Single-use bronchoscopes for pleural cavity access: cadaveric feasibility study.

Persistent air leaks (PALs) secondary to residual pleural spaces (RPSs) are the most common complication post-thoracotomy and positively correlate with the length of hospital stay. Among numerous treatment strategies, fibrin glue pleurodesis has the benefit of filling the RPS and can be used multiple times without anesthesia or sedation. A 71-year-old male presented with a 1 cm positron emission tomography positive nodule in the right upper lobe, who had undergone prior thoracotomy for a lung mass in 2011. Thoracotomy with wedge resection was performed with findings of diffuse lung parenchymal scarring and severe inflammatory adhesions requiring complete three-lobe decortication. Pneumothorax with a large air leak was noted postoperatively. Despite aggressive pulmonary toilet strategies, the persisting pneumothorax on postoperative day (POD) 3 required therapeutic bronchoscopy, rib resection, oversewing air leaks, topical sealant application, and three chest tube placements. Residual apical pneumothorax with PALs persisted postoperatively. Eight fibrin glue pleurodesis via a chest tube was completed over eight days, resulting in the cessation of air leak and resolution of apical pneumothorax. Fibrin glue served as a suitable pleurodesis agent in this case by filling the RPS and sealing air leaks. The body resorbs fibrin glue over time and can be performed serially to fill the RPS and avoid further surgery.

Introduction:The pericapsular nerve group (PENG) block is an emerging technique for perioperative analgesia in hip surgery, offering effective pain control while preserving motor function. Its use has been associated with reduced opioid consumption and improved early mobilization compared to conventional blocks. Despite these advantages, practical implementation of the technique remains variable across surgical settings. This study explores the anatomical feasibility of performing the PENG block intraoperatively by the surgeon, providing a potential alternative delivery route integrated within the surgical procedure.Materials and Methods:A cadaveric feasibility study was conducted on a fresh-frozen right lower limb from an 83-year-old male. An ultrasound-guided PENG block was first performed by an anesthesiologist using standard technique. Subsequently, a surgeon placed a second needle through a posterolateral approach under direct visualization of the anterior hip capsule. Needle positions were compared through surgical exposure through a Hueter-type anterior approach.Results:Both needles were located in the same myofascial plane between the iliopsoas tendon and pubic ramus, with the intraoperative needle positioned <1 cm proximal to the ultrasound-guided one. No neurovascular structures were compromised.Conclusion:This cadaveric study demonstrates that intraoperative surgeon-performed PENG block placement through a posterior approach is anatomically feasible and accurately replicates the needle position of the conventional ultrasound-guided technique. These findings support the anatomical validity of this approach; however, further in vivo studies are required to evaluate its clinical efficacy and safety.

Detethering of the C2 Nerve Root and Avoidance of Transection and Injury During C1 Screw Placement: A Cadaveric Feasibility Study

BackgroundPedicled nasoseptal flap (PNSF) has significantly improved the surgical outcomes of endoscopic endonasal approach (EEAs) by reducing cerebrospinal fluid (CSF) leakage. The purpose of this study is to assess the feasibility of using a PNSF for anterior skull base (ASB) reconstruction and to describe a method to compensate for a short flap based on our results.MethodsIn this cadaveric study, ASB dissection without sphenoidotomy was performed using 10 formalin-fixed and 5 fresh adult cadaver specimens, and the sufficiency of the PNSF to cover the ASB was assessed. After the sphenoidotomy, the length by which the PNSF fell short in providing coverage at the posterior wall of the frontal sinus (CPFS), and the extent of the anterior coverage from the limbus (CL) of the sphenoid bone was measured.ResultsWithout sphenoidotomy, the mean length of the remaining PNSF after the coverage of the posterior wall of the frontal sinus was 0.67 cm. After sphenoidotomy, the PNSF fell short by a mean length of 2.10 cm, in providing CPFS. The CL was 1.86 cm. Based on these findings, defects resulting from an endoscopic resection of ASB tumors were reconstructed using PNSF without total sphenoidotomy in 3 patients. There were no postoperative CSF leaks or complications.ConclusionsThe use of PNSF for ASB reconstruction may be insufficient to cover the entire ASB defect after removal of large lesions which need total sphenoidotomy. When possible, by leaving some portion of the anterior sphenoid wall for supporting the PNSF, successful ASB reconstruction could be achieved in endoscopic resection of ASB tumors. Additional methods might be needed in some cases of large ASB lesions wherein the anterior sphenoid wall should be removed totally and the ASB defect is too large.

