PSU Volume 67 No 01 JULY 2026

Koempel's Suprahyoid Technique

The Sistrunk procedure, first described in 1920, remains the standard of care for thyroglossal duct remnant (TGDR) excision. It requires removal of the cyst or sinus tract, the central portion of the hyoid bone, and a core of tissue extending superiorly to the foramen cecum. Despite nearly a century of surgical experience, recurrence rates have ranged from as low as 1.2% to as high as 20% across published series, and inadequate dissection of the suprahyoid region has consistently been identified as the primary contributing factor. In response to this persistent clinical challenge, a systematic, anatomically grounded approach to the suprahyoid area was developed through sixteen years of intraoperative observation and formally described in 2014 by Koempel. Koempel's technique, which transformed the most technically uncertain component of the Sistrunk procedure into a reproducible, landmark-guided dissection, achieved a 0% recurrence rate in 74 consecutive cases over nine years and has since been validated in a major systematic review and cited in leading single-institution series worldwide.

Thyroglossal duct remnants, encompassing both cysts and sinus tracts, represent the most common congenital anomaly of the anterior neck in childhood, affecting approximately 7% of the general population. The fundamental difficulty of the procedure lies not in the infrahyoid dissection — which is generally straightforward — but in the segment above the hyoid bone. A thyroglossal tract in the suprahyoid area is rarely visible or palpable during surgery, is often friable and easily disrupted, and may exist as multiple branching ducts rather than a single identifiable structure. Anatomical reconstruction studies using three-dimensional serial sectioning have demonstrated extensive broom-like branching of the thyroglossal duct both above and below the hyoid, with a single tract at the level of the bone itself. Serial pathological analysis of TGDR specimens further established that microscopic thyroglossal duct tissue was present superior to the hyoid in 74% of primary resections and in 100% of revision cases — making complete suprahyoid clearance not merely desirable but essential to surgical cure.

Prior descriptions of the suprahyoid component of the Sistrunk procedure offered little precise guidance. Authors recommended removing a "wide cuff of tissue" or a "generous core of tongue musculature" — language that left the extent of dissection entirely to the surgeon's judgment. Without a reliable anatomical landmark to define the margins of resection, the tissue removed varied substantially from case to case and surgeon to surgeon. Sistrunk himself recognized the difficulty of isolating the tract above the hyoid, cautioning against any attempt to do so, and recommended instead a blind coring technique toward the foramen cecum at a 45-degree angle. While conceptually sound, this guidance proved extremely difficult to reproduce consistently, and two recurrences within a short period prompted a careful re-evaluation of the procedure that ultimately led to the development of the technique described here.

Koempel's modified approach proceeds through twelve discrete steps. Soft tissue skin flaps are raised to 1 cm above the hyoid superiorly and 1 cm below the inferior extent of the TGDR. The median raphe of the strap musculature is divided, and the pretracheal fascia is identified and preserved as the posterior border of dissection throughout. As the surgeon proceeds toward the hyoid, several millimeters of the medial aspect of the strap muscles bilaterally are included in the specimen. Using the laryngeal prominence as a midline reference, 1 to 1.5 cm of the central hyoid is measured, and lateral cuts are made through the bone or cartilage before any tissue superior to the hyoid is addressed — a sequence that eliminates the risk of inadvertently transecting a suprahyoid tract during hyoid division.

The most distinctive and consequential step involves the identification of a specific tissue plane change in the suprahyoid region. Using monopolar electrocautery with a Colorado tip — chosen to minimize bleeding and prevent blood from obscuring the operative field — along with gentle blunt dissection with a small hemostat, the muscle fibers extending superiorly from the resected hyoid segment are carefully and slowly transected. These fibers run in a superior-to-inferior orientation. Dissection continues until the tissue surface transitions from these vertically oriented muscle fibers to a smooth, glistening appearance underneath. This visual and tactile change — representing the interface between the mylohyoid and geniohyoid muscles and a deeper fibrinous layer or a portion of the genioglossus muscle — constitutes the critical anatomical landmark that defines the anterior and lateral margins of suprahyoid resection. It is objective, reproducible, and present regardless of whether a gross duct tract is visible.

