4-step Technique Research Articles

Achieving a Strong and Straight Septal Extension Graft: A Novel Four-step Surgical Approach in Rhinoplasty.

Septal extension grafts allow the precise elongation of the nasal septum to attain facial harmony and optimize aesthetic outcomes. In this context, septal surgery requires meticulous design to address both functional and aesthetic goals. Traditional septoplasty techniques often overlook aesthetic considerations and postoperative nasal structural stability, resulting in unresolved or recurrent deviations, nose tip drooping, and obstruction recurrences. Despite advancements in surgical techniques, achieving simultaneous septal alignment and long-term stability remains a significant challenge. This study introduces a systematic 4-step technique. The procedure encompasses caudal septum liberation, placement of the septum extension cartilage graft, positioning of an ethmoidal bone graft, and redefinition through an intermediate cartilage. A retrospective analysis of outcomes involving 753 patients was conducted with a minimum follow-up of 6 months. During follow-up visits, 1.73% of cases exhibited residual columellar asymmetry, and 0.66% showed tip asymmetries. The infection rate was 0.40%, with no cases of tip drop identified. The overall satisfaction rating on the Rhinoplasty Outcomes Evaluation questionnaire at 12 months postoperative was 9.3. The technique provides a systematic approach to integrate functional and aesthetic objectives, emphasizing septal stability and alignment while concurrently addressing tip projection and stability. The study provides comprehensive insights into the principles, methodology, and advantages of this rhinoplasty technique. The outcomes underscore the efficacy of the technique, presenting a reliable and long-term stable solution.

From tradition to innovation: a comparison of the traditional 4-step approach versus a blended learning modification for technical skills teaching

BackgroundThis experimental study was performed to evaluate the role of blended learning for technical skill teaching on the European Trauma Course (ETC). While online modules are extensively used for theoretical teaching, their role in skills training remains less well explored. The ETC currently relies on the established 4-step technique for teaching technical skills. However, the required large cohort of skilled instructors and the time intensity prove increasingly challenging in a current climate of staff shortages and funding constraints. This study assesses if blended learning, combining pre-course online elements with face-to-face training matches the effectiveness of the traditional 4-step approach whilst being more time-efficient.MethodsIn a randomised, multi-centre trial, the conventional face-to-face 4-step technique for teaching a skill of medium complexity, the application of a pelvic binder, was compared with an innovative blended approach. It was hypothesised that the blended approach was non-inferior for skill performance measured after the teaching session and after two days (skill retention) with the time needed for teaching and student/teacher satisfaction as secondary outcomes.ResultsNinety participants, divided into 44 traditional and 46 blended method students, were analysed. Independent-samples t-test showed no significant difference in performance scores and non-inferiority of the blended approach with a half of one standard deviation margin. A statistically significant difference in mean retention scores favored the blended approach. A Mann–Whitney U Test revealed no significant difference in candidate satisfaction levels but a statistically significant difference in instructors' satisfaction levels in favour of the blended approach. Analysis with Welch' t-test demonstrated that the face-to-face teaching time needed for the blended approach was significantly shorter (by 6 min).ConclusionsThe integration of a blended approach with the 4-step technique for teaching pelvic binder application in the ETC streamlined teaching without compromising skill acquisition quality. This innovative approach addresses traditional limitations and shows promise in adapting medical education to modern learning and teaching demands. We suggest that blended learning could also be applied for other skills taught on life support courses.Trial registration: University of Dundee (Schools of Medicine and Life sciences Research Ethics Committee, REC number 22/59, 28th June 2022).

