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CASES in Obstetrics and Gynaecology Cecilia Bottomley MB BChir MRCOG Clinical Lecturer C.. Case Files Surgery, Fourth Edition. Cases In Surgery, Second Edition James A ppti.info The BookReader requires JavaScript to be enabled. Please check that your browser supports. 1 Cases in Surgery ANSWER 1 This woman has a right-sided femoral hernia . The neck of the femoral hernia lies below and lateral to the pubic tubercle.

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cases in surgery, second edition, Free download. International Standard Book Number (eBook - PDF) This book. The aim of the Cases series is to provide a novel learning and revision tool that works by guiding students through clinical cases, imitating those that. Cases in Surgery. FULL ACCESS. Full Access: You have full to read online and download this title. DownloadPDF MB Read online.

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The surgical procedure is illustrated in Fig. Images of the ROSA robot. A: The patient is positioned for surgery. The touch screen, on which all planning and registration data are centralized, can be seen on the right. B: The robot holds a noninvasive laser device to obtain measurements for frameless surface registration.

Automatic robotic frameless surface registration is performed. The robot is equipped with a registration system that combines robotic movements with noninvasive touch-free laser measurement for frameless surface registration.

The laser can be seen on the patient's skin. C: The accuracy of the registration is confirmed by the surgeon on several landmarks, such as roots of the nose, internal and external canthus, temples, and midline, as well as free landmarks chosen by the surgeon.

D: The laser is then used to show the entry point. The hair is shaved around this point, the skin is prepared, and then draping is completed. The drill follows the planned trajectory via a reducer held by the robotic arm which is in place. The dura is opened by electrocautery applied to a bushing-guided blunt stylet that is insulated except at its tip.

F: A Sedan side-cut biopsy needle mm specimen window, 2.

Other books: ASME Y14.100 PDF

For frameless biopsy with fiducial marker registration, robotized registration was performed by means of invasive bone fiducial markers or skin fiducial markers. Three positions were registered parked to place the O-arm away from the patient's head and to give enough space for the surgery; lateral and frontal to center the O-arm for imaging of the head to guide automatic movements of the O-shaped gantry during surgery.

The fiducials were placed on patient's head in the operative position. Automatic matching was performed with the preoperative MR images used for surgical planning. Share-controlled robotic fiducial registration was then performed. The rest of the procedure was conducted in the same way as frameless surface registration biopsy.

Except for the first 5 patients, operating time was consistently less than 2 hours, which included positioning of the head, installation of FPCT and robotic devices, CT imaging data set acquisition, and draping. Use of the robot coupled with an FPCT scanner. A: The patient is in the prone position and bone fiducials have already been placed.

C and D: As a result of the matching of the intraoperative CT data with preoperative planning data on Rosana software, the accurate placement of the Sedan needle can be checked. E and F: If necessary, the correction of the robotic arm position can be performed to finally confirm the accurate position of the needle in the target. Postoperative CT scans were matched with preoperative planning scans to check if the biopsy site was realized inside the tumor.

Patients were discharged to home on postoperative Day 1 or 2 when a satisfactory clinical status was observed. Patients returned to receive diagnostic information within 2 weeks after surgery when the definitive histology report and the multidisciplinary treatment proposal were available. Results Histological Diagnosis A wide range of histological subtypes was observed. Details on the accuracy of tissue diagnosis are presented in Fig.

A nonspecific inflammatory process was observed in 2 cases, and hemorrhage and a nonspecific inflammatory process were observed in 1 case. Twenty-eight lesions were deep brain lesions; 21 lesions were situated in the corpus callosum, diencephalon, pineal region, or hypothalamus; and 8 lesions were situated in the posterior fossa, brainstem, or cerebellum.

Twenty of these lesions were less than 15 mm in diameter. Upper: The various biopsy sites are shown.

The whole brain was explored as well as supratentorial, deep, or infratentorial lesions. Diagnostic Yield After matching between preoperative planning and postoperative CT scans, all biopsy sites were inside the tumor targeted Fig. A histological diagnosis was established for 97 of the biopsy targets. A nonspecific inflammatory process was described for 1 of the 3 nondiagnostic targets in a patient treated with steroids for 2 weeks that was not stopped before surgery.

