10-mm Incision Research Articles

Fewer-than-four ports versus four ports for laparoscopic cholecystectomy.

Traditionally, laparoscopic cholecystectomy is performed using two 10-mm ports and two 5-mm ports. Recently, a reduction in the number of ports has been suggested as a modification of the standard technique with a view to decreasing pain and improving cosmesis. The safety and effectiveness of using fewer-than-four ports has not yet been established. To assess the benefits (such as improvement in cosmesis and earlier return to activity) and harms (such as increased complications) of using fewer-than-four ports (fewer-than-four-ports laparoscopic cholecystectomy) versus four ports in people undergoing laparoscopic cholecystectomy for any reason (symptomatic gallstones, acalculous cholecystitis, gallbladder polyp, or any other condition). We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2013), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal to September 2013. We included all randomised clinical trials comparing fewer-than-four ports versus four ports, that is, with standard laparoscopic cholecystectomy that is performed with two ports of at least 10-mm incision and two ports of at least 5-mm incision. Two review authors independently identified the trials and extracted the data. We analysed the data using both the fixed-effect and the random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis, whenever possible. We found nine trials with 855 participants that randomised participants to fewer-than-four-ports laparoscopic cholecystectomy (n = 427) versus four-port laparoscopic cholecystectomy (n = 428). Most trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. Seven of the nine trials used a single port laparoscopic cholecystectomy and the remaining two trials used three-port laparoscopic cholecystectomy as the experimental intervention. Only one trial including 70 participants had low risk of bias. Fewer-than-four-ports laparoscopic cholecystectomy could be completed successfully in more than 90% of participants in most trials. The remaining participants were mostly converted to four-port laparoscopic cholecystectomy but some participants had to undergo open cholecystectomy.There was no mortality in either group in the seven trials that reported mortality (318 participants in fewer-than-four-ports laparoscopic cholecystectomy group and 316 participants in four-port laparoscopic cholecystectomy group). The proportion of participants with serious adverse events was low in both treatment groups and the estimated RR was compatible with a reduction and substantial increased risk with the fewer-than-four-ports group (6/318 (1.9%)) and four-port laparoscopic cholecystectomy group (0/316 (0%)) (RR 3.93; 95% CI 0.86 to 18.04; 7 trials; 634 participants; very low quality evidence). The estimated difference in the quality of life (measured between 10 and 30 days) was imprecise (standardised mean difference (SMD) 0.18; 95% CI -0.05 to 0.42; 4 trials; 510 participants; very low quality evidence), as was the proportion of participants in whom the laparoscopic cholecystectomy had to be converted to open cholecystectomy between the groups (fewer-than-four ports 3/289 (adjusted proportion 1.2%) versus four port: 5/292 (1.7%); RR 0.68; 95% CI 0.19 to 2.35; 5 trials; 581 participants; very low quality evidence). The fewer-than-four-ports laparoscopic cholecystectomy took 14 minutes longer to complete (MD 14.44 minutes; 95% CI 5.95 to 22.93; 9 trials; 855 participants; very low quality evidence). There was no clear difference in hospital stay between the groups (MD -0.01 days; 95% CI -0.28 to 0.26; 6 trials; 731 participants) or in the proportion of participants discharged as day surgery (RR 0.92; 95% CI 0.70 to 1.22; 1 trial; 50 participants; very low quality evidence) between the two groups. The times taken to return to normal activity and work were shorter by two days in the fewer-than-four-ports group compared with four-port laparoscopic cholecystectomy (return to normal activity: MD -1.20 days; 95% CI -1.58 to -0.81; 2 trials; 325 participants; very low quality evidence; return to work: MD -2.00 days; 95% CI -3.31 to -0.69; 1 trial; 150 participants; very low quality evidence). There was no significant difference in cosmesis scores at 6 to 12 months between the two groups (SMD 0.37; 95% CI -0.10 to 0.84; 2 trials; 317 participants; very low quality evidence). There is very low quality evidence that is insufficient to determine whether there is any significant clinical benefit in using fewer-than-four-ports laparoscopic cholecystectomy compared with four-port laparoscopic cholecystectomy. The safety profile of using fewer-than-four ports is yet to be established and fewer-than-four-ports laparoscopic cholecystectomy should be reserved for well-designed randomised clinical trials.

