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Background: The seatbelt sign (SBS) is a pattern of bruising/contusions on the chest and abdominal wall following motor vehicle collisions. The aim of this analysis is to investigate the influence of time to surgery following identification of the SBS on perioperative outcomes. Methods: A retrospective review of the Trauma Quality Improvement Program database from 2017 to 2019 was performed. Patients included in this retrospective analysis were involved in motor vehicle collisions, experienced blunt abdominal trauma, presented with skin abrasions/contusions in the SBS distribution, were hemodynamically stable, and underwent laparotomy. Demographics, vital signs, injury severity score, Glasgow coma scale, preoperative CT scans (P-CT), and time from presentation to surgery were recorded. Time from presentation to surgery was subdivided by data quartiles as immediate (4 h). The influence of operative timing on postoperative mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days was assessed in multivariate analyses. Results: A total of 1523 patients were included; 280 underwent immediate, 610 early, and 633 delayed surgery. Patients undergoing surgery in the early and delayed groups who received P-CT scans had shorter mean times to operation (4.52 h vs 5.24 h, p

Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical settings such as neurosurgery, cardiac surgery, and liver transplantation, but more recently, endoscopy, hemodialysis, thoracentesis, tissue biopsy, angiography, and central and peripheral venous access and removal have overtaken surgery and trauma as significant causes of vascular air embolism. The true incidence may be greater since many of these air emboli are asymptomatic and frequently go undiagnosed or unreported. Due to the rarity of vascular air embolism and because of the many manifestations, diagnoses can be difficult and require immediate therapeutic intervention. An iatrogenic air embolism can result in both venous and arterial emboli whose anatomic locations dictate the clinical course. Most clinically significant iatrogenic air emboli are caused by arterial obstruction of small vessels because the pulmonary gas exchange filters the more frequent, smaller volume bubbles that gain access to the venous circulation. However, there is a subset of patients with venous air emboli caused by larger volumes of air who present with more protean manifestations. There have been significant gains in the understanding of the interactions of fluid dynamics, hemostasis, and inflammation caused by air emboli due to in vitro and in vivo studies on flow dynamics of bubbles in small vessels. Intensive research regarding the thromboinflammatory changes at the level of the endothelium has been described recently. The obstruction of vessels by air emboli causes immediate pathoanatomic and immunologic and thromboinflammatory responses at the level of the endothelium. In this review, we describe those immunologic and thromboinflammatory responses at the level of the endothelium as well as evaluate traditional and novel forms of therapy for this rare and often unrecognized clinical condition.

Objective: To demonstrate a minimally-invasive method for excision of retrocrural masses. The patient was a 31-year-old male with mixed germ cell testicular cancer underwent left radical orchiectomy, chemotherapy, and open extraperitoneal retroperitoneal lymph node dissection (eRPLND), presented with recurrent disease two years later. Surveillance imaging demonstrated three enlarging retrocrural masses in the setting of normal tumor markers. Methods: The patient was placed in a reverse Trendelenburg position. The liver was retracted. Laparoscopic abdominal inspection demonstrated no adhesions as a benefit of his prior eRPLND. The da Vinci XI robot was docked, the gastrohepatic ligament and short gastric vessels were identified and divided. The stomach and gastro-esophageal junction were identified. The esophagus was mobilized at the level of the diaphragmatic crura before being retracted anterolaterally. The peritoneum was dissected and the diaphragmatic crura was split longitudinally. The larger mass was dissected off of the vena cava and aorta. Lumbar vessels and lymphatics were clipped. Additional inferior dissection was performed to excise the remaining two masses that were adjacent to the celiac artery. The diaphragmatic hiatus was repaired with interrupted sutures. Following closure, esophagogastroduodenoscopy identified viable esophageal mucosa without stricture or evidence of perforation. A drain was placed in the retrocrural fossa. Estimated blood loss was 50 mL. Results: Expected small bilateral pneumothoraces resolved by postoperative day (POD) 2. The drain was removed and the patient was discharged home on POD 2. Final pathology demonstrated metastatic mature teratoma in 3 of 3 nodes with the largest tumor measuring 4.4 cm. The patient has since continued surveillance with no evidence of disease. Conclusions: This video demonstrates the surgical benefits of eRPLND in facilitating reoperation in the abdomen. Furthermore, this video ultimately demonstrates an innovative, minimally-invasive method of removing teratomatous tumors from the retrocrural space through a robotic transabdominal approach.