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Tumors of the clival and parapharyngeal areas are a challenge because of their location. They used to be considered inaccessible because the aggressive approaches employed caused elevated levels of morbidity. This fact led to more conservative approaches that attempted to preserve the exposure of the lesion. These approaches were a combination of cranial and facial procedures, thus utilizing a combined effort between neurosurgeons and maxillofacial surgeons. We described our experience with a partial segmented Le Fort I osteotomy added to a transmandibular approach to expose a chordoma of the clivus and left parapharyngeal space. A three-dimensional imaging was used as a diagnostic tool and to plan the optimal surgical approach. The operative technique was described in this case study. Some important technical details of the approach are described. The global outcome was favorable.

Between April 1, 1989, and January 1, 1994, 38 patients with chronic acalculous cholecystitis underwent an advanced (3-puncture) laparoscopic cholecystectomy at our institution. The 30 women and 8 men had a mean age of 39 years (range, 23 to 65 years) and represented 4.5% of our overall gallbladder patient population. In each case, the disease produced typical biliary colic, but no gallstones were visualized on ultrasound examination; cholecystokinin-stimulated cholescintigraphy revealed a dysfunctional gallbladder, as evidenced by an ejection fraction of < or = 35% or nonvisualization or nonemptying of the organ. In all 38 cases, cholecystectomy resulted in the complete relief of symptoms. Although an increasing number of physicians are recommending this operation for acalculous gallbladder disease, it should not be performed on the basis of clinical history alone. Rather, objective criteria confirming the need for surgical intervention should be obtained by means of appropriate preoperative testing, including cholecystokinin-stimulated cholescintigraphy.