Thoracoscopic Resection of the Left Atrial Appendage After Failed Focal Atrial Tachycardia Ablation

This case series describes 3 patients with the unusual location of focal atrial tachycardia in the left atrial appendage who failed catheter ablation but were successfully treated by left atrial appendage resection by a totally thoracoscopic surgical technique. In all 3 cases, left atrial appendage resection was carried out by video-assisted thoracoscopic surgery using only 3 5- to 10-mm incisions, eliminating the need for median sternotomy or thoracotomy. An endoscopic stapler was used to resect the left atrial appendage at its base, successfully eliminating the source of the patients' focal atrial tachycardia. The mean operative time was 84 minutes. All3 patients tolerated the procedure without any complications and were discharged on postoperative day 3. At an average follow-up of 4.5 years, all patients remained asymptomatic and with normal ambulatory rhythm monitoring off all antiarrhythmic medications. Surgical resection of the left atrial appendage using a totally thoracoscopic approach is a safe and successful treatment option for patients who have failed endocardial catheter ablation. This novel approach utilizes smaller incisions and shorter operative times than the more invasive surgical techniques previously described in the literature.

Thorascopic Resection of Esophageal Heterotopic Pancreas

Heterotopic pancreas is normal pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Heterotopic pancreatic tissue is a rare congenital anomaly found usually in the stomach, duodenum, or jejunum and is rarely seen in the esophagus. This is a case of heterotopic pancreas found in the esophagus that was removed thorascopically.

Endoscopic Inguinal Lymphadenectomy for Penile Carcinoma and Genital Malignancy: A Preliminary Report

Open radical inguinal lymphadenectomy is reported to have morbidity as high as 50%. We describe our endoscopic inguinal lymphadenectomy that aims at decreasing the morbidity of the procedure without compromising the oncologic outcomes. Eleven groin dissections were undertaken in seven male patients. The procedure was performed via three ports. The first one was a 10-mm incision 3 mm distal to the apex of the femoral triangle. Two additional trocars (10 mm and 5 mm) were positioned 6 cm medially and laterally to the apex of the triangle, respectively. Taking the great saphenous vein as a landmark, the superficial and deep components were dissected. The boundaries of dissection were the same as those of radical inguinal lymphadenectomy. The numbers of lymph nodes harvested were recorded. The morbidity was retrospectively analyzed. The mean operative time was 126 minutes. The mean number of lymph nodes was 12.3. The averaged output of drainage per leg was 50.8 mL each day. There were only three minor complications: One patient had hypercarbia and pneumoderm, and another had 50 mL of seroma; the third had 180 mL of lymphocele. Follow-up ranged from 4 to 27 months (mean 16.3); there was no evidence of recurrence and other sequelae. Endoscopic inguinal lymphadenectomy is feasible for patients with penile cancer and genital malignancy. The technique reduces the risk of complication rate, and the oncologic outcome is highly promising. Larger studies, longer term follow-up are needed to assess the oncologic control and possible morbidity.