To evaluate the feasibility of a unique prototype foot-controlled robotic-enabled endoscope holder (FREE) in functional endoscopic sinus surgery. Cadaveric study. Using human cadavers, we investigated the feasibility, advantages, and disadvantages of the robotic endoscope holder in performing endoscopic sinus surgery with two hands in five cadaver heads, mimicking a single nostril three-handed technique. The FREE robot is relatively easy to use. Setup was quick, taking less than 3 minutes from docking the robot at the head of the bed to visualizing the middle meatus. The unit is also relatively small, takes up little space, and currently has four degrees of freedom. The learning curve for using the foot control was short. The use of both hands was not hindered by the presence of the endoscope in the nasal cavity. The tremor filtration also aided in the smooth movement of the endoscope, with minimal collisions. The FREE endoscope holder in an ex-vivo cadaver test corroborated the feasibility of the robotic prototype, which allows for a two-handed approach to surgery equal to a single nostril three-handed technique without the holder that may reduce operating time. Further studies will be needed to evaluate its safety profile and use in other areas of endoscopic surgery. NA. Laryngoscope, 126:566-569, 2016.

BackgroundTransoral robotic and laser surgery is rising in popularity due to the increasing incidence of Human Papilloma Virus (HPV) related oropharyngeal cancer. However, adequate exposure of the tongue base remains a major hurdle in many cases. This study introduces a novel surgical technique called the Floor of Mouth Window, which can be used to improve tongue base exposure at the time of transoral surgery.MethodsThis is a preclinical anatomic cadaver study. Seven fresh cadavers were used for this study. Exposure of the tongue base was compared between conventional mouth gags – the Feyh-Kastenbauer and McIvor – and our novel procedure, the Floor of Mouth Window. Exposure was compared subjectively using endoscopic and extracorporeal photographs, as well as objective measurements of inter-incisor distance, and oral cavity volume.ResultsThe exposure achieved by the Floor of Mouth Window technique was superior to the mouth gags. Inter-incisor distance and oral cavity volume measurements were all more favorable with the Floor of Mouth Window. This technique allowed for successful transoral laser tongue base and tonsil resection without the use of gags or scopes.ConclusionThe Floor of Mouth Window is an adjunctive procedure that simply and reliably improved exposure for transoral oropharyngeal surgery in this cadaveric feasibility study. This improved exposure may help increase the adoption of transoral surgery and reduce the number of aborted cases due to anatomic limitations.

Getting the Wind Knocked out of Your Chest: A Case of Endobronchial Valve Placement for Bronchocutaneous Fistula Following Thoracoplasty for Pulmonary Tuberculosis and Aspergillosis

19-year-old man presented with mild respiratory distress, subcutaneous emphysema, and decreased right-sided breath sounds after a high-speed vehicle crash. A supine chest radiograph showed a large right pneumothorax, right first rib and clavicle fractures, and pneumomediastinum. A large air leak and pneumothorax (Fig. 1A) persisted despite two tube thoracostomies. CT aortography showed a persistent large right pneumothorax, pneumomediastinum, and a tracheal rupture (Fig. 1B). Operative bronchoscopy confirmed the injury, which was repaired primarily. Tracheobronchial injuries affect approximately 3% of all patients who sustain blunt chest trauma. Eighty percent of intrathoracic tracheobronchial injuries are within 2.5 cm of the carina, most commonly involving the proximal right main stem bronchus. Eighty percent of these patients die within 2 hr from associated injuries [1]. Fifty to one hundred percent of patients who sustain blunt tracheobronchial injuries have major associated injuries, including esophageal perforation in up to 20%. The most frequent symptoms of all blunt airway injuries are dyspnea (76‐100%) and hoarseness (46%). The most common clinical signs are subcutaneous emphysema (35‐85%) and hemoptysis (14‐25%) [2]. Conventional chest radiography shows pneumomediastinum in 60% and pneumothorax in up to 70% of injuries. Other supportive radiographic signs include overdistention of endotracheal tube cuff, displacement of endotracheal tube, or, in the case of complete transsection, the fallen lung sign of Kumpe [3, 4]. A persistent pneumothorax with a large air leak despite a well-placed chest tube also suggests this diagnosis, as in our patient. Rarely, a pneumothorax with no air leak at thoracostomy occurs when mediastinal soft tissue or blood obstructs the ruptured bronchus. CT is indicated in the stable patient for the evaluation of possible associated injuries. An unrevealing CT scan does not obviate bronchoscopy if intrathoracic tracheal rupture is suspected. The presence of significant air leak alone is sufficient to mandate bronchoscopy without the need for advanced imaging.