Once this plane is reached, a 1 cm diameter area of tongue base is outlined and resected en bloc with the specimen. Careful observation is maintained throughout for the appearance of mucinous material, which would indicate the need for wider excision. The tongue musculature defect is closed with a figure-of-eight suture of absorbable material followed by a second running layer. The hyoid ends are not reapproximated. A rubber band drain is brought out through both ends of the wound. Notably, no attempt is made at any point to isolate or follow a specific duct tract — consistent with the original Sistrunk recommendation — thereby eliminating the risk of tract disruption and incomplete resection that had historically contributed to recurrence.

The clinical impact of adopting this approach was immediate and substantial. In a retrospective series of 94 patients treated over a 16-year period, including both primary and revision cases, 92 underwent a Sistrunk procedure and were eligible for recurrence analysis. Mean patient age was 5.2 years, ranging from 9 months to 16 years. Before consistent application of the suprahyoid technique in 2004, the recurrence rate following a Sistrunk procedure was 11.1% (2 of 18 cases). After systematic adoption of the technique, not a single recurrence was observed in 74 consecutive cases over the following nine years — a difference that was statistically significant by Fisher's exact test (p = 0.037). The overall recurrence rate across the entire Sistrunk cohort was 2.2%, and intraoperative visualization of a suprahyoid tract was documented in only 26.6% of cases, confirming that the technique functions effectively precisely because it does not depend on tract identification.

External validation arrived the following year through the first systematic review specifically addressing surgical management of recurrent thyroglossal duct cysts in children. Nine studies meeting predefined inclusion criteria were identified, comprising 66 patients who underwent 114 secondary surgeries across four main surgical approaches: repeat Sistrunk procedure, en bloc central neck dissection, suture-guided transhyoid pharyngotomy, and the suprahyoid technique described above. Repeat Sistrunk procedures carried a 30.12% recurrence rate. En bloc central neck dissection achieved a 20% recurrence rate. In contrast, both suture-guided transhyoid pharyngotomy and the suprahyoid technique reported 100% success rates in their respective patient cohorts. The review's authors concluded that these were the only two approaches that clearly delineated the specific amount of suprahyoid tissue to be removed, and that this specificity was the likely driver of their superior outcomes. Additional prospective studies and broader institutional adoption were called for to confirm reproducibility.

A 28-year single-surgeon series examining central neck dissection for recurrent and infected thyroglossal duct remnants provided further context. That analysis subdivided the challenges of TGDR surgery into three anatomical compartments — infrahyoid, posterior hyoid, and suprahyoid — and assigned a different surgical strategy to each. Central neck dissection, operating along fascial planes rather than following embryological remnants, reliably controls infrahyoid disease and improves access to the hyoid and posterior hyoid space. However, that same analysis explicitly acknowledged that central neck dissection does nothing to address the difficulties of following the thyroglossal tract into the tongue base — the domain where the suprahyoid technique operates. The two approaches are therefore not competing strategies but complementary ones, with the suprahyoid technique addressing the anatomical frontier that central neck dissection leaves unresolved.

The advantages of the suprahyoid technique are multiple and clinically meaningful. It is applicable to both primary and revision cases, with no difference in the identifiability of the key anatomical landmarks even in previously operated fields — a finding attributed to the fact that in most revision procedures, the hyoid and suprahyoid structures are found largely undisturbed. It requires no specialized equipment, no intraoperative imaging, and no entry into the pharynx. Its defining landmark — the transition from vertically oriented muscle fibers to a smooth, glistening deep plane — provides an objective, reproducible criterion for determining the extent of resection that replaces the subjective estimation inherent in previous descriptions. And its step-by-step structure makes it teachable and applicable by surgeons-in-training and low-volume TGDR surgeons who would otherwise have the highest rates of recurrence.

The technique does not replace the Sistrunk procedure. It refines it at its most vulnerable point, converting the least reproducible component of an otherwise well-defined operation into a systematic, anatomically grounded dissection. The evidence base, while primarily derived from single-institution retrospective series and one systematic review, is internally consistent and directionally unambiguous: where the technique has been applied systematically, recurrence rates fall to zero. Its inclusion in the routine management of both primary and revision thyroglossal duct remnants is supported by the available literature and should be considered by any surgeon seeking to reduce recurrence in this most common of pediatric congenital cervical anomalies.

