Succeeding in Continuing Trauma Education During a Pandemic.

BACKGROUND: Corona virus disease 2019 (Covid-19) impacted continuing medical education programs such as the Advanced Trauma Life Support (ATLS) course. Modifications made to medical training like teleconferencing could affect students' learning success. We sought to evaluate the effects of the American College of Surgeons modifications on success rates in passing the ATLS course. METHODS: This study evaluated 28 ATLS 10th edition courses educating 898 students at our region before and after Covid-19 modifications. Traditional two-day courses were performed in-person while modified courses were conducted with a one-day teleconference followed by a second in-person practical day. We compared the characteristics and course pass rates between the traditional and modified ATLS courses. RESULTS: Modified ATLS courses had significantly lower pass rates (81.0%; 95% confidence interval = [74.8-87.3]) compared to traditional ATLS courses (94.3%; [92.2-96.3]). CONCLUSIONS: Modifications to the ATLS course are associated with lower student pass. This is possibly due to ineffective knowledge consolidation. Better modifications to the course are required such as use of electronic learning tools with modification to course schedule or returning to the traditional course but with the use of Covid-19 vaccines and other protective measures. These suggestions should be considered and evaluated further by ATLS program leaders.

The POEM bottom-up technique for achalasia.

BACKGROUND: POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique. METHODS: A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied. RESULTS: POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group. CONCLUSIONS: As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.

The Effect of POSS Type on the Shape Memory Properties of Epoxy-Based Nanocomposites.

Thermally activated shape memory polymers (SMPs) can memorize a temporary shape at low temperature and return to their permanent shape at higher temperature. These materials can be used for light and compact space deployment mechanisms. The control of transition temperature and thermomechanical properties of epoxy-based SMPs can be done using functionalized polyhedral oligomeric silsesquioxane (POSS) additives, which are also known to improve the durability to atomic oxygen in the space environment. In this study, the influence of varying amounts of two types of POSS added to epoxy-based SMPs on the shape memory effect (SME) were studied. The first type contained amine groups, whereas the second type contained epoxide groups. The curing conditions were defined using differential scanning calorimetry and glass transition temperature (Tg) measurements. Thermomechanical and SME properties were characterized using dynamic mechanical analysis. It was found that SMPs containing amine-based POSS show higher Tg, better shape fixity and faster recovery speed, while SMPs containing epoxide-based POSS have higher crosslinking density and show superior thermomechanical properties above Tg. This work demonstrates how the Tg and SME of SMPs can be controlled by the type and amount of POSS in an epoxy-based SMP nanocomposite for future space applications.

Reusable single-port access device shortens operative time and reduces operative costs.

BACKGROUND: In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS: We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS: SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION: Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

[Single incision laparoscopic combined cholecystectomy, bilateral salpingo-oophorectomy and omentectomy].

Single Incision Laparoscopic Surgery (SILS) is gaining popularity as a modality in surgery which reduces the number and size of skin incisions. General surgeons and urologists were the first to implement this technique, however, recently gynecologists have also started performing SILS procedures. We present the case of a 70 year old female who underwent a combined SILS procedure which included cholecystectomy, bilateral oophorectomy and omentectomy. The procedure lasted 100 minutes and the patient was discharged home the day after the operation. No operative or post-operative complications were noted. In this case report we present the technical details and demonstrate the collaboration between different disciplines which enables performing this complex and demanding procedure.

Endovascular management of blunt renal artery trauma.

BACKGROUND: Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported. OBJECTIVES: To present our experience with endovascular management of blunt renal artery injury, and review the literature. METHODS: We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications. RESULTS: Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered. CONCLUSIONS: Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

Disparities in trauma care education: An observational study of the ATLS course within a national trauma system.

BACKGROUND: Disparities in trauma systems, including gaps between trauma center levels, affect patient outcomes. Advanced Trauma Life Support (ATLS) is a standard method of care that improves the performance of lower-level trauma systems. We sought to study potential gaps in ATLS education within a national trauma system. METHODS: This prospective observational study examined the characteristics of 588 surgical board residents and fellows taking the ATLS course. The course is required for board certification in adult trauma specialties (general surgery, emergency medicine, and anesthesiology), pediatric trauma specialties (pediatric emergency medicine and pediatric surgery), and trauma consulting specialties (all other surgical board specialties). We compared the differences in course accessibility and success rates within a national trauma system which includes seven level 1 trauma centers (L1TC) and twenty-three non-level 1 hospitals (NL1H). RESULTS: Resident and fellow students were 53% male, 46% employed in L1TC, and 86% were in the final stages of their specialty program. Only 32% were enrolled in adult trauma specialty programs. Students from L1TC had a 10% higher ATLS course pass rate than NL1H (p = 0.003). Trauma center level was associated with higher odds to pass the ATLS course, even after adjustment to other variables (OR = 1.925 [95% CI = 1.151 to 3.219]). Compared to NL1H, the course was two-three times more accessible to students from L1TC and 9% more accessible to adult trauma specialty programs (p = 0.035). The course was more accessible to students at early levels of training in NL1H (p < 0.001). Female students and trauma consulting specialties enrolled in L1TC programs were more likely to pass the course (OR = 2.557 [95% CI = 1.242 to 5.264] and 2.578 [95% CI = 1.385 to 4.800], respectively). CONCLUSIONS: Passing the ATLS course is affected by trauma center level, independent of other student factors. Educational disparities between L1TC and NL1H include ATLS course access for core trauma residency programs at early training stages. Some gaps are more pronounced among consulting trauma specialties and female surgeons. Educational resources should be planned to favor lower-level trauma centers, specialties dealing in trauma care, and residents early in their postgraduate training.

Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application.

BACKGROUND: Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS: The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS: The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION: The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.

Involvement of surgical residents in the management of trauma patients in the emergency room: does the presence of an attending physician affect outcomes?

BACKGROUND: Few studies have investigated whether the presence or absence of attending physicians (AP) in the emergency department (ED) during the management of trauma patients by residents. METHODS: Six level 1 trauma center admissions for years 2006-2008 were analyzed to determine whether presence of an AP affected the time spent in the ED, post-ED disposition, and in-hospital mortality. RESULTS: Patient demographics differed in relation to the presence of APs (P < 0.01). Patients with ISS > 25 who died during hospitalization were more often managed when APs were present. Male patients, those <65, and patients with Injury Severity Score (ISS) > 16 were more often treated in the presence of an AP (P < 0.01). Penetrating, terror trauma, motor vehicle collision and assaults were more often managed in the presence APs. Presence of APs differed by hospital (P < 0.0001). Adjusted logistic regression revealed that patients spent less time in the ED, went directly to the operating room or the ICU for definitive care, if an AP was present. CONCLUSIONS: Presence of an attending physician improved and focused patient triage, disposition decisions, and outcomes.

Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter.

BACKGROUND: From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized. METHODS: We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999-2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010. RESULTS: Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010. CONCLUSIONS: Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.

Ultraviolet Measurements and Photoclimatotherapy for Psoriasis at the Dead Sea: 25 Years of Experience.

BACKGROUND: The Dead Sea basin is the lowest terrestrial site on the globe and is internationally recognized as a photoclimatotherapy center. Since the last century, questions were raised regarding a possible presence of unique incident ultraviolet irradiation, allowing the successful treatment of psoriasis, atopic dermatitis and other dermatological diseases. AIM: This research study aims to determine the characteristics of solar ultraviolet irradiation and to understand the mechanism of action of photoclimatotherapy while applying results to clinical protocols of treatments. METHODS: A meteorological station was established at the Dead Sea basin to continuously measure global, UVB and UVA irradiation. The same irradiation parameters are also monitored continuously by a set of identical ultraviolet irradiation instruments installed on the campus of the Ben-Gurion University of the Negev in Beer Sheva. RESULTS: This study details the results of these long-term measurements, as well as their correlation with the success obtained by clinicians treating psoriasis patients. CONCLUSIONS: A database of more than 25 years has enabled medical staff to establish tailor-made protocols for sun-exposure time intervals as a function of particular month and hour of day. The availability of such information significantly improved the results of photoclimatotherapy for psoriasis and simultaneously increased the safety of sun exposure at the Dead Sea.

Influence of POSS Type on the Space Environment Durability of Epoxy-POSS Nanocomposites.

In order to use polymers at low Earth orbit (LEO) environment, they must be protected against atomic oxygen (AO) erosion. A promising protection strategy is to incorporate polyhedral oligomeric silsesquioxane (POSS) molecules into the polymer backbone. In this study, the space durability of epoxy-POSS (EPOSS) nanocomposites was investigated. Two types of POSS molecules were incorporated separately-amine-based and epoxy-based. The outgassing properties of the EPOSS, in terms of total mass loss, collected volatile condensable material, and water vapor regain were measured as a function of POSS type and content. The AO durability was studied using a ground-based AO simulation system. Surface compositions of EPOSS were studied using high-resolution scanning electron microscopy and X-ray photoelectron spectroscopy. It was found that with respect to the outgassing properties, only some of the EPOSS compositions were suitable for the ultrahigh vacuum space environment, and that the POSS type and content had a strong effect on their outgassing properties. Regardless of the POSS type being used, the AO durability improved significantly. This improvement is attributed to the formation of a self-passivated AO durable SiO2 layer, and demonstrates the potential use of EPOSS as a qualified nanocomposite for space applications.

The solar ultraviolet B radiation protection provided by shading devices with regard to its diffuse component.

