The patient is a man in his forties with two-level cervical myelopathy, C5-6 and C6-7. He presented with significant balance issues, as well as hyperactive reflexes, neck pain, and numbness going down both of his arms and his legs. His MRI showed us that he had two large disc herniations, the biggest being at C6-7, where he also had myelomalacia of the spinal cord with also a cord compressive disc herniation of the C5-6 level in addition. He does have other spondylotic changes, as we'll see in his imaging, but I felt that, given his symptoms, and the compression areas being most significant at C5-6 and C6-7, then an operation at these two levels would be most appropriate. We are going to treat this patient anteriorly because there's anterior base compression of the spinal cord. Our plan will be to do a two-level anterior discectomy and fusion. We are going to do this in a less invasive manner than a traditional ACDF. We're going to be using a zero-profile device at the two levels. I believe what this allows us to do is to do a small dissection, less retraction around the esophagus, and then ultimately, once the implant is in place, we are going to be able to have a device that's completely within the disc space, as opposed to having an external plate on, which, I believe, is correlated with dysphasia. The final thing that this implant allows is that we stay completely away from the adjacent disc levels, and so I believe that we reduce the likelihood of adjacent level ossification disease. The key things are getting a good decompression, and then ultimately for long-term success having an implant that's well placed, that's not going to subside, and that's going to lead to a solid fusion is what's going to allow us to have both a great short-term outcome and a great long-term outcome.
This procedure involves the surgeon making a four-inch incision through the front of the leg, rather than the back (the entry point for the more conventional posterior hip replacement surgery). Frontal entry makes it possible to reach the joint by separating rather than cutting and then reattaching muscles. The anterior hip replacement may also result in a swifter recovery and shorter hospital stay for patients, perhaps due to less muscular damage. (https://www.hss.edu/conditions_anterior-hip-replacement-overview.asp)
Sometimes cancer can be detected simply by looking at your skin, but the only way to accurately diagnose melanoma is with a biopsy. In this procedure, the entire mole or growth is removed along with a small border of normal-appearing skin. (Ref: https://www.mayoclinic.org/diseases-conditions/melanoma/diagnosis-treatment/drc-20374888)
The patient is a 54-year-old, very active woman who is a tennis player, and she has developed end-stage osteoarthritis of her hip. I am going to be performing a direct anterior approach total hip replacement. I like the direct anterior approach for her because I believe it will lead to an easier recovery with fewer restrictions, and I think ultimately it will give her the stability she needs to carry on her active lifestyle. With this approach, I hope to show you the exposure we need to see the acetabulum, preservation of the capsule, with the use of a special fracture table called the Hana table. And, I hope to show you the releases we need of the capsule to get the exposure of the femur.
The patient is an 84-year-old woman with a changing mole just above the labia; skin cancer until proven otherwise. The dermatologist biopsied and showed superficial spreading melanoma with a depth of just over one millimeter. What we are going to do today is a wide local excision, at least one-centimeter margins with an elliptical incision. We have to be careful doing that next to the labia so as not to hurt and distort things. And then we are going to do a sentinel lymph node biopsy. She was injected this morning and is showing a hot signal in the left groin. So our plan is wide local excision of the skin and to remove a sentinel lymph node biopsy to prove there's no spread from this melanoma.
Paraesophageal hernia occurs when part of the stomach protrudes into the thoracic cavity through the esophageal hiatus of the diaphragm. Although paraesophageal hernias are uncommon, they are potentially life-threatening because of the risk of volvulus and incarceration. (Ref: https://emedicine.medscape.com/article/369510-overview)
Hiatal hernia repair with a frontal placation and a possible Collis Gastroplasty. The patient presented with a giant paraesophogeal hernia. He had the typical symptoms of heartburn and regurgitation. Manometry did show that he had good esophageal reserve, with no evidence of an effect to his esophageal motility, and upper GI did show that most of his stomach was intra-thoracic. Cedars-Sinai tends to do more Collis Gastroplasties than most other institutions, so there is a high likelihood that this patient will get a Collis Gastroplasty. It’s usually an intra-operative decision; however, most patients that present with a 5cm or larger tumor typically end up getting a Collis Gastroplasty.