Alternative Management of Giant Omphalocele

Giant omphalocele (GO) remains one of the most formidable challenges in neonatal surgery. Its definition lacks consensus across the literature — most authors require either a defect of 5 cm or more in diameter and/or significant liver herniation within the sac, though some set the threshold at 7 cm or specify that more than 50–75% of the liver must be contained — but regardless of the precise criterion used, GO is not simply a structural anomaly — it is a condition embedded in a web of associated malformations, pulmonary hypoplasia, cardiac defects, and chromosomal aberrations that together dictate its prognosis far more than the defect size alone.

Omphalocele occurs in approximately 1 in 4,000 to 10,000 live births, and its incidence continues to decline in regions where prenatal screening leads to elective termination of pregnancies complicated by severe associated anomalies. Yet for those infants who are born with giant omphalocele, the surgical and neonatal teams face a condition for which no universally accepted treatment protocol exists.

The fundamental problem is biomechanical. The abdominal cavity has never fully developed to accommodate the herniated viscera, and any attempt at immediate primary closure risks catastrophic intra-abdominal hypertension, abdominal compartment syndrome, respiratory failure, and death. This visceroabdominal disproportion has driven clinicians to devise a wide spectrum of approaches, ranging from purely nonoperative strategies that allow epithelialization of the sac over months or years, to minimally invasive staged reduction techniques that aim for definitive fascial closure within the first weeks of life. Understanding how these approaches evolved — and how they compare — is essential for the modern pediatric surgeon.

For decades, the nonoperative "paint-and-wait" strategy served as the default approach for infants whose comorbidities made early surgery prohibitive. This method involves the application of topical escharotic or antimicrobial agents — most commonly silver sulfadiazine, silver-impregnated dressings, or povidone-iodine — to the intact omphalocele membrane, allowing progressive desiccation, eschar formation, granulation tissue development, and ultimately epithelialization of the sac surface. The resulting ventral hernia is then repaired electively, often years later, when the child is larger and physiologically more robust. Advocates of this approach note its low early mortality, avoidance of neonatal anesthesia, and allowance of early enteral feeding. A systematic review by Bauman and colleagues, frequently cited across the literature, concluded that nonoperative delayed closure was associated with lower mortality and faster achievement of full enteral feeding compared to early staged surgical approaches. However, the morbidity and social costs of leaving a child with an unrepaired giant abdominal wall defect for years, the risk of infection, and the need for eventual complex surgical reconstruction are real and significant limitations.

The question of which topical agent to use within the paint-and-wait paradigm has itself generated debate. Dörterler, reporting on 22 infants treated in Turkey, described a protocol combining daily povidone-iodine application with a powdered antibiotic spray (polymyxin B, bacitracin, and neomycin) and circumferential elastic bandaging using a cohesive elastic wrap. In this series, conservative management lasted a mean of 11 days before early graft closure was performed, with a mean total hospital stay of only 35 days among survivors. Seven patients died in the first week, all with larger defects and higher rates of complications — a sobering reminder that even with optimized topical care, the most severe cases carry a mortality approaching 30%. The elastic bandaging component of this protocol deserves attention. By providing gentle circumferential compression from xiphoid to pubis, it facilitates gradual reduction of sac contents while supporting repositioning of the liver toward the midline, effectively functioning as a noninvasive silo. This principle — gradual, controlled external compression to recruit abdominal domain — is the conceptual thread that runs through virtually all the alternative strategies reviewed here.

Kogut and Fiore formalized this concept with their serial taping technique, reported from a Las Vegas tertiary children's hospital. In their series of 10 infants treated between 2010 and 2017, the omphalocele sac was serially taped at the bedside in the NICU using Mastisol adhesive and strips of clear Tegaderm applied in a criss-cross fashion across the defect. No infant underwent an attempt at primary closure first. Tape was applied daily in successive layers, maintaining forward tension on the lateral abdominal wall muscles while gently reducing the volume of the amniotic sac. Crucially, this was done on the awake infant — a built-in safety mechanism, since an awake baby cannot be taped too tightly without protest. The mean time to operative closure was 13.7 days. Six of the ten infants achieved primary fascial closure without any mesh; four required a small Gore-Tex patch, most of which were subsequently removed and replaced with primary repair. This approach is compelling in its simplicity. It requires no special materials beyond adhesive tape and skin preparation, avoids operative anesthesia during the reduction phase, preserves the fascial edges and amnion intact, and keeps the option of topical escharotic therapy available if the method fails. Complications were minimal, and sac integrity was maintained in all cases until operative closure.