The final diagnosis of T-cell lymphoma was established 1 month after stopping steroid therapy. Coregistration of postoperative CT data with preoperative planning data is shown. A and B: Two preoperative planning images are shown left and 2 postoperative CT images matched with preoperative planning are shown right.

In all cases, biopsies were obtained within the tumor targeted. C: Postoperative CT images coregistered and merged with preoperative planning images. Bone print arrow indicating the hole made during surgery and air bubble confirming that the biopsies were obtained inside the tumor. In all cases, the biopsy site was inside the tumor targeted. A diagnosis of inflammatory process was also reported for a patient with a 1-cm contrast-enhancing frontobasal lesion but without hyperperfusion or tumor spectra on MRI spectroscopy.

The multidisciplinary team decided not to perform a second biopsy but chose to conduct MRI every 3 months. After 9 months of follow-up, the lesion remained unchanged in terms of size and signal characteristics. The last nondiagnostic biopsy was associated with intracystic catheter placement.

This year-old patient was urgently referred to our institution with a deteriorating level of consciousness and massive right hemiparesis. Preoperative MRI showed a partly cystic diencephalic lesion, the solid portion of which showed massive hemorrhagic transformation. Intracystic catheter placement allowed the patient's level of consciousness to return to normal. The histological diagnosis of the lesion was hemorrhage, necrosis, and inflammatory cells.

In view of the typical appearance of the lesion and the patient's poor clinical status, the multidisciplinary team treated the tumor as glioblastoma by chemotherapy alone. The lesion rapidly progressed and the patient died within 2 months.

Bleeding Rate Postoperative CT demonstrated bleeding in 10 patients. Intralesional bleeding associated with transient clinical symptoms was observed in 2 cases. Minimal third ventricle hemorrhage with no clinical manifestations was observed after pineal tumor biopsy in 1 case.

Minimal bleeding along the biopsy trajectory or at the biopsy site was observed in 7 cases. All 7 cases of bleeding were clinically asymptomatic. Representative postoperative CT scans showing the 2 types of bleeding observed in this series. A and B: Images revealing the 2 intralesional hemorrhages that were responsible for transient clinical deterioration. C: Images illustrating the minimal bleeding arrows not associated with any clinical changes after biopsy.

D and E: Postoperative CT scans demonstrating 2 other asymptomatic hemorrhages arrows. Mortality, Transient Morbidity, and Permanent Sequelae No mortality, infectious morbidity, or permanent sequelae related to stereotactic biopsy were observed. Six patients experienced transient morbidity. Transient deterioration of preexisting hemiparesis and oculomotor palsy Parinaud syndrome occurred in 1 patient with a pontine tumor.

The patient's previous neurological status recovered within 10 days following stereotactic biopsy. The tumor was a large B-cell lymphoma.

The presence of a fever with signs of peritonism suggests that the bowel is ischaemic and a perforation is immi- nent. This is most likely to occur in the caecum due to the distensibility of the bowel wall at this point. The patient should be examined carefully for tenderness in the right iliac fossa, and the caecal diameter noted on the radiograph. Conservative treatment involves keeping the patient nil by mouth, intravenous fluids and nasogastric decompression.

A flatus tube can be placed by rigid sigmoidoscopy to relieve some of the distension. Decompression is more effectively achieved by colonoscopy. Fluid and electrolyte abnormalities should be corrected and drugs affecting colonic motility dis- continued, e. He has tried taking simple analgesics with no benefit. The pain is progressively getting worse and he is now finding it uncomfortable to walk or sit down.

He is otherwise fit and well, and smokes ten cigarettes a day. The swelling is warm, exquisitely tender and fluctuant. There is no other obvious abnormality. The organisms responsible tend to be either from the gut Bacteroides fragilis, Escherichia coli or enterococci or from the skin Staphylococcus aureus. Anorectal abscesses originate from infection arising in the cryptoglandular epithelium lining the anal canal.

The internal anal sphincter can be breached through the crypts of Morgagni, which penetrate through the internal sphincter into the intersphincteric space. Once the infec- tion passes into the intersphincteric space, it can spread easily into the adjacent perirectal spaces.

Classification of anorectal abscesses See Figure 4. The abscess should be treated by incision and drainage, and pus should be sent for culture.