Behind the scenes clip of Dr. Maurice Garcia discussing how "transgender medicine touches on a lot of the reasons why most of us became doctors. We like people and it's very fulfilling to help people." Check out the full interview on GIBLIB.com
"My portion of the operation is laparoscopically harvesting the right side of the colon to ultimately serve as the intestinal neovagina. We divide the terminal ileum and the transverse colon. I hand the stapled end of the transverse colon down through a peritoneal rent to Dr. Garcia to have that sewn to the vaginal introitus and then I proceed by performing a side-to-side ileotransverse colon anastomosis in a laparoscopic intracorporeal manner. I complete my portion of the operation by pexing the back end of the intestinal neovagina to the abdominal wall as to prevent future prolapse" -Yosef Nasseri, MD, FACS, FASCRS Watch the case on giblib.com !
"The most challenging aspect of a salvage colon vaginoplasty is dissecting along the plane as needed to get between the perineum and the pelvis anterior to the rectum and posterior to the prostate and bladder." -Maurice Garcia, MD, MAS Watch the case on giblib.com !
The patient is a 53-year-old transgender woman who underwent gender affirming vaginoplasty surgery with creation of a vaginal canal over a year ago. Unfortunately, the vaginal canal prolapsed and became unfunctional and it was removed, leaving her essentially with a shallow depth neovagina. That is a normal vagina that has no vaginal canal. Today she presents for salvage surgery and a urethroplasty.
Stone To remove a smaller stone in a patient's ureter or kidney, a doctor may pass a thin lighted tube (ureteroscope) equipped with a camera through the urethra and bladder to the ureter. Once the stone is located, special tools can snare the stone or break it into pieces that will pass in the patient's urine. A doctor may then place a small tube (stent) in the ureter to relieve swelling and promote healing. (Ref: https://www.mayoclinic.org/diseases-conditions/kidney-stones/diagnosis-treatment/drc-20355759)
The patient is a 64-year-old gentleman with bilateral nephrolithiasis. He has a right proximal ureteral stone that's obstructive and has some other stones in his left kidney, as well as some cysts on that kidney. He would like to have both of those done at the same time, so we talked about the risks, benefits, and alternatives of simultaneous bilateral ureteroscopy. We'll be using the new Lumenis P 120 high watt holmium laser.
Total extraperitoneal (TEP) laparoscopic inguinal hernia repair is preferred to the transabdominal preperitoneal (TAPP) repair since it preserves peritoneal integrity. However, in general it is considered to be more difficult than the latter because of the peculiarity of anatomy and limitation of working space. Therefore it has been assigned with a "steep learning curve" that the surgeon needs to climb steadily and slowly. This paper offers a working protocol, which is aimed at reducing the steep limb of this curve. (Ref: https://www.ncbi.nlm.nih.gov/m/pubmed/15026913/)
The patient is a young gentleman with a persistent right-sided inguinal hernia. He was originally diagnosed with the hernia at age two and had a recurrence nearly 30 years later when it was repaired with a panel of mesh. The patient came to Mayo looking for a recurrent repair. Dr. Farley has chosen to do the repair laparoscopically and prefers a TEP Inguinal Hernia repair, in which he will get into a pre-peritoneal space, go in from the back side, release the peritoneum, find the hernia sac and bring it in, then tack a mesh panel over the remaining hole. Dr. Farley will also check the left side to ensure there isn't a second hernia there. This patient has elected to have a vasectomy during the same surgery and will undergo resection of his Vas Deferens on both sides.
The forehead flap is one of the oldest recorded surgical techniques for nasal reconstruction. As "the gold standard" for nasal soft tissue reconstruction, the forehead flap provides reconstructive surgeons with a robust pedicle and large amount of tissue to reconstruct almost any defect. (Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743909/)
The patient is a young woman with a history of Tessier 0 facial cleft. She has a significant nasal deformity that requires nasal reconstruction. She has had multiple surgeries done in the past and continues to have soft tissue deficiency and lack of structural support in her nose, so the goals for this operation are a first-stage reconstruction, which will consist of removing previously placed porous poly-ethylene implants and structural reconstruction with rib cartilage grafting. Then, a forehead flap for coverage of partial tip subunit, right soft triangle subunit, columellar, and intranasal reconstruction.