Albumin-Coated Bioactive Suture for Cell Transplantation

Cell therapy holds the promise for a novel modality in the surgical toolkit; however, delivery of cells into damaged soft tissues constitutes a challenge. The authors hypothesized that growing stem cells on the surface of absorbable sutures in vitro and then implanting them via stitching would be a suitable delivery route for cell therapy. Fibronectin, poly-L-lysine, and albumin coatings were used to increase attachment of human and rat bone-marrow-derived mesenchymal stem cells (BMSC) to polyfilament absorbable sutures in vitro. Fluorescence microscopy was performed to localize the cells on the suture. After 48 hours of incubation, the albumin-coated sutures had the highest cell number, and after 168 hours cell number reached confluency. In the in vivo experiments, a 10-mm incision was made on the triceps surae muscle of male Wistar rats and rat BMSC coated sutures were placed into the muscle. Two days after the implantation, cells were seen on the surface of the sutures as well as in the surrounding muscle tissue. Long-term results at 5 weeks showed that transplanted cells survived and the sutures were partly absorbed. In conclusion, coating absorbable sutures with proteins, especially serum albumin, improves attachment and proliferation of cells, and only 48 hours in culture is enough to cover the sutures sufficiently. Using these stitches in vivo resulted in short-term and long-term survival of cells. As a result, albumin-coated suture can be a vehicle for stem cell therapy in soft tissues such as muscle, tendon, or peripheral nerves.

Laparoscopic Intersphincteric Resection With a SILS Port for Very Low Rectal Cancer

Since intersphincteric resection (ISR) for rectal cancer was established in the 1990 s, this technique has been applied to very low rectal cancer. This procedure requires advanced techniques for anorectal surgery. However, it is indicated only for early lesions and should be as minimally invasive as possible. We describe a minimally invasive ISR with a single-incision laparoscopic surgery (SILS) port. Our case involves a 59-year-old man with hemorrhage from the rectum. Pathologic examination of the transanally resected specimen revealed that the tumor had invaded into the deeper submucosa. To minimize surgical incisions, a SILS port was utilized in place of a 10- and a 5-mm trocar. The SILS port was inserted through a 2.5 cm transverse incision in the right lower abdomen, where a diverting stoma would be created. Two flexible or straight forceps introduced through this port afforded an easier dissection of the rectum to the levator ani muscle, and transanal dissection of the internal sphincter was performed in the standard manner to connect with the abdominal dissection. The only postoperative incision other than a stoma and surgical drain was one 10-mm incision above the umbilicus. Our technique of ISR with the SILS port is a useful clinical application of minimally invasive surgery.

Height and torsional stiffness are most sensitive to annular injury in large animal intervertebral discs

Acute annulus fibrosus injury has been identified as a contributing factor to intervertebral disc (IVD) degeneration. Injuries as small as those resulting from needle injection result in localized mechanical disruption via fiber breakage, but it is unknown whether these injuries initiate degeneration locally or through changes in the mechanical behavior of the entire disc. However, in vitro biomechanical studies of injury are limited to a single type of injury or measurements in only one or two degrees of freedom. The aim of this study is to provide a comprehensive assessment of the joint level mechanical response to IVD injuries of various sizes in a large animal model. We hypothesize that annular injuries will affect disc mechanics differently depending on size, location, and mode of loading. We further hypothesize that a large injury to one side of the disc will induce a bending moment reaction under axial compression, which may decrease spinal column stability. A comprehensive biomechanical study investigating effects of small and large injuries on IVD pressurization and six-degree-of-freedom stiffness behaviors using bovine motion segments. Bovine caudal motion segments were subjected to a series of annular injuries ranging from 21-gauge needle puncture to 10-mm scalpel incisions and evaluated before and after injury with both mechanical testing under multiple degrees of freedom (axial compression, flexion-extension, lateral bending, and torsion) and nucleus pulposus (NP) fluid pressurization tests. Mechanical tests showed that axial torsional stiffness and disc height under resting compressive load were the parameters most sensitive to large annular injury. Bending and compressive stiffnesses, as well as bending moments induced by axial compression, were not significantly changed by scalpel incisions. Additionally, large injuries resulted in altered relaxation behavior after NP pressurization indicative of increases in both radial bulge compliance and fluid flow rates. These findings suggest that loss of disc height, torsional stiffness, and NP fluid pressurization are the immediate results of acute annular injury and are therefore those properties that IVD repair strategies must strive to restore or maintain. The lack of change in bending stiffness and moment under compression suggests that acute annular tears alone are not sufficient to induce off-axis motion and instability.