The most technically sophisticated evolution of the staged reduction concept is the nonsurgical silo technique described by Abello and colleagues, developed over 25 years at institutions in Colombia and Chile. Their technique employs DuoDERM hydrocolloid dressing cut in a "T" shape, fixed bilaterally to the skin lateral to the defect and wrapped around the omphalocele sac to construct a 360-degree silo without a single suture. Tongue depressors placed at the apex of the silo serve as gentle clamps that are progressively tightened every one to two days under continuous monitoring of intra-abdominal pressure, with a strict ceiling of 20 cm H2O. The protocol unfolds in three phases: silo reduction until the liver and bowel are fully reintegrated (Phase 1), amnion inversion with skin edge approximation to simulate definitive closure and assess tolerance (Phase 2), and definitive surgical closure in the operating room (Phase 3). In a multicenter retrospective cohort of 40 patients spanning 1994 to 2019, anatomical closure was achieved in 95% of cases, median time to closure was 12 days, and there were no deaths attributable to the technique itself. The four deaths observed were all related to severe associated cardiac or pulmonary conditions — precisely the comorbidities that drive mortality in GO regardless of surgical approach.

A parallel retrospective cohort study by Barrios-Sanjuanelo and colleagues specifically analyzed mortality predictors among 30 neonates treated with the Abello technique in Barranquilla, confirming an overall mortality rate of 16.7% — well within the 13–25% range typically cited for giant omphalocele — with mortality significantly associated with the presence of other malformations, congenital heart defects, pentalogy of Cantrell, and pulmonary hypertension. Critically, no mortality was associated with technique-related complications, silo reduction time, or abdominal closure timing. This finding reinforces a principle that is now widely accepted but not always acted upon. In giant omphalocele, survival is determined far more by associated anomalies than by the choice of surgical technique. This has important implications for counseling families and for designing future comparative studies.

For the subset of patients in whom neonatal closure is not achievable and "paint-and-wait" becomes the de facto management, the challenge eventually becomes one of delayed fascial reconstruction, often years later. Boglione and colleagues from Buenos Aires reported their experience using the San Martín technique — an anatomo-physiological procedure originally described for large midline incisional hernias in adults — for the delayed closure of giant omphaloceles in eight children at a median age of six years. The technique involves bilateral curvilinear release incisions on the outer aspect of the anterior rectus sheath, mobilizing aponeurotic flaps medially and suturing them together at the midline over the posterior sheath, followed by approximation of the rectus muscles and any remaining anterior sheath. No prosthetic mesh was required in any of the eight patients. Median postoperative mechanical ventilation was three days, enteral feeding resumed at a median of four days, and hospital stay was ten days — strikingly efficient outcomes for what represents some of the most complex abdominal wall reconstruction in pediatric surgery. There were no complications attributable to the technique itself during follow-up ranging from 18 months to eight years.

Finally, at the frontier of adjunctive therapies, Armijo and colleagues described the combined use of preoperative botulinum toxin A injections and subfascial tissue expanders in a four-year-old boy with giant omphalocele and multiple comorbidities including chronic lung disease, tracheostomy, and pulmonary hypertension. Botulinum toxin A, injected under ultrasound guidance into the transversus abdominis, internal oblique, and external oblique muscles bilaterally, induces a reversible flaccid paralysis of the lateral abdominal wall musculature that peaks at four to six weeks and subsides over three months. This chemically induced muscle relaxation reduces fascial tension at closure, decreases intraabdominal pressure, and may even attenuate postoperative pain by inhibiting the release of substance P and glutamate. When combined with the domain-expanding effect of the tissue expanders, definitive midline fascial closure was achieved with the patient remaining complication-free at nine months postoperatively.