The patient is an 11-year-old girl who was born with a unilateral cleft lip and palate. She has already had an alveolar bone graft. She is most concerned about nasal asymmetry, as she has a classic nasal deformity associated with a unilateral cleft lip patient. Her nasal tip is twisted and rotated and her caudal septum is deviated to the non-cleft side, which is causing the tip rotation and angulation of the columella. She has weak alar support of the cleft side with notching, causing nostril asymmetry. Today's surgery will be an open approach tip rhinoplasty to correct these issues, as well as a minor scar revision
The cleft nasal deformity is a common problem that has both consistent and reliable findings, as well as distinctive nuances. The deformed soft tissue and skeletal foundation are further complicated by the long-term effects of anatomic growth and surgical scarring. The goals of primary rhinoplasty are to restore symmetry and reposition the nasal structures such that further growth will not exacerbate deformities. Cleft nasal deformity is a complicated problem that should be addressed during multiple stages of the patient's life. (Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706043/)
The patient is a 75-year-old male with a five-centimeter aortic root aneurysm and moderate to severe aortic root regurgitation, along with multi-vessel coronary artery disease. The plan for the surgery is a multi-vessel coronary artery bypass graft and aortic root replacement with a bio-root.
In this procedure, also called IPAA (ileal pouch-anal anastomosis), the surgeon removes the part of the patient's bowel that's causing trouble, including the colon and rectum. The surgeon will use the end of the patient's small intestine, called the ileum, to make a pouch inside the body that collects waste. Then the surgeon will connect the pouch to the patient's anus. (Ref:https://www.webmd.com/ibd-crohns-disease/ulcerative-colitis/uc-surgery#1)
The patient is a 37-year-old female who, several months prior to this case, underwent an emergent total abdominal colectomy and the creation of an end ileostomy for ulcerative colitis that was refractory to medical management. She has done well since then and is in today for the second stage of the surgery today, which is a robotic completion proctectomy and creation of an ileal pouch-anal anastomosis, as well as creating a temporary diverting loop ileostomy.
The presence of cleft palate has both aesthetic and functional implications for patients in their social interactions, particularly on their ability to communicate effectively and on their facial appearance with or without involvement of the lip. Midfacial skeletal growth may be affected by the surgical repair of the palate. The treatment plan focuses on two areas: speech development and facial growth. Speech development is paramount in the appropriate management of cleft palate. Many surgical techniques and modifications have been advocated to improve functional outcome and aesthetic results. The most controversial issues in the management of cleft palate are the timing of surgical intervention, speech development after various surgical procedures, and the effects of surgery on facial growth. The major goals of surgical intervention are normal speech, minimizing growth disturbances, and establishing a competent velopharyngeal sphincter. (Ref: https://emedicine.medscape.com/article/1279283-overview#a4)
The patient is an infant boy who was born with a unilateral cleft lip and palate and is now ready for a palate repair. The technique will be a Bardach Two-Flap Palatoplasty using Vomer Flaps and an Intravelar Veloplasty.
Coronary artery bypass grafting (CABG) is performed for patients with coronary artery disease (CAD) to improve quality of life and reduce cardiac-related mortality. The usual incision used for CABG is a midline sternotomy, although an anterior thoracotomy for bypass of the LAD or lateral thoracotomy for marginal vessels may be used when an off-pump procedure is being performed. Cardiopulmonary bypass, cardioplegic arrest, and placement of the graft follows. (Ref: https://emedicine.medscape.com/article/1893992-overview)
Alveolar bone grafting is a technique in which bone is grafted into the cleft site inside the jaws. The bone is most commonly taken from the iliac or hip bone. The primary aim of any cleft-related surgery is to restore proper function of the patient with respect to occlusion. The eruption of teeth in proper order and chronology is an important factor. In cleft patients due to the presence of the cleft over the alveolus, the teeth in the vicinity of the cleft fail to erupt. It is required to fill up the gap in the bone so that teeth can erupt into the new bone. Also, it helps raise the base of the all of the nose and assists in Rhinoplasty. (Ref: https://facesurgeon.in/alveolar-bone-grafting-sabg/)
The patient is a 9-year-old girl who was born with left-sided cleft lip, alveolus, and palate. This surgery will be a bone graft for her using morselized cortical cancellous bone from the iliac crest over the alveolar defect. Dr. Richardson will also use the platelet-rich fibrin to ensure that the bone graft is more secure and to provide better regeneration.