Retroperitoneal Laparoscopic Kidney Biopsy: Technical Tips for a Minimally Invasive Approach

Nowadays, ultrasound-guided percutaneous kidney biopsy (PKB) is the gold standard for renal biopsies. Nevertheless, PKB is still contraindicated by conditions such as bleeding diatheses, severe obesity, solitary kidney, uncontrolled hypertension, and previous failed attempts at PKB. In these cases, the laparoscopic approach may offer a valid and mini-invasive alternative to open biopsy. We describe our technique and report indications and outcomes of a consecutive series of retroperitoneal laparoscopic kidney biopsies (LKB). In a retrospective review of patients who underwent LKB, we examined indications, outcomes, and complications, stratified according to the Clavien classification. In all, 40 patients underwent LKB between 2001 and 2010 (mean age 58.85 years, SD 10.87). Mean serum creatinine at surgery was 3.02 mg/dL. Indications for LKB included coagulopathy (30%), polycystic kidney or multiple renal cysts (30%), solitary kidney (12.5%), and morbid obesity (10%). All the biopsies were performed with a Trucut needle. All the procedures were successful and led to pathological diagnosis. The most common pathological findings were glomerulonephritis (47.5%) and glomerulosclerosis (27.5%). All biopsies were performed in less than 1 hour. Only three complications (7.5%) were reported: two grade I and one grade IIIa according to Clavien classification. In three selected cases, we used a particular "ready-to-laparo" open surgical technique, which allowed to view a part of kidney parenchima through the 10-mm incision made for the Hasson trocar sufficient for Trucut biopsies and hemostasis under direct vision. This study shows that LKB is a safe, effective, and minimally invasive procedure that allows direct control of hemostasis and lower risks of postoperative morbidity compared with open biopsy. When PKB is contraindicated, LKB should be the first-choice alternative.

Unusual Dermoid Cyst with Surprise

A 35-year-old nulliparous woman with a clinical history of chronic pelvic pain and an ultrasound scan showing a 6-cm complex mass within the left ovary underwent laparoscopy for excision of the cystic mass. The surgical procedure required 3 abdominal accesses: a 10-mm umbilical wound and 5- and 10-mm pelvic incisions.

TULC – Total Umbilikale Laparoskopische Cholezystektomie

Except for some few cases only symptomatic cholecystolithiasis constitutes an indication for operative treatment. The gold standard meanwhile has been the laparoscopic cholecystectomy, because the method shows good results with short hospital stay. Recently there has been an intensive discussion about combination of laparoscopic techniques with natural body orifice using surgery (NOTES). These techniques permit further reduction of surgical trauma and enhancing of cosmetic results. However, the technical effort is significant and most of the times a combination (hybrid procedure) of NOTES with standard laparoscopic procedure is performed, so that we concentrated on performing a laparoscopic cholecystectomy using a single incision through the umbilicus. A 5-mm incision left deep in the umbilicus and a 10-mm incision directly below were used for creating a pneumoperitoneum and for inserting the ports for the optic and the dissector. Exposition of the gallbladder was carried out by sutures, that were penetrated from outside through the abdominal wall into the abdominal cavity and transfixed through the gallbladder in order to hang up the gallbladder like a puppet by penetrating the abdominal wall again to the outside. Removal occurred through the umbilical incision. We successfully operated on 90 patients in a 12-month period. Mean operating time was 48 (39-71) min whereby no conversion to open surgery was necessary. No intra- or postoperative complications occurred in any patient. Average hospital stay was 2.5 (2-4) days, postoperative examination showed no differences to the usual laparoscopic cholecystectomy with a good cosmetic result and no visible scars. The purpose of our study was to further improve the cosmetic results of minimally invasive surgery of the gallbladder by operating totally through the umbilicus, using 2 ports deep in the umbilicus. We thereby avoid further surgical trauma due to creating an access through another organ as is done in the NOTES technique. For this operation no special equipment like flexible endoscopes was needed as common laparoscopic instruments were used.

