An aesthetic approach to the anterior cranial fossa: the endoscopic transadnexal transorbital roof method.

BACKGROUND: This case report describes a transadnexal transorbital roof approach to the anterior cranial fossa to treat an epidural abscess in a patient who had previously undergone extensive craniofacial reconstruction secondary to fibrous dysplasia. A standard frontal craniotomy or even a supraciliary craniotomy would have been burdensome due to the positioning of the porous polyethylene implant as well as extensive scar tissue and adhesions from prior surgical procedures. METHODS: We performed a retrospective review of the case of a 15-year-old male with an epidural abscess treated at a university hospital. RESULTS: The patient tolerated the procedure well with no postoperative complications. Surgical operative time was approximately 1.5 h with minimal blood loss and the patient was discharged on postoperative day 2. Six weeks after antibiotic therapy (intravenous ampicillin/sulbactam, 2,000 mg q.i.d. for 6 days total), an MRI showed complete resolution of the epidural abscess. At that time the patient had no visual changes, extraocular muscle dysfunction, headaches, periorbital cellulitis, or further seizures and is on no antiepileptic therapy. CONCLUSION: Minimally invasive approaches to treat complex problems in certain circumstances can yield excellent results and limit morbidity encountered by more extensive procedures. In the future, more formal studies with a larger subset of patients will help determine what role these approaches will ultimately have. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Laparoscopic excision of an antenatally diagnosed large simple hepatic cyst in the newborn.

Non-parasitic hepatic cysts are rare in infants and children. Advances in antenatal imaging have improved their detection, while development of laparoscopic techniques has expanded options for treatment. We present a case of an antenatally diagnosed non-parasitic hepatic cyst in a neonate, which was successfully excised laparoscopically with no recurrence.

Diagnosis and management of internal hernias after laparoscopic gastric bypass.

BACKGROUND: Internal hernia is a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). However, no consensus exists regarding optimal diagnostic modality and management. We reviewed the literature and our own experience, and present an algorithm for the diagnosis and management of internal hernia after LRYGBP. METHODS: A retrospective review of 290 retrocolic LRYGBPs was performed to identify those who developed postoperative small bowel obstruction due to internal hernia. Demographics, clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiological diagnostic accuracy. RESULTS: Over a 43-month period, 11 out of 290 (3.79%) post-LRYGBP patients with symptoms suggestive of a small bowel obstruction underwent operative exploration. The most common clinical symptoms included intermittent abdominal pain, and/or nausea/vomiting. All patients were initially explored laparoscopically. Etiology of obstructions included internal hernias--6 [at the transverse mesocolon (n = 1), Petersen's space (n = 2), and at the jejunojejunostomy (n = 3)], adhesions (n = 4) and a negative laparoscopy (n = 1). The mean time for development of internal hernias was 13.7 months. Mean loss of BMI units at time of re-operation was 17 kg/m2. Of the 6 patients with internal hernia, 2 (30%) had normal preoperative radiological work-up. On review of the preoperative films by the surgeon, signs of internal herniation were seen in all the patients. Management included initial laparoscopic exploration, lysis of adhesions, reduction of internal hernia and closure of mesenteric defects in all the patients. There were 2 conversions to laparotomy. CONCLUSION: Small bowel obstruction in the post-LRYGBP patient is difficult to diagnose, especially when due to an internal hernia. Most patients present with intermittent abdominal pain and/or nausea. The most frequently used radiologic study is CT scan, which is most accurate when reviewed by the bariatric surgeon preoperatively.