Skin organisms are less commonly associated with fistulae than gut organisms. Anorectal fistulas occur in 30—60 per cent of patients with anorectal abscesses. If a fistula is found at the time of incision and drainage, the location should be noted and the patient brought back once the sepsis has resolved. It is itchy but has not changed colour or bled. There is no relevant family history. He is fit and well otherwise. As part of his job he spends half the year in California. He smokes five cigarettes per day.

Examination He appears well. Several moles are present over the neck and trunk. All appear benign, except the one he points out that he is concerned about. The lesion is non-tender with a slightly irregular surface. There is a surrounding pink halo around the lesion. The local lymph nodes are not enlarged. Abdominal, chest and neurological examinations are normal.

This is then assessed by a histopathologist. Both give impor- tant prognostic information. Treatment is predominantly surgical with wide local excision. When examining patients with suspicious moles, lymphadenopathy must be sought, as this indicates spread of the malignant melanoma. In cases with metastasis, malignant melanoma usually involves the lungs, liver and brain. On further question- ing he says he has passed a small amount of flatus yesterday but none today.

He has had a previous right-sided hemicolectomy 2 years ago for colonic carcinoma. He lives with his wife and has no known allergies. Examination His blood pressure and temperature are normal. He has obvious abdominal distension, but the abdomen is only mildly tender centrally. The hernial orifices are clear.

There is no loin tenderness and the rectum is empty on digital examination. The bowel sounds are hyperactive and high pitched. Chest examination finds reduced air entry bibasally. Figure 6. In this case it is most likely to be secondary to adhesions from his previous abdominal surgery, but may also be due to recurrence of his can- cer. Typical features on the x-ray include dilated gas-filled loops of bowel and air-fluid levels.

The small bowel is distinguished from the large bowel by its valvular conniventes radiologi- cally transverse the whole diameter of the bowel. The large bowel has haustral folds, which do not fully transverse the diameter of the bowel.

Small-bowel loops usually lie centrally and large-bowel loops lie peripherally. If a patient develops any systemic signs of sepsis or peritonism, then strangulation of the bowel should be considered. If this occurs, the patient will require urgent resuscitation and a laparotomy. If the patient is systemically well, with a diagnosis of adhesional obstruction, then management is as below. He has no abdominal pain and has not vomited. There is no previous history of altered bowel habit. His appetite is normal and he reports no recent weight loss.

He has recently been diagnosed with mild hypertension. He takes bendroflume- thiazide 2. Examination He looks pale and sweaty.

His temperature is normal. His abdomen is soft with no evidence of disten- sion.

The rest of his examination is unremarkable. Rectal examination reveals altered blood mixed with the stool and there are some blood clots on the glove. Rigid sigmoidoscopy was unsuccessful due to the presence of blood and faeces. Bloods should be taken for a full blood count, coagulation screen, renal function and a crossmatch for at least four units.

Intravenous fluids should be started and a urinary catheter inserted to monitor hourly urine output.

The patient is best monitored closely until he becomes stable with regular observations. Campylobacter, Salmonella, E.

If the bleeding continues, an oesophagogastroduodenoscopy OGD should be done first to rule out an upper gastroin- testinal cause for the bleeding. Colonoscopy can then be performed to assess the large bowel for a cause. Unfortunately, because of the presence of blood, views are often poor. If the approximate area of affected bowel can be established, it allows better planning for surgical intervention. If the bleeding is quite dramatic, mesenteric angiography should be considered, to delineate the anatomy and identify any bleeding vessels.

Selective embolization may be employed to stop the bleeding in certain cases. If the source of bleeding is not known and other measures have failed, the patient may require a sub-total colectomy. He has noticed this over the past few months and his pain is worse on exer- tion. He has also noticed an intermittent swelling. He is otherwise fit and well.

There is a family history of bowel cancer. He is a smoker of 25 cigarettes per day and drinks 10 units of alcohol per week. Examination He is apyrexial with normal blood pressure and pulse. The abdomen is grossly normal but there is some tenderness in the right groin. The patient is asked to stand. In the right groin, there is a swelling, which is more pronounced when the patient coughs.

The other groin and the scrotal examination are normal. The boundaries of the inguinal canal are: Indirect inguinal hernial sacs are found lateral to the inferior epigastric vessels at the deep inguinal ring.