Prospective, Randomized, Controlled Trial Comparing a Tissue Adhesive (Dermabond™) with Adhesive Strips (Steri-Strips™) for the Closure of Laparoscopic Trocar Wounds in Children

4 methods are used in pediatric laparoscopic surgery to close trocar wounds. While tissue adhesives or adhesive strips have been shown to produce fewer wound complications and a better cosmetic result compared to trans- or only subcutaneous sutures, the choice of technique is still often based on the surgeon's personal experience. Thus, the objective of this trial was to assess the impact of tissue adhesives (Dermabond™) compared to adhesive strips (Steri-Strip™) on potential complications of wound healing, wound pain, cosmetic outcome, and patient satisfaction after laparoscopic appendectomy in children. 49 patients undergoing laparoscopic appendectomy were enrolled in this prospective randomized trial. In every patient, two 5-mm and one 10-mm port-site incision was closed either with Dermabond™ or Steri-Strip™ after placing subcuticular absorbable sutures (4-0 Vicryl™). Postoperative complications, pain, and patient satisfaction with scars were evaluated at follow-up on day 10 and day 90 after the operation using a questionnaire and a visual analogue scale (VAS). Photographs of scars taken on day 90 were evaluated on a VAS by 2 pediatric surgeons blinded to the closure method used. According to the surgeons' evaluation of the cosmetic outcome, a significant difference between the 2 groups with regard to the cosmetic score was found on day 90 of follow-up, favoring Steri-Strip™ wound closure (p < 0.05). On day 10 and 90 there were no statistical differences between the 2 methods as regards the result of patient evaluations (p > 0.05). Only one wound infection (4%) was observed in the Steri-Strip™ group (n = 25) on day 10. At follow-up on day 90 two patients (9.1%) in the Dermabond™ group and one (4.8%) in the Steri-strip™ group complained of wound pain (p = 0.52). Both tissue adhesives and adhesive strips are excellent "no needle" alternatives for the closure of laparoscopic port-site incisions in children. As regards cosmetic outcome, Steri-Strip™ wound closure seems to be the most suitable and is also the less expensive technique.

Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study

In ten ovarian endometriomas of diameter exceeding 30 mm, managed by complete vaporization of the inner surface using plasma energy followed by cystectomy, we performed histologic evaluation of the depth of necrosis and the effectiveness of endometrial tissue ablation. We observed that plasma energy allows the ablation of endometrial tissue with minimal damage to the ovarian parenchyma, which suggests that this technique might be of particular interest for women with risk factors of postoperative ovarian reserve impairment, such as recurrent and bilateral endometriomas.

Comparison between transumbilical and transabdominal ports for the laparoscopic retrieval of benign adnexal masses: a randomized trial

Objective To compare the feasibility, operative time, specimen retrieval time, and effect on postoperative pain of laparoscopic retrieval of benign adnexal masses between a 10-mm transumbilical and a 10-mm transabdominal port. Study design Fifty women with adnexal masses who were scheduled for a laparoscopic procedure between July 2008 and April 2009 were enrolled. The patients were randomized into two groups; these were patients where a transumbilical port was used for specimen retrieval (transumbilical group, n = 25) and patients where a transabdominal port was used for specimen retrieval (transabdominal group, n = 25). Preoperative suspicion of malignancy and indications suggesting a need for hysterectomy or myomectomy were considered to be exclusion criteria. Randomization was centralized and computer-based. Patients recorded the severity of incisional pain on a visual analog scale (VAS) with 0 meaning no pain and 10 meaning unbearable pain. Results There were no significant differences in age, body mass index, umbilical thickness, abdominal thickness, cyst size, cyst amount, cyst weight, histology, complications and duration of hospital stay when the two groups were compared. Patients in the transumbilical group had a significantly shorter specimen retrieval time (0.7 ± 1.8 min vs. 4.9 ± 12.6 min, p = 0.006) and a significantly lower postoperative day (POD) 0 VAS pain score (5.2 ± 2.1 vs. 6.6 ± 2.2, p = 0.015). Significantly fewer patients in the transumbilical group had a specimen retrieval time of ≥10 min (0% vs. 20%, p = 0.025) and a POD 0 VAS pain score of >5 (36% vs. 84%, p < 0.001). However, the average POD 1 VAS pain score (3.2 ± 1.8, vs. 3.6 ± 1.6) and the proportion with a POD 1 VAS pain score >5 (12% vs. 12%) were similar for the two groups. Conclusion When laparoscopic surgery on benign adnexal masses is carried out using a 10-mm incision wound, removal of the specimen via the umbilical port has a shorter retrieval time and produces less postoperative pain than retrieval via a lateral abdominal port.