BACKGROUND: The composition of the incident solar global ultraviolet B (UVB) radiation with regard to its beam and diffuse radiation fractions is highly relevant with regard to outdoor sun protection. This is especially true with respect to sun protection during leisure-time outdoor sun exposure at the shore and pools, where people tend to escape the sun under shade trees or different types of shading devices, e.g., umbrellas, overhangs, etc., believing they offer protection from the erythemal solar radiation. The degree of sun protection offered by such devices is directly related to the composition of the solar global UVB radiation, i.e., its beam and diffuse fractions. METHODS: The composition of the incident solar global UVB radiation can be determined by measuring the global UVB (using Solar Light Co. Inc., Model 501A UV-Biometer) and either of its components. The beam component of the UVB radiation was determined by measuring the normal incidence beam radiation using a prototype, tracking instrument consisting of a Solar Light Co. Inc. Model 501A UV-Biometer mounted on an Eppley Solar Tracker Model St-1. The horizontal beam component of the global UVB radiation was calculated from the measured normal incidence using a simple geometric correlation and the diffuse component is determined as the difference between global and horizontal beam radiations. RESULTS: Horizontal and vertical surfaces positioned under a horizontal overhang/sunshade or an umbrella are not fully protected from exposure to solar global UVB radiation. They can receive a significant fraction of the UVB radiation, depending on their location beneath the shading device, the umbrella radius and the albedo (reflectance) of the surrounding ground surface in the case of a vertical surface. CONCLUSIONS: Shading devices such as an umbrella or horizontal overhang/shade provide relief from the solar global radiation and do block the solar global UVB radiation to some extent; nevertheless, a significant fraction of the solar global UVB radiation does penetrate this supposedly 'protective or comfort zone'. As a result, it is imperative to either apply sunscreen or cover up the exposed body surfaces even when under such shading devices.

Posttraumatic stress disorder in hospitalized terrorist bombing attack victims.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a psychiatric disorder that results from exposure to a traumatic event and consists of intrusive and unwanted recollections; avoidance followed by emotional withdrawal; and heightened physiologic arousal. Hospitalized victims of suicide bombing attacks (SBAs) are unique because of the circumstances and severity of their injuries, which could affect the occurrence and delay the recognition of PTSD. Our objectives were to evaluate the prevalence and severity of PTSD among hospitalized SBA victims and to assess variables of physical injury as risk factors for the development of PTSD. METHODS: Forty-six hospitalized SBA victims were evaluated for PTSD using the PTSD symptom scale self-report questionnaire by phone. Demographic and medical data regarding the severity and type of injury and medical treatment were collected from medical files. Injury Severity Score was used to assess severity of physical injury. RESULTS: Twenty-four of 46 (52.2%) hospitalized SBA victims developed PTSD. Presence of blast lung injury was significantly higher in the PTSD group compared with the non-PTSD group (37.5% versus 9.1%, respectively; p < 0.04). There was no significant difference in Injury Severity Score between PTSD and non-PTSD groups. Blast lung injury and intracranial injury were found to be positive predictors of PTSD (odds ratio, 125 and 25, respectively). No correlation was found between the length of stay, length of intensive care unit stay, or severity of physical injuries and the severity of PTSD. CONCLUSIONS: Hospitalized victims of SBA are considerably vulnerable to develop PTSD. Victims should be monitored closely and treated in conjunction with their physical treatment. Blast lung injury and intracranial injury are predictors of PTSD.

A mouse model for sleeve gastrectomy: applications for diabetes research.

INTRODUCTION: Discovery of enhanced glucose tolerance following bariatric surgery has sparked renewed interest in the investigation of unchartered underlying pathways of glucose homeostasis. Delineation of this pathway may ultimately be the first step in the creation of a novel therapy for type II diabetes. Nevertheless, the technical complexity and formidable nature of these surgeries coupled with the fragile nature of small rodents has made the creation of a mouse model to study these effects incredibly challenging. We have created a simplified sleeve gastrectomy mouse model to study the effects of bariatric surgery on glucose tolerance and beta cell proliferation. METHODS: Nineteen mice were randomized to undergo either sleeve gastrectomy (SG) (9) or sham operation (SH) (10). Weight and serum glucose were measured three times weekly and serum insulin measurements and pancreatic harvest were performed at the time of sacrifice. Five mice from each group were sacrificed after one week and the remainder sacrificed after one month. RESULTS: Survival of mice was 100% for both groups. The SG group demonstrated an initial drop in weight and serum glucose as compared to SH, which normalized by one month following surgery. Serum insulin levels and rate of beta cell proliferation were similar in both groups after one week and one month. CONCLUSION: The simplified sleeve gastrectomy is a technically straightforward, low-mortality technique for creating a bariatric mouse model which most faithfully replicates bariatric surgery performed in humans. This model can be a valuable tool to investigate the glucose tolerance and beta cell effects of bariatric surgery.

[Surgery without incisions--the third generation of surgery].

In the past, abdominal surgery mandated a large abdominal wall incision. The minimal invasive surgery techniques including Laparoscopy, created an option for performing intraabdominal surgery through small incisions. In this article, the authors present new surgical techniques: the natural orifice trans-luminal endoscopic surgery (NOTES], and the singLe incision laparoscopic surgery (SILS). It seems that these evolving techniques are the third generation of surgery.

Left laparoscopic paraduodenal hernia repair.

BACKGROUND: An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically. METHODS: To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words "laparoscopic," "paraduodenal," and "hernia" as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed. RESULTS: In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group. CONCLUSION: The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically.

Providing more through less: current methods of retraction in SIMIS and NOTES cholecystectomy.

BACKGROUND: As the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries. METHODS: SIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures. RESULTS: Successful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops. CONCLUSION: Adequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.