Direct her- nias are found medial to the inferior epigastric vessels and are a result of a weakness in the posterior wall. This distinction between the two can only be made with certainty at the time of surgery. The key in distinguishing between femoral and inguinal herniae is their point of reduction. Femoral herniae reduce below and lateral to the pubic tubercle, and inguinal her- niae above and medial to the tubercle. This can be done by either an open or laparoscopic approach.

Both involve reduction of the hernia and placement of a mesh to prevent recurrence. The pain is constant, and simple analgesia has not helped. She has vomited once in the department. Her menses are regular and she is now on day 12 of her cycle. There is no history of vaginal discharge or urinary symptoms. She has no children. She has not undergone any previous surgery but has a history of sexually transmitted disease 2 years ago, treated with antibiotics.

There is no other relevant medical history. She takes no current medication and has no allergies. She is a non-smoker. Her temperature is There are no palpable masses and the loins are not tender. Bimanual per vaginal examination reveals adnexal tenderness on the right. The young female with right iliac fossa pain is often difficult to diagnose. The other differen- tial diagnoses of right iliac fossa pain mimicking appendicitis are shown below.

In clear-cut cases of appendicitis, the patient is taken to theatre for appendicectomy. If the diagnosis is most likely gynaecological, the patient should be referred to the gynaecologists for a transvaginal ultrasound scan and high vaginal swabs.

Where there is doubt, the patient can be taken for diagnostic laparoscopy. If the appendix is abnormal, it can then be removed laparoscopically. The pain localized to the right iliac fossa and a diagnosis of acute appendi- citis was made. At operation, the appendix was found to be normal and the anomaly shown in Figure Figure This is a remnant of the omphalomesenteric duct.

The mode of presentation may be: The diverticulum should be removed by a segmental small-bowel resection. A symptomless diverticulum that is an incidental finding at laparotomy should not be excised, but the patient should be informed of its existence.

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He normally opens his bowels once a day, but has recently been passing loose motions up to four times a day. The motions have been associated with the passage of blood clots and fresh blood mixed within the stools. His appetite has been normal, but he reports a 2-stone weight loss. The past history was otherwise unremarkable. His father died from cancer at the age of 45 years, but he is unsure of the origin.

Examination No pallor or lymphadenopathy is present. The abdomen is soft and non-tender with no pal- pable masses. Digital rectal examination is normal.

A biopsy of the lesion should be taken at the time of sigmoidoscopy to confirm the diagnosis of rectal cancer. Blood tests including full blood count, liver function tests and tumour markers e.

An urgent colonoscopy is required to deter- mine whether there are any synchronous cancers 5 per cent or synchronous polyps 75 per cent in the rest of the large bowel. The patient should be staged using computerized tomography CT of the chest and abdomen to check for chest, mediastinal and intra-abdominal metastases.

Magnetic resonance imag- ing MRI of the pelvis is used to ascertain the depth of tumour invasion through the rectal wall and any regional nodal metastases.

For tumours penetrating the rectal wall, preoperative radiotherapy is beneficial, and more recently a combination of chemotherapy and radiotherapy has been advocated for some tumours.

He is off his food and has lost 2 stone in weight over the previous 2 months.

He reports no rectal bleeding or change in bowel habit. His father died at the age of 58 years from a colonic tumour. He is otherwise well and not on any regu- lar medication. His GP referred him to the colorectal clinic, as he was concerned about his blood results and his strong family history of colorectal cancer.

Examination On examination, his conjunctivae are pale and he looks cachectic. There is no jaundice or palpable lymphadenopathy. The chest is clear and the heart sounds are normal. Examination of the abdomen reveals a fullness in the right iliac fossa. There is no associated hepatomegaly. The patient should then have their urine checked for haematuria, a rectal examination, and should be screened for coeliac disease.

OGD and colonoscopy should be performed to exclude malignancy. One of the most common causes of iron-deficiency anaemia is from medications such as aspirin or other non-steroidal anti-inflammatory drugs. The CT scan in this patient shows a caecal tumour.

These can present insidiously and may only present with iron-deficiency anaemia. Further investigations should include liver func- tion tests and a CEA tumour marker level. A CT scan of the chest, abdomen and pelvis will delineate the nature of the mass and any metastatic disease. A colonoscopy provides a tissue diagnosis and will rule out any synchronous tumours in the large bowel. In the absence of metastatic disease, the patient should undergo right hemicolectomy.