<h3>Introduction</h3> Aqueductal stenosis is a prevalent cause of obstructive hydrocephalus, resulting in progressive ventricular dilation and neurological deterioration. Traditional interventions—ventriculoperitoneal, endoscopic third ventriculostomy, and classic aqueductoplasty—can restore CSF flow but are often complicated by cerebral parenchymal injury, infection, and long-term failure due to shunt malfunction or aqueductal reocclusion. As neurosurgery advances toward minimally invasive strategies, there is a growing demand for alternatives that avoid transgression of deep brain structures. This cadaveric feasibility study introduces a novel neurointerventional approach for aqueductal stenosis, utilizing subarachnoid access via the foramen magnum, foramen of Magendie, and fourth ventricle to catheterize the cerebral aqueduct with standard endovascular tools, aiming to enable future aqueductoplasty and stenting. <h3>Methods</h3> Three formalin-flushed, six-vessel silicone-injected, alcohol-preserved human cadaveric heads were studied. Initial Cone-Beam CT (CBCT) failed to delineate the ventricular system due to the lack of CSF contrast. To overcome this, a 5 mm burr hole was drilled in the parieto-occipital region to access the atrium of the lateral ventricle, and iodinated contrast was injected intraventricularly, enabling clear visualization of the lateral, third, and fourth ventricles on subsequent CBCT.A neurointerventional access route was then established via a simulated lumbar puncture or through the foramen magnum using a standard endovascular catheter system. Under real-time CBCT and fluoroscopy, the catheter was advanced through the cisterna magna into the fourth ventricle, then navigated cranially toward the aqueduct of Sylvius. Siemens DynaCT needle guidance software facilitated precise trajectory planning. Anatomical accuracy was confirmed endoscopically via an anterior interhemispheric transcallosal approach to the third ventricle through the foramen of Monro. Guidewires introduced from the subarachnoid route were visualized emerging from the aqueduct, just posterior to the interthalamic adhesion. <h3>Results</h3> Neurointerventional access to the cerebral aqueduct was successfully achieved. The catheter traversed the subarachnoid space from the foramen magnum to the fourth ventricle and was advanced into the aqueduct under image guidance, demonstrating the technical feasibility of this minimally invasive approach. Intraventricular contrast injection reliably delineated the ventricular anatomy, improving planning and trajectory accuracy. Direct endoscopic inspection confirmed the precise localization of the guidewires within the aqueduct. Although ballon dialation and stent deployment was not performed in this preliminary study, all procedural steps required for aqueductoplasty were successfully completed. <h3>Conclusion</h3> This novel, minimally invasive, image-guided technique demonstrates the feasibility of aqueductal catheterization without parenchymal violation. It lays the groundwork for future neurointerventional aqueductoplasty and stenting procedures and warrants further in vivo investigation. <h3>Disclosures</h3> <b>S. Rahmanov:</b> None. <b>Y. Ramesh Babu:</b> None. <b>H. Borghei-Razavi:</b> None. <b>B. Adada:</b> None. <b>M. Obrzut:</b> None.

Facial nerve injury with resultant facial muscle paralysis is disfiguring and disabling. Reanimation of the facial nerve has been performed using different regional nerves. The nerve to the mylohyoid has not been previously explored as a donor nerve for facial nerve reanimation procedures. Five fresh adult human cadavers (10 sides) were dissected to identify an additional nerve donor candidate for facial nerve neurotization. Using a curvilinear cervicofacial skin incision, the nerve to the mylohyoid and facial nerve were identified. The nerve to the mylohyoid was transected at its point of entrance into the anterior belly of the digastric muscle. Measurements were made of the length and diameter of the nerve to the mylohyoid, and this nerve was repositioned superiorly to the various temporofacial and cervicofacial parts of the extracranial branches of the facial nerve. All specimens had a nerve to the mylohyoid. The mean length of this nerve available inferior to the mandible was 5.5 cm and the mean diameter was 1 mm. In all specimens, the nerve to the mylohyoid reached the facial nerve stem and the temporofacial and cervicofacial trunks without tension. No gross evidence of injury to surrounding neurovascular structures was identified. To the authors' knowledge, the use of the nerve to the mylohyoid for facial nerve reanimation has not been explored previously. Based on the results of this cadaveric study, the use of the nerve to the mylohyoid may be considered for facial nerve reanimation procedures.

The authors describe a technique in which the cervical portion of the vagus nerve is exposed during procedures such as neuroma resection or, more commonly, during the placement of a vagus nerve stimulator. To test their hypothesis that a posterolateral approach to the vagus nerve may be feasible and efficacious, the authors performed dissection of the left-sided vagus nerve in 13 adult cadavers. The carotid sheath was exposed via the posterior cervical triangle, and the vagus nerve was identified posterolaterally. Measurements were made of the length of available nerve, and the anatomical approach was documented. As part of a comparison study regarding the available length of nerve, the authors exposed the left vagus nerve in five additional adult cadavers via a standard anterior approach to the carotid sheath, and compared the results obtained with each technique. A mean length of 12 cm of the vagus nerve was isolated when using the posterior approach to the carotid sheath, whereas a mean length of 11 cm of the nerve was documented when using the anterior approach. With the aforementioned posterior approach, no obvious injury occurred to the vagus nerve or other local neurovascular structures such as the spinal accessory nerve. Evaluation of the findings obtained in the present cadaveric study showed that a posterior approach to the vagus nerve is feasible. The technique for posterior exposure of the carotid sheath may prove useful in surgical exposures of the vagus nerve when a standard anterior method is not possible.