Occasionally, the lip and the roof of the mouth, or palate, do not form properly during fetal development. This is usually discovered right after an infant is born or spotted in an ultrasound prior to birth. A cleft palate is a common birth defect thought to be the result of a combination of genetic and environmental factors, suggesting there is little parents can do to prevent the condition. However, if your child has cleft lip or palate, it is extremely important that you consult a team of experienced medical professionals. If insufficiently treated, a cleft palate can cause lasting dental, nutrition, hearing and speech problems. (Ref: https://www.stanfordchildrens.org/en/service/cleft-and-craniofacial-center/cleft-lip-palate)
The patient is a young boy who has a history of bilateral cleft lip and palate. He presented to the Richardson Dental and Craniofacial Hospital in Nagercoil, India with a complex total hard palate fistula. The plan for reconstruction is palatal turnover flaps for nasal lining and a first-stage reconstruction using a tongue flap.
Holmium laser prostate surgery is a minimally invasive treatment for an enlarged prostate. Also known as holmium laser enucleation of the prostate (HoLEP), the procedure uses a laser to remove tissue that is blocking urine flow through the prostate. A separate instrument is then used to cut the prostate tissue into easily removable fragments. (Ref: https://www.mayoclinic.org/tests-procedures/holmium-laser-prostate-surgery/about/pac-20384871)
The patient is a 59-year-old gentleman with a 206g prostate that’s been in urinary retention and has a folely catheter. I hope to show you some of the highlights of this technique including how hemostatic it is, how easy it is to get this tissue out, and how fast this procedure can be. The patient also has some bladder stones that we may have to deal with at the same time.
Most children who have Chiari decompression surgery experience improvement in their symptoms within a week or two of the surgery. While most children only need one surgery to correct their CM1, some children require subsequent surgical procedures to treat their CM1. In very young children, for example, removed bone can grow back and compress the cerebellum again, or the lower portions of the cerebellum may again fall below the foramen magnum and impede the flow of CSF. Syrinx may also reform, necessitating surgical treatment with a repeat Chiari decompression or the installation of a shunt into the syrinx. The goal of surgery is to maximize the quality of life for the child so he or she can be a kid again. (Ref: https://www.stanfordchildrens.org/en/service/brain-and-behavior/conditions/chiari-malformations/treatment)
Surgery for CM1 is called posterior fossa decompression surgery, or sometimes just Chiari decompression. It begins with the removal of a portion of the skull bone (craniectomy) on the lower part of the back of the skull to take pressure off the herniated cerebellum and restore the unimpeded flow of CSF. The surgeon then removes a part of the arched, bony roof of the spinal canal, called C1, to make more room and relieve pressure on the spinal cord. Sometimes the surgeon will then round out the cerebellar tonsils to further improve CSF flow. Finally, using a microscope, the surgeon sews a flexible, durable patch over the area to protect the underlying tissue while allowing room for the cerebellar tonsils and aiding the free flow of CSF. The surgery typically takes between two and three hours. (Ref: https://www.stanfordchildrens.org/en/service/brain-and-behavior/conditions/chiari-malformations/treatment)
Chiari malformations are structural defects in which a small portion of the back of the brain descends into the spinal column, where it can impede the flow of cerebrospinal fluid (CSF). There are four types of Chiari malformations. Types 2, 3 and 4 can usually be identified at birth. Type 1, our focus here, develops as the skull and brain grow throughout childhood and often cannot be diagnosed until late childhood or adolescence. Type 1 Chiari malformation treatment (CM1) vary depending on the size and shape of the cranial malformation responsible for the descending brain tissue and the intensity of the symptoms. If the condition is diagnosed early enough and treated properly, most young patients will recover fully and lead normal lives. (Ref: https://www.stanfordchildrens.org/en/service/brain-and-behavior/conditions/chiari-malformations/treatment)
The patient is a young female, who has had a long history of headaches. The headaches are in the back of the head and is disabling, both affecting the patient to cope at school and play sports. She was found to have a Chiari-I malformation, where the back of the brain descends down below the skull, called the frame of magnum. This can be quite common. However, this patient has severe symptoms related to this with a very tight compression of the brain stem. The procedure is going to decompress that area and restore spinal fluid flow back to normal, which will give her immediate relief of her symptoms.
Dr. Zaghiyan graduated magna cum laude from University of California, Los Angeles, with a Bachelor of Science degree in Biology. She received her medical degree from University of California, San Diego. She then commenced her general surgery residency at the prestigious Cedars Sinai Medical Center. During her training, she dedicated a year as a clinical research scholar, investigating surgical outcomes in inflammatory bowel disease. After general surgery, she completed her fellowship in Colon and Rectal Surgery at Cedars Sinai Medical Center with advanced training in laparoscopic, single incision and robotic techniques.
