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Laparoscopic-Assisted Stomas and Stoma Reversal
Published in Haribhakti Sanjiv, Laparoscopic Colorectal Surgery, 2020
Most commonly, however, a Hartmann's colostomy is performed for rectosigmoid disease. Therefore, the rectal stump is left within the pelvis, and prevented from dropping into the lower pelvis by tacking the rectum to the promontory of the sacrum or the anterior abdominal wall using ProleneTM sutures. These sutures also assist in eventual laparoscopic identification of the staple line. In the case of resection for diverticular disease, care must be taken to resect the entire distal sigmoid colon. Leaving behind only the rectum simplifies the reversal, as further bowel resection will not be needed. It is also important not to dissect the presacral space unnecessarily during the initial colon resection. Any dissection will result in fibrosis of this plane, complicating Hartmann's reversal.
A patient with an anorectal malformation who has been previously repaired and who is “not doing well”
Published in Alejandra Vilanova-Sánchez, Marc A. Levitt, Pediatric Colorectal and Pelvic Reconstructive Surgery, 2020
Victoria Lane, Jeffrey Avansino
Pelvic MRI: Presacral space evaluation.ROOF identification.
Colorectal surgical myths
Published in Onnalisa Nash, Julie M. Choueiki, Marc A. Levitt, Fecal Incontinence and Constipation in Children, 2019
Your EUA is completed and you find a well-centered anus surrounded by muscle complex having good contraction with stimulation. You are able to pass a size 18 Hegar dilator. There is no anal stricture present or rectal prolapse. The kidney ultrasound shows bilateral hydronephrosis, right greater than left; normal sonographic appearance; and the renal parenchyma without mass, cyst, or scar. There is moderate-to-large-volume post-void residual. The contrast enema via the rectum reveals a well-formed sacrum, normal caliber colon with redundant transverse colon. The presacral space is normal (see Figure 34.8).
Topography of the pelvic autonomic nerves – an anatomical study to facilitate nerve-preserving total mesorectal excision
Published in Acta Chirurgica Belgica, 2022
Jan Gaessler, Friedrich Anderhuber, Sabine Kuchling, Ulrike Pilsl
Its parasympathetic afferences reach the plexus via the PSN. Zhang et al. [12] located the PSN underneath the presacral fascia. Hypogastric nerves and the sacral sympathetic trunks provide sympathetic input to the plexus [26,29]. Kirkham et al. [29] qualified the latter ones' contributions as 'less significant' by comparison with the hypogastric nerves. At the level of the sacral promontory, the hypogastric nerves are usually seen roughly 10 mm lateral to the midline [18]. Following their entry into the lesser pelvis, the hypogastric nerves run parallel to the 20 mm laterally located ureters [10,12]. In the majority of examined bodies, the hypogastric nerves appeared as networks of fine filaments instead of distinct nerves. Lin et al. [10] and Kirkham et al. [29] have made similar observations. Our results matched the observation of Bissett et al. [24] that the hypogastric nerves are confined to the presacral space and, thus, do not enter the 'holy plane'. In contrast, other studies found the hypogastric nerves in front of the presacral fascia and closely attached to the MRF [10,29]. We agree with Bisset et al. [24] who postulated that the existence of 'multiple layers in the parietal fascia with the presence of intervening loose areolar tissue' could pose the reason for such misconceptions. Dissection outside the hypogastric nerves in a separate layer of PPF would thereby be possible, and explain for the nerves' erroneous localisation in relation to the presacral fascia.
Advances in surgical strategies for prolapse
Published in Climacteric, 2019
A. Giannini, M. Caretto, E. Russo, P. Mannella, T. Simoncini
The last Cochrane revision on pelvic floor reconstructive surgery published in 201325 outlines how abdominal procedures (sacral colpo/cervicopexy) have superior outcomes in terms of anatomic and subjective and objective cure rates when compared to vaginal procedures, including transvaginal sacrospinous ligament suspension, uterosacral ligament suspension, and transvaginal meshes, particularly in elder women. Minimally invasive sacrocolpopexy is the gold standard procedure for stage III–IV apical prolapse treatment, and it is performed with traditional laparoscopy or, more frequently, robot-assisted surgery. Many operators tend to avoid this excellent procedure for the treatment of POP as the isolation of the presacral ligament requires working close to delicate anatomical structures such as the vena cava bifurcation and iliac vessels. Moreover, performing the dissection of the presacral space, a dangerous area, carries potentially life-threatening bleeding complications which can be difficult to manage. Therefore, the perfect tensioning of the mesh represents another critical surgical step of sacrocolpopexy: an excessive laxity of the prosthetic device can undermine the surgery’s utility, while excessive tension of the mesh can cause chronic pain and discomfort26. In this context, surgical planning of sacrocolpopexy with a patient-specific three-dimensional reconstruction of the pelvic anatomy could be helpful to perform a safer, patient-tailored surgery.
Durable response after VNCOP-B and rituximab in an elderly patient with high-grade B-cell lymphoma
Published in Acta Clinica Belgica, 2018
Emanuele Cencini, Alberto Fabbri, Luana Schiattone, Francesco Gentili, Maria Antonietta Mazzei, Monica Bocchia
The patient was a triple-expressor in immunohistochemistry and the phenotype was GCB according to Hans’s algorithm [12]. Physical exam showed no enlarged lymph nodes, at complete blood cell count (CBC) mild anemia was reported (Hb value 10.8 g/dl) without other alterations. Lactate dehydrogenase (LDH) was elevated (431 U/l, upper normal limit 225 U/l); bone marrow biopsy showed normal cellularity without lymphoid infiltrates. Anti-HBs and anti-HBc antibodies were positive, HBV DNA was negative, a small monoclonal component IgM/k was observed by immunofixation (IgM value 82 mg/dl). Computed tomography (CT) scan, performed for staging purpose, demonstrated diffuse thickening of the bladder walls, with pathological tissue infiltrating the mesorectum, the left obturator and the presacral space; moreover, a peritoneal diffusion with pathological mesenteric and mediastinal lymph nodes was reported, while spleen was not involved (Figure 1).