Adjuvant chemotherapy may be required, depending on the depth of the resected tumour and involvement of the local lymph nodes. If metastatic disease is present, then a palliative resection should be considered in patients with anaemia or obstruction. He has not opened his bowels for 5 days. He suffered a major stroke in the past and requires constant nursing care.

He has a history of chronic constipation. Previous medical history includes chronic obstructive airways disease for which he is on regular inhalers. He is allergic to penicillin and is an ex-smoker. His temperature is There is gross abdominal distension with tenderness, most marked on the left-hand side.

The abdomen is resonant to percussion and digital rectal examination reveals an empty rectum. There is a soft systolic murmur and mild scattered inspiratory wheeze on auscultation of the chest. The sigmoid colon is grossly dilated and has an inverted U-tube shape. The involved bowel wall is usually oedematous and can form a dense central white line on the radiograph. X-ray appearances are diagnostic in 70 per cent of patients. Colonoscopy can be used to decompress the bowel and may resolve the volvulus.

It may be appropriate to use only conservative treatments in some patients. Sigmoid volvulus is predisposed to by a long, narrow mesocolon and chronic constipation. The rotation of the gut can lead to obstruction and intestinal ischaemia. The sigmoid is the commonest part of the colon for this to occur, although the caecum and splenic flexure are other potential sites. The pain is around the anus and typically lasts an hour after passing stool. He normally suffers with constipation but this has now worsened as he is reluctant to pass motion because of the pain.

He intermittently notices a small amount of fresh blood on the tissue paper after wiping himself. He has no family history of inflammatory bowel disease or colorectal cancer. He is otherwise well and takes no regular medications.

Examination The patient appears well with no evidence of pallor, jaundice or lymphadenopathy. Abdominal examination is unremarkable. Rectal examination could not be performed as it caused too much discomfort for the patient. Examination typically reveals a linear tear in the midline and posteriorly.

Anterior fissures are more common in female patients. Chronic fissures are associated with skin tags, and the exposed fibres of the internal sphincter may be visible at their base. This should include the use of laxatives, high dietary fibre, fruit and plenty of fluids to ensure the stool is soft. Topical local anaesthetic e. Non-healing fissures may respond to the use of topical 0. This ointment can cause headaches and dizziness, so is not suitable for all patients.

Direct injection of botulinum toxin into the anal sphincter helps relieve spasm and promotes healing. Lateral sphincter- otomy is used less frequently now as it is associated with a small risk of incontinence. He has been vomiting for the past 2 days and last opened his bowels 3 days ago. He reports a 2-stone weight loss in the past year but is other- wise fit with no other past medical history of note.

He currently lives on his own and leads an active life, walking his dog every day. Cardiovascular and respiratory examinations are unremarkable. The abdomen is distended and tympanic to percussion with lower abdominal tenderness.

The hernial orifices are empty and digital rectal examination reveals an empty rectum. Large-bowel obstruction classically pres- ents with lower abdominal pain, abdominal distension and absolute constipation.

Vomiting is a late feature. The common causes of large-bowel obstruction are listed below: The large bowel gradually dilates with maximal dilatation occurring in the caecum. Decompression of the large bowel with either a colonic stent or defunc- tioning loop colostomy may be required. More definitive surgery can then be planned after optimization and further imaging. A contrast enema or contrast CT can be used to determine the level of the obstruction and if it is complete.

If the patient is stable and is suspected of having a tumour, then histology should be gained and staging completed by computerized tomography of the chest, abdomen and pelvis prior to definitive surgery. The barium enema demonstrates a stenosis at the rectosigmoid junction secondary to a tumour arrow in Figure She vomited once yesterday and has opened her bowels normally today. She usually suffers with constipation. The pain is severe and constant with no relieving factors.

She has had one previous episode a year ago, which was treated with antibiotics. She was investigated once her symptoms had subsided, but is unclear about the final diagnosis. Examination She looks flushed, with dry mucous membranes and is febrile at Abdominal examination reveals localized tenderness and peritonism in the left iliac fossa.

