Surgery is the only curative treatment for primary hyperparathyroidism. Several intraoperative adjuncts have been developed to facilitate parathyroidectomy to achieve a successful outcome. These include sestamibi-SPECT scanning, cervical ultrasound, 4D-CT scans, and intraoperative parathyroid hormone monitoring. One technology often overlooked is radioguided parathyroidectomy. Radioguided parathyroidectomy is closely related to other radioguided techniques already in use for breast cancer, malignant melanoma, thyroid cancer, and colon cancer. A radiotracer is administered, which accumulates preferentially in the targeted tissue. Radioguided techniques localize specifc tissue through the use of radioactivity, theoretically minimizing dissection and decreasing overall operative time. The radiotracer utilized for radioguided parathyroidectomy is technetium 99mTc–sestamibi, which is the same compound used for preoperative parathyroid imaging. Its use is based upon the principle that enlarged, hypercellular parathyroid glands contain an increased number of mitochondria, and these mitochondria take up and retain 99mTc– sestamibi longer than surrounding tissues. Thus, the abnormal parathyroid becomes “hot” relative to surrounding structures. A hand-held gamma probe can then be utilized to detect the enlarged parathyroid gland. Once resected, the parathyroid gland can be assessed ex vivo for its radioguided counts. The counts are then used to determine if the gland is abnormal.
In 1946 hemorrhagic shock was induced in animal models and a stratification system emerged: simple hypotension, which was noted to always be reversible if identified and treated; impending shock, which was reversible if treated ggressively; and irreversible shock state, where hypotension, sustained by high-volume blood loss, correlated to notable metabolic derangement . The authors concluded that hemorrhagic shock did not occur at a specific volume loss or blood pressure, but was rather a fluid state that required early recognition by the treating physician and immediate intervention during the reversible period. Hemorrhagic shock is defined as a mismatch between cellular perfusion and metabolism. Strict adherence to the definition results in difficulty identifying compensated shock states, however, since compensated shock does not always have a straightforward clinical picture. Compensated and severe hemorrhagic shock occur on a spectrum of metabolic acidosis, blood loss, poor tissue perfusion, tissue injury, and ineffective oxygen extraction (Table 1.1 and Fig. 1.1) . Hemorrhage is commonly categorized by volume and percent blood loss with specific findings at defined losses . Interestingly these categories are largely based on opinion rather than objective clinical data. Clinical parameters are not markedly different from baseline in phases one and two of shock, contributing to the difficulty in recognizing shock in its early stages.
Although pituitary surgery via the transsphenoidal approach has been performed for over a century, it has only gained widespread acceptance over the past 50 years. As various advances in illumination and magnifcation through microscopic and endoscopic approaches have improved the safety and effcacy of this technique, it has become the workhorse approach for surgery on the pituitary gland. Further advances, including better understanding of pituitary adenoma biology and improved reconstruction techniques, have extended the utility of this approach to treatment of pathology beyond the sella turcica and its contents. We review the history of pituitary surgery with an emphasis on advances with the transsphenoidal approach.
The Western proverb says that “beauty is only skin-deep.” So, is it true? I do not agree. If that is true, plastic surgery might be only a single chapter in dermatology. Moreover, many plastic surgeons complain that even after a successful operation on one’s eyes or nose, the overall change on the patient’s aesthetics is not that big at all. Now we all know very well that without any change on this shape of the face, there are limitations with any other kind of cosmetic surgeries. The shape of one’s face is constructed with bone. The marked differences between Caucasian and Asian face mainly come from the facial bone structure. Now we can say that “beauty is bone-deep.”
Modern hepatic surgery, and in particular the surgery of liver metastases, on patients with advanced and recurrent disease, as well as chemotherapy-induced liver injury, demands the pursuit of the apparently conﬂicting goals of radicality and tissue-sparing. Successful procedures require a perfect knowledge of the vascular anatomy of the liver, commonly based on Couinaud’s ideal representation that will be illustrated in detail. Alternative anatomical representations will be brieﬂy presented, as they allow a better understanding of some surgical procedures such as central hepatectomies. We will argue that the best results will be obtained by deep understanding of the individual real anatomy of the patient, based on radiological reconstructions that are now more widely available on the surgeon’s laptop, and on intraoperative ultrasound. In addition, we will detail the anatomical characteristics of some structures of the liver, such as features particular to individual segments, the glissonean pedicles, the hepatic veins, the vestigial structures such as the umbilical and Arantius’ ligaments, and the surgical approaches and maneuvers that knowledge of these structures allows. The customized procedures that result go beyond the conventional segmental representation, are best described as tailored territorial liver resections, ft the concept of precision liver surgery to which the authors fully subscribe , and illustrate the evolution from surgical anatomy to anatomical surgery that was anticipated in earlier work.