Platelet-Rich Fibrin Versus Albumin in Surgical Wound Repair

To study the effects of autologous platelet-rich fibrin (PRF) versus human albumin on incisional wound breaking strength and subcutaneous collagen deposition in patients undergoing laparoscopic cholecystectomy in a randomized trial. Platelet peptidic growth factors may stimulate collagen synthesis and tissue repair. One expanded polytetrafluoroethylene (ePTFE) tube was inserted subcutaneously from the edge of each of the two 10-mm trocar incisions in 51 patients. Treatment with PRF prepared from the patient's own blood or human albumin was randomized to respective wound site by concealed allocation. On postoperative day 10, breaking strength of the incisional wounds as well as the collagen concentration, type I procollagen mRNA, type III procollagen mRNA, matrix metalloproteinase-1 mRNA, and fibroblast density in the ePTFE tubes were determined. All analyses were assessor-blinded. The trial was registered in the Current Controlled Trials Registry (ISRCTN34481461). Local PRF had no significant effect on incisional wound-breaking strength. In the ePTFE tubes, PRF treatment decreased collagen concentration by 24% (P=0.046) and type I procollagen mRNA level by 29% (P=0.003), but had no significant impact on type III procollagen mRNA, matrix metalloproteinase-1 mRNA or fibroblast infiltration. The profibrotic transforming growth factor-beta1 level increased (P<0.0001) 2-fold with PRF. Collagen concentration in albumin-treated ePTFE tubes correlated with breaking strength of the skin incisions (rs=0.48, P=0.03). PRF did not improve wound strength significantly compared with albumin but suppressed subcutaneous collagen synthesis and deposition during early repair of surgical wounds in humans. Furthermore, deposition of reparative collagen in the subcutaneous ePTFE tube model partly predicted the breaking strength of an incisional skin wound.

Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER)

The lack of triangulation of standard endoscopic devices limits the degree of freedom for surgical maneuvers during natural orifice transluminal endoscopic surgery (NOTES). This study explored the feasibility of adapting an intuitively controlled master and slave transluminal endoscopic robot (MASTER) the authors developed to facilitate wedge hepatic resection in NOTES. The MASTER consists of a master controller, a telesurgical workstation, and a slave manipulator that holds two end-effectors: a grasper, and a monopolar electrocautery hook. The master controller is attached to the wrist and fingers of the operator and connected to the manipulator by electrical and wire cables. Movements of the operator are detected and converted into control signals driving the slave manipulator via a tendon-sheath power transmission mechanism allowing nine degrees of freedom. Using this system, wedge hepatic resection was performed through the transgastric route on two female pigs under general anesthesia. Entry into the peritoneal cavity was via a 10-mm incision made on the anterior wall of the stomach by the electrocautery hook. Wedge hepatic resection was performed using the robotic grasper and hook. Hemostasis was achieved with the electrocautery hook. After the procedure, the resected liver tissue was retrieved through the mouth using the grasper. Using the MASTER, transgastric wedge hepatic resection was successfully performed on two pigs with no laparoscopic assistance. The entire procedure took 9.4 min (range, 8.5-10.2 min), with 7.1 min (range, 6-8.2 min) spent on excision of the liver tissue. The robotics-controlled device was able to grasp, retract, and excise the liver specimen successfully in the desired plane. This study demonstrated for the first time that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures. With it, the triangulation of surgical tools and the manipulation of tissue became easy, and wedge hepatic resection could be accomplished successfully without the need for assistance using laparoscopic instruments.