100 Cases In Surgery Paperback Pdf

The rectum contains soft faeces on digital rectal examina- tion. The previous investigation from a year ago is shown in Figure There are multiple diverticula of the sigmoid colon giving a diagnosis of diverticular disease.

Diverticula are outpouchings of the mucous mem- brane alongside the taenia coli, at the entry point of the supplying blood vessels. Diverticular disease is very common, with over 60 per cent of the population affected by the age of 80 years.

It is more common in developed countries due to low-fibre diets. The low-bulk stool leads to increased segmentation of the colon during propulsion, causing increased intralu- minal pressure and formation of diverticula.

They are found most commonly in the sigmoid colon 95—98 per cent of diverticula , but any part of the bowel may be affected.

The majority of patients with diverticula remain symptomless. Fifteen per cent complain of colicky abdominal pain without inflammation diverticulosis , and 5 per cent develop acute diverticulitis. The impaction of faecal material in the neck of the diverticulum leads to trap- ping of bacteria. The bacteria then replicate in the occluded lumen, leading to infection and inflammation. Diverticular disease is also a common cause of lower gastrointestinal bleed- ing. The small blood vessels, which are stretched over the dome of the diverticula, can rup- ture causing bleeding.

Initial investigations should include urinalysis, blood tests, blood cultures and a plain abdominal x-ray. Treatment should commence with intravenous access, intravenous fluids, analgesia, oxygen, broad-spectrum antibiotics and thromboprophylaxis. The patient should be monitored closely. Patients in whom a diverticular perforation is suspected may require a laparotomy. Barium enema will confirm the diagnosis of diverticular disease, but this should not be performed in the acute setting.

Once an acute episode has resolved, the patient should commence on a high-roughage diet to reduce the incidence of further attacks. The blood is always bright red, separate from the stool and drips into the pan.

He also complains of itching around the anus. There is no other past medical history of note. Examination Abdominal examination is unremarkable. Haemorrhoids are con- gested vascular cushions containing dilated veins and small arteries.

A low-fibre diet results in straining with defecation, causing engorgement of the tissue. This leads to enlargement of the cushions and prolapse. Pregnancy and abnor- mally high tension of the internal sphincter muscle can also cause haemorrhoidal problems. If there is any doubt as to the cause of bleeding, especially in the older patient, a flexible sig- moidoscopy or full colonoscopy should be carried out.

Haemorrhoids can be classified as: Large second-degree and third-degree piles may require haemorrhoidectomy. For the past 7 weeks he has been passing more frequent stools 3—4 times per day. The motions are looser than normal, but do not contain any blood. He has lost a stone in weight in the past 6 months. Past history includes a fractured femur 8 years ago and an appendicectomy at the age of 20 years. His mother had ulcerative colitis.

He is very active and a keen golfer. Examination The temperature is The abdomen is soft and non-tender with no masses or organomegaly. Urgent investigation is requested and shown below. A colonoscopy would help to delineate the pathology within the colon and would allow biopsy to provide a tissue diagnosis. The colon can also be examined for synchronous tumours found in 3 per cent. A CT scan of the chest, abdomen and pelvis is then required to stage the tumour and to determine operability.

Most cancers are thought to arise within pre-existing adeno- mas.

Right-sided lesions can present with iron-deficiency anaemia, weight loss or a right iliac fossa mass. Left-sided lesions present with alteration in bowel habit, rectal bleeding, or as an emergency with obstruction or perforation. Adjuvant radiotherapy is given for rectal cancer either pre- or postoperatively to prevent local recurrence.

Adjuvant chemotherapy improves survival in locally advanced tumours.

Frameless robotic stereotactic biopsies: a consecutive series of 100 cases

His stool is looser than normal and occa- sionally contains mucus. His appetite has been healthy, but he has lost half a stone in weight. He also describes an intermittent colicky lower abdominal pain that occurs most days and is relieved by opening his bowels.

He is otherwise well with no history of recent foreign travel.A diagnosis of inflammatory process was also reported for a patient with a 1-cm contrast-enhancing frontobasal lesion but without hyperperfusion or tumor spectra on MRI spectroscopy. He has lost a stone in weight in the past 6 months. The laser can be seen on the patient's skin. FPCT reference imaging was performed with the patient in place and surgery was planned on the basis of the preoperative MRI. He smokes five cigarettes per day.

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