Taken together, these six bodies of work map a continuum of therapeutic strategies for giant omphalocele that is far richer — and far more nuanced — than the binary "operate early versus paint-and-wait" framing that has historically dominated the literature. The choice among serial taping, elastic bandaging with topical agents, nonsurgical silo reduction, delayed fascial reconstruction with anatomical techniques, or botulinum toxin augmentation is not simply a matter of surgeon preference; it must be individualized to the infant's physiology, the severity of associated anomalies, the institutional resources available, and a candid assessment of what the family can sustain over what may be a months- or years-long treatment course. What the evidence increasingly supports is that gradual, monitored, external pressure — however it is applied — is the key mechanism driving successful domain recruitment, and that the infant's associated comorbidities, not the defect itself, are the true arbiters of survival.

Peritoneal Loose Body

Peritoneal loose bodies (PLBs) represent one of the more curious and frequently overlooked entities in abdominal medicine. These free-floating intraperitoneal masses are benign in nature, yet their rarity and nonspecific clinical presentation make them a persistent diagnostic challenge for surgeons, radiologists, and clinicians alike. Most physicians will encounter one only by accident — during an imaging study ordered for an unrelated complaint, during an exploratory laparoscopy, or at autopsy. This incidental quality defines much of what makes PLBs so medically interesting. They exist quietly inside the abdomen, often causing no trouble at all, yet they occasionally grow large enough to compress surrounding structures and provoke symptoms that mimic far more serious disease.

The most widely accepted explanation for how PLBs form begins with the epiploic appendages — small, fat-filled pouches that hang from the outer surface of the colon along its antimesenteric border. When one of these appendages undergoes torsion, its blood supply is interrupted. Ischemia follows, leading to infarction and aseptic fat necrosis. The necrotic tissue then undergoes saponification, a chemical transformation of fat, followed by progressive calcification and fibrosis. As the connecting pedicle atrophies, the calcified mass detaches completely from the colon wall and becomes a free body within the peritoneal cavity. This sequence — torsion, ischemia, necrosis, saponification, calcification, detachment — was first conceptualized in the nineteenth century and remains the dominant theory today, though it is not the only one.

Alternative origins have been proposed. Autoamputated adnexal tissue, subserosal uterine leiomyomas that detach and undergo calcification, pancreatic fat, and even the products of a medically managed ectopic pregnancy have all been identified as sources of PLBs in isolated reports. The common thread is a process of detachment, necrosis, and subsequent encapsulation by fibrous tissue, after which the mass becomes independent of any vascular supply. This absence of blood supply is, in fact, one of the defining characteristics of a true PLB — along with its high mobility within the peritoneal cavity and the absence of tumor markers when evaluated.

Once free within the peritoneum, these bodies do not remain static. They are thought to slowly accumulate protein-rich exudate from peritoneal fluid on their surface, growing in a manner that has been compared to the formation of a pearl — layer upon layer deposited over an initiating core. The increased temperature of the peritoneal environment contributes to the characteristic appearance of the cut surface, which resembles a hard-boiled egg: a white, firm outer shell of lamellar fibrous tissue surrounding a central yellowish zone of calcified necrotic fat. This "boiled egg" appearance is now considered a hallmark of PLBs both grossly and radiologically.

The typical PLB is small, ranging from roughly half a centimeter to two and a half centimeters in its largest dimension. At this size, it is virtually always asymptomatic and is rarely detected during life. However, PLBs can grow substantially larger. When a PLB exceeds five centimeters in diameter, it is classified as a giant PLB; those exceeding ten centimeters have been designated super-giant. The distinction matters clinically because size correlates with the likelihood of causing symptoms. The largest PLBs documented in the literature have approached twenty centimeters, though such extremes are extraordinarily rare. Cases of multiple simultaneous PLBs found in the same patient have also been reported.

Demographically, PLBs show a strong predilection for men, with a male-to-female ratio reported in the range of 17:3 to 18:4 across accumulated case series. They occur predominantly in middle-aged and older individuals, most commonly between the fifth and seventh decades of life, though cases in younger patients and even in children have been described. The pelvic cavity is the most frequent site of discovery, a consequence of gravity drawing the freely mobile mass to the most dependent part of the abdomen.