We wish to report a case of tracheal tube pilot balloon failure which has not previously been reported in the literature. A middle-aged man required prolonged ventilatory support following coronary artery bypass grafting. A large air leak was detected at the patient's mouth which was presumed to be coming from around the tracheal tube. The pilot balloon of the tracheal tube was noted to be partially inflated and air was gradually injected through the pilot balloon valve until it became maximally inflated. Despite this measure the air leak continued and mechanical ventilation became inadequate. A decision was made to extubate and re-intubate the patient's trachea. The tracheal tube was secured at the patient's lips with a cotton tie which was cut and the air withdrawn from the pilot balloon valve to deflate the pilot balloon. The patient's trachea was extubated and immediately re-intubated with a new tracheal tube. The original tracheal tube was examined and the pilot balloon tubing was seen to be kinked at the site of the knot of the cotton tie around the tube (Fig .6). The kink had completely obstructed the pilot balloon tubing. Cotton tie kinking pilot balloon tubing. Lewer et al. have previously reported a large air leak due to kinking of the pilot balloon tubing at the junction with the tracheal tube due to a manufacturing defect [1]. Chua et al. have recently described a large air leak due to a defect in the tracheal tube itself [2]. In this case the pilot balloon failed to indicate the state of the tracheal tube cuff. Careful tying to avoid the pilot balloon tubing or the use of adhesive tape to secure the tracheal tube should prevent this complication with the attendant risks of inadequate ventilation and aspiration of gastric contents.

Intrapleural Instillation of Autologous Blood for Persistent Air Leak in Spontaneous Pneumothorax in Patients With Advanced Chronic Obstructive Pulmonary Disease

Blockade of the pudendal nerve (PN) using ultrasound (US) guidance has been described at the levels of the ischial spine and Alcock's canal. However, no study has been conducted to compare anatomical accuracy between different approaches in targeting the PN. To investigate the accuracy of US-guided injection of the PN at the ischial spine and Alcock's canal levels. This study also compared the accuracy of the infiltrations by three sonographers with different levels of experience. Eight Thiel-embalmed cadavers (16 hemipelvises). Three physiatrists trained in musculoskeletal US imaging with 12 years, five years, and one year of experience performed the injections. Each injected a 0.1-mL bolus of colored dye in both hemipelvises of each cadaver at the ischial spine and Alcock's canal levels under US guidance. Each cadaver received three injections per hemipelvis. The accuracy of the injection was determined following hemipelvis dissection by an anatomist. The injections were accurate 33 times out of the total 42 attempts, resulting in 78% accuracy. Sixteen out of 21 injections at the ischial spine level were on target (76% accuracy), while the approach at Alcock's canal level yielded 17 successful injections (81% accuracy). The difference between the approaches was not statistically significant. There was also no significant difference in accuracy between the operators. US-guided injection of the PN can be performed accurately at both the ischial spine and Alcock's canal levels. The difference between the approaches was not statistically significant.

Aqueductal stenosis is a common cause of obstructive hydrocephalus, resulting in ventricular dilation and neurological deterioration. Standard treatments such as shunting, endoscopic third ventriculostomy, and traditional aqueductoplasty are effective but are associated with risks including parenchymal injury, infection, and long-term failure. As neurosurgery shifts toward minimally invasive techniques, there is a growing interest in approaches that avoid brain parenchyma transgression. This study introduces a novel neurointerventional method for treating aqueductal stenosis via the subarachnoid route through the foramen magnum and the fourth ventricle using standard endovascular tools. Five formalin-fixed, silicone-injected, alcohol-preserved cadaveric heads were studied. Contrast was injected into the ventricular system. Catheters were introduced via simulated lumbar puncture or cisterna magna access and then advanced via the foramen of Magendie into the fourth ventricle and then through the aqueduct, utilizing Cone-beam CT, needle guidance software, and biplane fluoroscopy-guided navigation. A self-expanding stent was deployed in the aqueduct, and balloon aqueductoplasty was performed. Anatomical accuracy and technical success were confirmed via endoscopy through a transcallosal approach. Aqueductal access was successfully achieved in all specimens without brain parenchymal violation. Stent placement and balloon dilation were performed without complications and confirmed endoscopically. This novel, image-guided, minimally invasive approach enables aqueductal catheterization via the subarachnoid route. It offers a brain-sparing alternative for treating aqueductal stenosis and may extend to future subarachnoid procedures such as third ventriculostomy or cyst fenestration. In vivo studies are warranted.