele using lymphatic mapping with isosulphane blueCLINICAL TRANSPLANTATION, Issue 1 2009A. Cakmak Abstract:, Lymphocele development after renal transplantation is a well-recognized complication that occurs with the incidence of 0.6,18%. Although the majority of patients are asymptomatic, post-renal transplant lymphocele continues to be a major cause of morbidity if it is left untreated. The standard approach for the treatment of symptomatic lymphoceles is accepted to be laparoscopic or open marsupialization in many centers if simple drainage and conservative measures fail. However, marsupialization is almost impossible under certain circumstances, such as in the case of excessive abdominal adhesions. Hence, direct visualization of the lymphatic leak and suture ligation may become inevitable, which is usually a challenging procedure for the surgeon. Herein we report a case of post-renal transplant lymphocele treated by the direct identification and suture ligation of injured lymphatic vessel using a new method similar to sentinel lymph node detection using the dye isosulphane blue. [source] CLINICAL CONSIDERATIONS FOR RESTORING MANDIBULAR INCISORS WITH PORCELAIN LAMINATE VENEERSJOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY, Issue 4 2008Robert D. Walter DDS Authors Porcelain laminate veneers have been proven to be a successful treatment modality for maxillary incisors in clinical practice and in controlled clinical studies. However, the data in clinical studies on the success of veneers for restoring mandibular incisors are limited. Clinically, the successful restoration of mandibular incisors with porcelain laminate veneers is one of the more challenging procedures in all of esthetic restorative dentistry. Limited coronal dimensions, the small amount of enamel available for bonding (particularly in the cervical areas), materials and techniques for the bonding procedures, and the response of the tooth,veneer complex to forces generated during the incisal loading in both functional as well as parafunctional contacts must be considered as potential sources of success or failure. This Critical Appraisal reviews three recent scientific articles to shed some light on these issues and, as in all research endeavors, leads the reader to identify additional areas of concern that might stimulate further scientific inquiry. The first publication studied predictors for enamel thickness for mandibular incisors. The second examined bonding protocols for exposed dentin and suggested immediate dentin sealing. The third paper addressed fracture behavior of mandibular incisors restored with porcelain laminate veneers in vitro. [source] Reconstruction of the chestwall and thorax,JOURNAL OF SURGICAL ONCOLOGY, Issue 6 2006Roman J. Skoracki MD Abstract Chest wall reconstructions can be complex and challenging procedures and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are the repair of defects due to tumor ablation, infection, radiation necrosis, congenital deformities, and trauma. Flap reconstruction by plastic surgery is often required when skin is removed as part of the chest wall resection or when radiation therapy is given pre- or post-operatively. Tissue flaps may be needed to provide vascularized tissue over alloplastic materials used to stabilize the chest wall, to cover vital structures of the chest cavity, to fill dead space, and to improve cosmesis. J. Surg. Oncol. 2006;94:455,465. © 2006 Wiley-Liss, Inc. [source] Training for laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgeryBJU INTERNATIONAL, Issue 6b 2010Sean P. Stroup A combination of refinements in laparoscopic instrumentation and increasing surgical experience has driven innovation in the area of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). By combining working ports and the extraction incision into one site, LESS allows access to the peritoneum with fewer incisions and less scarring than the traditional multiport laparoscopic technique. Reduced incisional morbidity and improved cosmesis have sparked a growing interest in the utilization of these techniques to perform urological surgery. Mastering of the technique requires training and repetition to develop the muscle memory required to perform these challenging procedures. Although there has been an explosion of literature published about initial experiences with LESS and NOTES, little has been written about training and implementation of this approach. Here, we describe our institutional experience and the essential elements of a LESS and NOTES training curriculum and offer some insight into establishing a successful programme. [source] | |||||||||||||||||||