Dr. Erik Castle received his MD from University of Texas, Southwestern Medical Center at Dallas in 1998. Dr. Castle is a Professor of Urology at the Mayo Clinic in Arizona, specializing in Surgical Urology. He currently practices in Scottsdale, Arizona and two other locations. Dr. Castle is also the director of the Desert Mountain Care Prostate Cancer Research Fund. Since 2008, Dr. Castle has served as the Director of the International Laparoscopic Nephrectomy Training Courses throughout Mexico on behalf of the American Urological Association (AUA). He has been a voting member of the Laparoscopic, Robotic and New Surgical Technology Committee since 2010. Also with the AUA, Dr. Castle was a member of the Microscopic Hematuria Guidelines Committee from 2010-2012 and was the President of the Society of Urologic Robotic Surgeons from 2009-2010. Now, he is the Associate Editor with the Journal of Robotic Surgery, and has been since 2010. Dr. Castle’s research interests include prostate cancer, bladder cancer, and kidney cancer. In basic science research, he focuses on novel secondary hormonal therapies for prostate cancer and apoptotic pathways related to manipulations of the androgen and estrogen receptors. He also performs research into the genomics of prostate and bladder cancer. Dr. Castle directs the outcomes research of robotic and laparoscopic surgery for these three cancers, and he is the principal investigator in the ongoing urologic oncology biorepository in his laboratory.Dr. Castle has been the Director of the International Laparoscopic Nephrectomy courses throughout Mexico on behalf of the American Urological Association (AUA) since 2008 and has been a voting member of the Laparoscopic, Robotic and New Surgical Technology Committee since 2010. Also with the AUA, Dr. Castle was a member of the Microscopic Hematuria Guidelines Committee from 2010-2012 and was the President of the Society of Urologic Robotic Surgeons from 2009-2010. Now he is the Associate
When cancer is found in the sigmoid colon, the sigmoid colon is removed. The descending colon is then reconnected to the rectum. At Cedars-Sinai, the majority of colon and rectal operations are performed using minimally invasive techniques. (Ref: https://www.cedars-sinai.edu/Patients/Health-Conditions/Sigmoid-Colectomy.aspx)
Surgical adrenalectomy is performed for benign (hormonally active or nonfunctional) and malignant tumors. The optimal approach for adrenalectomy continues to evolve as surgeons develop expertise with minimally invasive surgery (both abdominal and retroperitoneal) in different clinical settings. Regardless of surgical approaches, adrenalectomy is a challenging procedure that, in general, should only be performed by surgeons with specialized training. (Ref: https://www.uptodate.com/contents/adrenalectomy-techniques)
The patient is a 58-year-old male who recently was diagnosed with a sigmoid colon cancer, which was about 25cm from the anal verge. He has had staging CTs that have demonstrated no metastatic disease. During the case, the procedure is performed laparoscopically with a medial dissection of the inferior mesenteric artery and a distal transection of the colon. One of the challenges of the procedure was mobilization of the splenic flexure. Although the decision to mobilize the splenic flexure is controversial, we didn't have adequate length for an anastamosis and therefore had to mobilize the splenic flexure.
The patient is a male who has undergone a previous robot assisted radical cystoprostatectomy with extended pelvic lymphadenectomy two years ago. He did develop a single element of metastatic disease in his left adrenal gland, and it's his only evidence of metastatic disease. He's already had systemic therapy in the past, and at this point the plan is to take him into the operating room and perform an adrenalectomy in this region. The hope is that you'll be able to see the benefits of the minimally invasive approach, the steps involved and the goals, and plans and principles of surgery for this procedure.
Dr. Phillips is the chair of surgery at Cedars Sinai. His areas of clinical focus are: Achalasia Adrenalectomy (Adrenal Gland Removal) Anti-Reflux Surgery / Surgeries Bariatric Surgery / Surgeries Breast Cancer Surgery / Surgeries Colectomy Colorectal Cancer Surgery / Surgeries (Colon, Rectal) Congenital Diaphragmatic Hernias Gallbladder Surgery / Surgeries (Cholecystectomy) Gastroesophageal Reflux (GERD) Heller Myotomy Hernia Repair Surgery / Surgeries Hernias Mastectomy Nissen Fundoplication Pheochromocytoma Splenectomy (Spleen Removal) Stomach (Gastric) Cancers Stomach (Gastric) Surgery / Surgeries