Complex surgical procedures carry signifcant risks and potential for complications, whether performed alone (as single procedure) or in combination (as multiple surgical procedures). Despite the most conscientious preoperative preparations, surprising events may still occur. If the operation takes an unplanned turn, the surgeon has to make diffcult decisions. Some of the most important elements of any surgical procedure are the decisions that the surgeon makes before, during, and after the surgery itself. Notewithstanding its enormous signifcance and regardless of the implications that this decision-making process (DMP) has on surgical outcomes, the subject has received minimal attention in the literature . Subsequently, there are only a few studies that investigate how these decisions are made, although DMP is of great importance both for training and patient safety purposes. How do we surgeons make intraoperative decisions under what can be inauspicious conditions? Some describe these decisions as “intuition” or “gut-level” responses. However often we surgeons have diffculty in describing exactly how we came to specifc decisions during surgery. Clearly, there are many factors that affect decisionmaking of surgeons before and during operations. These factors are the physiologic state of the surgeon, the harmony of teamwork, external factors at work, and the surgeon’s ability to adapt quickly to a changing environment, to name only a few. Yet, the question remains, how to perform an evaluation of the surgical decision and gaining a better understanding of a seemingly gut- level process, which helps surgeons combat the external factors experienced before and during surgery?
Endoscopic assessment of mucosal lesions has emerged as an important concept of disease activity in inﬂammatory bowel disease (IBD), and recently mucosal healing has generally been regarded as a therapeutic goal not only in ulcerative colitis (UC) but also in Crohn’s disease (CD). Several pieces of evidence have now accumulated to show that mucosal healing determined by endoscopy can alter the course of IBD, as it is associated with sustained clinical remission, and reduced rates of hospitalization and surgical resection. Generally, clinical activity indices established in IBD are mainly determined based on subjective/objective signs and the results of laboratory tests. However, those indices sometimes lead to discrepancy compared with endoscopic indices. Although endoscopy has been rarely investigated as a predictor of the clinical course of IBD, there is now growing evidence that morphological examination, including endoscopy, may help to identify among IBD patients those who should be treated with more intensive treatments. Furthermore, as demonstrated in a recent study assessing early intervention with combination of biologics and immunomodulators, endoscopy may help to select patients who will obtain the best results with early intervention. This chapter summarizes the role of endoscopy in IBD by introducing several modalities such as
colonoscopy, balloon-assisted enteroscopy, and video capsule endoscopy, as well as CT colonography and MR enterography.
It has been said that there are only two periods in the history of surgery – before Lister and after Lister” Harvey Graham (1939-) Surgery has come a long way since the days of Hippocrates when operations were often deemed to be the last resort, and doctors preferred to practice conservative measures before reaching for the knife. The past 2000 years have seen huge paradigm shifts in the theories of science and medicine, and surgery was by no means separated from this. Without the advent of germ theory, the discovery of both asepsis and antibiotics, and the development of anaesthesia, surgery as we know it today would simply not exist. However, surgery did not only have these scientifc barriers to deal with, but it also had to overcome millennia of negative publicity surrounding the profession. Despite these hurdles, the practice of surgery can be traced back as far as pre-historic times, before the advent of written historical records. Indeed, excavations of Ancient Egyptian burial sites have revealed splints made of bark which were used to immobilise a fractured forearm, and ancient tomb paintings reveal the practice of circumcision . The pictures of a variety of surgical instruments inscribed onto the tomb of Kom Ombo, suggest that the repertoire of the Ancient Egyptian surgeon spanned beyond just those two procedures.
Cataract phacoemulsifcation training poses a unique challenge of learning a delicate, complex task in which only one person can operate at any given time. The majority of patient’s remain awake during surgery and training usually has to proceed in a setting of service provision . Not only is an understanding of how the process of phacoemulsifcation surgery will be taught is important for the novice surgeon, it is equally important for the experienced surgeon embarking on a phacoemulsifcation teaching role to determine how to teach the novice surgeon. Given the plethora of techniques possible for every stage of the cataract procedure, the Trainer may no longer perform surgical steps in a basic fashion. Instead advanced skills, developed over years of practice will be applied to complete their own cases. Though important to ensure acquisition of a broad repertoire of skills by the end of training, the novice surgeon needs to be taught basic, fundamental phacoemulsifcation skills initially. The novice surgeon may fail to perform advanced intraocular movements if their confdence or skill level has not developed suffciently, consequently it may not be appropriate to mimic such techniques. Surgical steps should not be ‘challenging’ but rather remain well within the Trainee’s competency and comfort level. The book aims to provide a framework for phacoemulsifcation training: concepts are introduced over the course of the book and a training program for the Trainer to follow. Important concepts will be repeated in successive chapters to reiterate the concept for the Trainee.
Te literature in radiology and urology is predominantly orientated to diagnosis and disease management. Although compli cations and outcomes are included under ‘management’, the clinician is often left in the dark about anatomical and physiological changes that follow successful treatment. Tis is particularly true where there has been conservative or reconstructive surgery. We are faced with patients who have a new set of symptoms, images that look different from those seen before treatment and physiology that requires definition of new normal values. Clinicians are therefore left wondering what is a complication and what an inevitable consequence of the management?What, for example, is the normal appearance of a kidney cancer after radiofrequency ablation (RFA) and what does a local recurrence look like? How does the urine flow down the ureters after a trans-uretero-ureterostomy? What is the new normal appearance of theurinary tract after a cystoplasty?