Benefits of immediate dermoglandular preserving reconstruction following giant fibroadenoma excision in two patients.

Giant fibroadenoma is a rare, benign stromal tumor that typically occurs in adolescent women. This rapidly-growing tumor can result in a significant aesthetic and psychosocial morbidity due to gross asymmetry changes in the overlying skin envelope and concerns about malignancy. On initial work-up this lesion must be differentiated from other rare primary breast tumors, including phyllodes tumor, or metastatic disease. Appropriate treatment of giant fibroadenoma requires surgical excision; however, many surgeons are reluctant to perform a concomitant mastopexy or reconstruction at the time of tumor extirpation. This conservative approach results in a loose, ptotic, aesthetically displeasing breast postoperatively. While some degree of skin retraction is expected, patients may have to wait for up to a year to see final results, and further surgical correction may still be required. It is unknown whether these surgeons are not familiar with these techniques or hesitate to increase the amount of scarring on the breast mound of a young female. Using an immediate dermoglandular preserving mastopexy after giant fibroadenoma excision, we have decreased postoperative breast ptosis, removed much of the lax, poor-quality skin and achieved stable, long-term results in two patients. This technique improves the immediate aesthetic outcome, reduces the psychosocial comorbidity associated with waiting for skin retraction and decreases the likelihood of a second surgery.

Parastomal herniation of the gallbladder.

Parastomal hernias can occur in up to 31% of patients following an enterostomy (Cheung in Aust N Z J Surg 65:808-811, 1995). This type of hernia develops through an intentional fascial defect. Commonly, most parastomal hernias involve a reducible segment of omentum, small bowel, or colon. Typically, these hernias are asymptomatic and associated rarely with strangulation or obstruction. Patient preference and clinical scenario may dictate management of these hernias. Non-operative management of parastomal hernias includes abdominal binders and enterostomy belts. Operative management includes a host of options including mesh repair, a new stoma site, or revision. This paper documents the first reported case of a parastomal hernia involving the gallbladder. Optimal technique and site placement of a stoma are also discussed.

A new Dual-hemostat technique to facilitate the closure of small laparoscopic trocar incisions.

BACKGROUND: The introduction of any surgical procedure brings with it new technical challenges. The use of laparoscopy offers patients a reduction in pain and better cosmesis. However, over time, new technical challenges associated with laparoscopic surgery are becoming more evident. In particular, the closure of the small trocar site fascial incisions is often awkward and time consuming. The aim of this article is to introduce a closing procedure that facilitates the safe approximation of the abdominal fascia in these wounds. METHOD: One hemostat is used to visualize the fascia of one side of the wound and separate the fascia from the underlying abdominal viscera. Another hemostat retracts the opposite side of the wound. The suture needle is passed through the fascia and between the open tips of the hemostat. The tips of the second hemostat grasp the driven needle and carry it out of the wound. CONCLUSION: The use of two hemostats to close these wounds not only facilitates the closure but is also probably safer than the standard technique.