Primary Nipple Reconstruction with AlloDerm: Is a Dermal Flap Always Necessary?

Sir: Nipple reconstruction in patients following mastectomy and placement of breast implants can be hazardous if the soft-tissue envelope is thin. To circumvent potential implant exposure, we have been introducing an AlloDerm (LifeCell Corp., Branchburg, N.J.) cylinder into a subdermal pocket to simulate a normal nipple. This construct offers the look and feel of the autologous nipple-areola complex without jeopardizing the underlying implant. Although AlloDerm (cadaveric dermis) has been used as an adjunct to primary or secondary nipple reconstruction with dermal flaps, the use of AlloDerm alone for this purpose has not been reported.1,2 We describe the successful implementation of primary AlloDerm nipple constructs without the use of autologous dermal flaps for select patients with thin skin following breast implant reconstruction. The patient is anesthetized with 1% lidocaine with epinephrine. A 10-mm semicircular incision is then created along the inferior base of the proposed nipple. A subdermal pocket measuring approximately 1.5 × 1.5 cm is made using sharp dissection. A 4 × 7-cm piece of AlloDerm 0.76 mm in thickness is reconstituted according to protocol. The AlloDerm is folded onto itself and held together with through-and-through 5-0 nylon sutures, creating a cylinder or oblong construct. The grafts are then placed into the subdermal pockets and anchored to the base by a single simple interrupted Monocryl (Ethicon, Inc., Somerville, N.J.) suture (Fig. 1). The skin is draped over the graft and incisions are closed with 5-0 Monocryl deep dermal stitches followed by simple interrupted stitches with 6-0 nylon. A protective dressing is placed over the nipple until the follow-up visit in 2 weeks.Fig. 1.: Technique for primary nipple reconstruction with AlloDerm construct. A 10-mm semicircular incision is marked and a subdermal pocket is created for the AlloDerm cylinder. The construct is inserted (above) and the skin closed with Monocryl deep dermal sutures followed by nylon simple interrupted skin sutures (below).AlloDerm has been used widely in aesthetic and reconstructive plastic surgery secondary to its biological inertness, strength, and stretchability. In this article, we describe the use of AlloDerm grafts in primary nipple reconstruction in patients after breast implant reconstruction whose thin skin prevents the use of autologous dermal flaps. This simple technique is performed safely and retains nipple projection over time. Our favorable experience with AlloDerm in implant breast reconstruction led us to use this material in other aspects of our practice.3,4 Like others, we feel it is an adjunct to autologous dermal flaps for primary or secondary nipple reconstruction in patients who desire moderate to superior nipple projection. We have also been pleased with long-term maintenance of low-profile projection in 55 nipple reconstructions followed over 3 years. An important modification of our original technique is to use permanent sutures to create the AlloDerm cylinder to prevent graft unrolling following dissolution of the absorbable suture. We have not experienced graft unrolling or suture extrusion since this modification. In conclusion, primary nipple reconstruction with AlloDerm can be used without the need for dermal flaps in select patients with thin skin following breast implant reconstruction. DISCLOSURE Karl H. Breuing, M.D., is on the speaker's bureau for LifeCell. Amy S. Colwell, M.D. Division of Plastic Surgery Massachusetts General Hospital Karl H. Breuing, M.D. Division of Plastic Surgery Brigham and Women's Hospital Boston, Mass.

Corneal Wavefront Errors 24 Months after Deep Lamellar Endothelial Keratoplasty and Penetrating Keratoplasty