The vast majority of PLBs produce no symptoms whatsoever. They are identified incidentally during imaging performed for other reasons, or are found unexpectedly during abdominal surgery or autopsy. When symptoms do occur, they are typically nonspecific: dull lower abdominal discomfort, a vague sense of fullness, or intermittent constipation. Giant PLBs, by virtue of their size and mobility, can cause more pronounced problems. Compression of the rectosigmoid colon may produce constipation or even frank bowel obstruction. Pressure on the bladder or urethra can result in urinary retention or urinary tract infections. Neurological symptoms involving the lower extremities have been described when a large pelvic mass compresses adjacent nerve structures.

Beyond these compressive complications, PLBs can serve as an unexpected hazard during invasive procedures. A large intraperitoneal mass with a hard, smooth surface can act as a fulcrum beneath loops of bowel during percutaneous procedures such as peritoneal dialysis catheter placement, potentially predisposing the bowel to perforation. This underscores the importance of recognizing PLBs on preoperative imaging before undertaking any percutaneous abdominal intervention.

Preoperative diagnosis of a PLB is notoriously difficult, and in the majority of reported cases, the correct diagnosis was not suspected before surgery. The condition is simply too uncommon for most clinicians to include it readily in their differential, and its imaging features, while distinctive in retrospect, overlap considerably with other entities. The differential diagnosis is broad and includes both benign and malignant conditions: teratoma, calcified uterine leiomyoma, mesenteric tumor, ovarian cancer, colorectal cancer, peritoneal metastases, calcified lymph nodes, urinary or biliary calculi, tuberculous granulomas, appendicoliths, and retained foreign bodies.

Computed tomography is the most useful imaging modality. A PLB characteristically appears as a well-defined, oval or round mass with central calcification and a distinct surrounding soft tissue component, with a clear fat plane separating it from adjacent organs. Because PLBs are freely mobile, rescanning the patient in a different position — prone instead of supine, for example — can demonstrate a change in the location of the mass, which is highly suggestive of this diagnosis. On magnetic resonance imaging, PLBs show low signal intensity on both T1 and T2 sequences, similar to that of muscle or dense collagen, and crucially, they show no contrast enhancement — a feature that helps distinguish them from leiomyomas and teratomas, both of which typically enhance. Ultrasound may reveal a hypoechoic round mass that shifts with probe compression. Plain radiography, when calcification is present and the mass is large, may show a mobile calcified density within the abdomen.

Despite these imaging clues, definitive diagnosis almost always requires surgical exploration and histopathological confirmation. Under direct vision, PLBs have a distinctive appearance: smooth, white to pale yellow, ovoid, hard, and glistening, resembling a boiled egg. Microscopy reveals the characteristic architecture of laminated, acellular fibrous tissue surrounding a core of calcified necrotic fat, often with numerous microcalcifications throughout the fibrous layers.

The management of PLBs is guided primarily by symptoms and the certainty of diagnosis. In asymptomatic patients where the imaging appearance is sufficiently characteristic to allow a confident diagnosis, conservative observation with serial imaging is a reasonable approach. No recurrences have been reported following excision, and no malignant transformation has been documented in the literature. Surgical removal is indicated when the PLB is symptomatic, when it is large enough to risk causing complications, or when the diagnosis remains uncertain and malignancy cannot be excluded. Laparoscopy is now the preferred approach when the diagnosis is considered preoperatively, as it offers all the advantages of minimally invasive surgery and is entirely adequate for extracting even large PLBs. Open laparotomy has historically been more common simply because the diagnosis was rarely made before the abdomen was opened. Any PLB removed surgically should be sent for pathological examination to confirm the diagnosis and exclude other pathology.

Peritoneal loose bodies occupy a peculiar niche in clinical medicine — benign, slow-growing, overwhelmingly asymptomatic, and almost always stumbled upon rather than sought. Their rarity ensures that most clinicians will never encounter one deliberately. Yet awareness of this entity has real practical consequences: it can prevent unnecessary anxiety over a benign finding, avoid misdiagnosis as a malignant pelvic mass, prevent procedural complications during abdominal interventions, and guide appropriate management. As imaging technology continues to improve and abdominal CT and MRI become ever more routine, PLBs are likely to be detected with increasing frequency. Recognizing the boiled egg in the peritoneal cavity for what it is remains both an intellectual exercise and a genuine clinical imperative.