To evaluate high-order aberrations (HOA) induced by the anterior corneal surface after deep lamellar endothelial keratoplasty (DLEK) and penetrating keratoplasty (PK). Prospective, randomized clinical trial. Twenty-eight eyes of 25 patients with corneal edema resulting from Fuchs dystrophy underwent DLEK with a 9- to 10-mm incision (n = 13) or PK with double-running sutures (n = 15) at the Cornea Service, Mayo Clinic Department of Ophthalmology, Rochester, Minnesota. The main outcome measures were HOA from the anterior corneal surface calculated from corneal topography and decomposed into Zernike polynomials to the sixth order, high- and low-contrast visual acuity (VA), and contrast sensitivity. Variables after surgery were compared with those before surgery and between treatments by using generalized estimating equation models with Bonferroni adjustment. Total HOA through 24 months (0.48 +/- 0.15 microm) after DLEK was similar to total aberration before surgery (0.44 +/- 0.23 microm; P = .10). After PK, total HOA remained elevated through 24 months (1.68 +/- 0.58 microm) compared with that before surgery (0.49 +/- 0.27 microm; P < .005) and compared with that after DLEK (P < .006). At 24 months after PK, corneas with sutures removed had greater total HOAs than corneas with sutures intact (1.90 +/- 0.52 microm vs 1.18 +/- 0.33 microm; P = .001). High- and low-contrast VA and contrast sensitivity at 24 months after PK did not correlate with any HOA. HOAs from the anterior corneal surface were higher after PK compared with after DLEK but did not correlate with visual function after PK.

Application of amniotic membrane as xenograft for urethroplasty in rabbit

Uroepithelium repair has always been the subject of discussion in urology surgeries. Using human amniotic membrane allograft has already proved to be useful in other fields. In this study, we use amniotic membrane to repair uroepithelium injuries in rabbits. Twenty healthy rabbits underwent surgery to induce a 10-mm incision, 10 mm from the meatus on ventral part of the urethra. Then a 5 x 10 mm patch of amniotic membrane was sutured to the incised urethra. All of the rabbits were catheterized for a week and then the patches were removed. The rabbits were studied for a month for any signs of infection and fistula formation. All samples revealed complete re-epithelialization of reconstructed urethra by transitional epithelium. There was one case of infection and following fistula (5%). There were two cases of urethral strictures (10%). The result from this study suggests that amniotic membrane is an inexpensive, easy, and biodegradable graft with very little antigen effect which seems to be the ideal solution for urethroplasty.

Adjunctive Transcanthotomy Lateral Suborbicularis Fat Lift and Orbitomalar Ligament Resuspension in Lower Eyelid Ectropion Repair

Severe or recurrent lower eyelid ectropion can be challenging to correct. Studies on the role of upper midface ptosis in lower eyelid malposition have been published. The authors describe their technique of supporting the lateral cheek by lifting and reestablishing support for the orbitomalar ligament through a 10-mm canthotomy incision as an adjunct to a lateral tarsal strip procedure. In many cases, this technique allows the eyelid to be properly repositioned without skin grafting. A retrospective chart review of patients with severe multifactorial or recurrent lower eyelid ectropion. A preperiosteal dissection over the malar eminence and resuspension of the lateral aspect of the suborbicularis oculi fat was performed through a 10-mm lateral canthotomy at the time of lateral tarsal strip procedure. The longest follow-up was 20 months, with an average of 7.8 months postoperatively. Postoperative eyelid position and patient symptoms were used as outcome measures. Twelve patients underwent repair of severe ectropion with a lateral tarsal strip procedure and adjunctive transcanthotomy lateral suborbicularis oculi fat lift with orbitomalar ligament resuspension. In 3 cases of severe paralytic ectropion and in 1 patient with poor healing, a small lateral tarsorrhaphy was also performed. The patients achieved excellent improvement in lower eyelid position, with resolution of symptoms and satisfactory aesthetic outcomes. Elevating the lateral suborbicularis oculi fat by resuspending the orbitomalar ligament was effective in supporting the lateral cheek. This resulted in recruitment of anterior lamella and allowed for good lower eyelid repositioning. The extent of dissection could be graded to achieve the desired surgical objectives. More invasive surgery such as full-thickness skin grafting was avoided. This technique can be a relatively noninvasive, yet powerful adjunct in the treatment of severe or recurrent lower eyelid ectropion.

Laparoscopic boxmodel and surgical dexterity

Laparoscopic boxmodel and surgical dexterity