Evaluation of the \u2018Spaarne soft tissue procedure\u2019 as a treatment for recurrent patellar dislocations: a four-in-one technique

PurposeThe ‘Spaarne soft tissue procedure’, is a 4-in-1 soft tissue procedure that treats recurrent patellar dislocations in the young and active population. The procedure has not yet described elsewhere. The purpose of this study is to analyse the redislocation rate and to evaluate the postoperative knee function and patient satisfaction.MethodsTwenty-seven patients (34 knees) underwent the four-in-one SST-procedure. The 4-step technique required a minor change in 2010, including the use of a smaller strip of the patellar tendon for transposition. After a median follow-up of 10.4 years, the redislocation rate was evaluated as the primary outcome measure. Secondary outcome measures were functional outcome (IKDC, Kujala, Lysholm and Tegner activity scale) and Numeric Rating Scales for satisfaction and pain.ResultsRedislocation occurred in 8 cases (23.5%) and subluxation occurred in 13 cases (38.2%) post-surgery. A significant higher number of redislocations and subluxations were seen before 2010 (p = 0.04, p = 0.03). The median postoperative IKDC, Lysholm and Kujala scores for the total group were 54, 76 and 81 respectively. Pre- and postoperative Tegner activity scale were both level 3. Median NRS scores during rest, walking and sports were 1, 3 and 5 respectively. Satisfaction with the procedure was reported as ‘excellent’ or ‘good’ by 79% of the patients.ConclusionDespite the high overall redislocation rate and increased pain scores, the SST-procedure shows to be a safe procedure in patients with recurrent patellar dislocations based on the cases after 2010. Mid- and long-term results show moderate to good functional outcomes and satisfaction.Level of evidenceTherapeutic retrospective cohort study, LEVEL III

Relocating the C5 nerve stump in C5 nerve grafting to prevent iatrogenic phrenic nerve injury.

Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity. A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored. We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10years. We have experienced no adverse respiratory events. This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.

Efficient and Safe Method for Splenic Flexure Mobilization in Laparoscopic Left Hemicolectomy: A Propensity Score-weighted Cohort Study.

Because methods of performing laparoscopic left hemicolectomy differ between surgeons, standardizing the procedure is crucial to reduce complications and secure good oncologic outcomes. This is a retrospective hospital-based cohort study using a propensity score-weighted method. This study was conducted at the department of colorectal surgery in a tertiary teaching hospital between October 2007 and December 2017. The short-term and long-term outcomes of open and laparoscopic left hemicolectomy from 10 years of experience using a standardized 4-step laparoscopic procedure at one institution were compared. Short-term outcomes were postoperative morbidity and mortality. Long-term outcomes were disease-free survival and overall survival. We enrolled 564 patients who underwent open or laparoscopic left hemicolectomy for primary colon adenocarcinoma. The open surgery and laparoscopy groups had 357 and 207 patients, respectively. Compared with the open surgery group, the laparoscopy group had significantly shorter hospital stays (open vs. laparoscopy, 10 vs. 7 d, P<0.001), less postoperative morbidity (open vs. laparoscopy, 16.5% vs. 9.2%, P<0.001), and lower risks of superficial surgical site infections, lung complications, and gastrointestinal complications. No differences were observed between the groups in postoperative mortality (open vs. laparoscopy, 0.6% vs. 0.0%, P=0.23), disease-free survival curves (P=0.69), or overall survival curves (P=0.85). Our standardized 4-step technique of laparoscopic left hemicolectomy is more efficient, has fewer surgical complications, and yields better short-term and similar long-term oncologic outcomes compared with open surgery.

Primary Aneurysmal Bone Cyst of the Spine in Children: Updated Outcomes of a Modern Surgical Technique.

Aneurysmal bone cysts (ABC) are benign but locally aggressive lesions. Treating children with spinal ABC poses risks due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability after surgery. This study reports the updated outcomes of a uniform aggressive initial surgical technique for the treatment of spinal ABC in children. Twenty-nine cases of spinal ABC were collected from a tertiary pediatric tumor center over a 24-year period (January 1990-September 2014). The study patients were divided into 2 groups based on the performed procedure: a traditional approach consisting of curettage and bone grafting (group 1) and a 4-step approach consisting of intralesional curettage, high-speed bur, electrocautery, and bone grafting (group 2). The study population was composed of 12 males and 17 females with a mean age of 12.2 years at the time of diagnosis and a mean postoperative follow-up of 4.03 years. Twenty-one patients underwent the 4-step approach, while 8 patients were treated with the traditional technique. The recurrence rate was 50% (4/8 patients) with the traditional technique (group 1) and 19% (4/21) in the 4-step technique (group 2) (P = .164). Regardless of the technique used, the presence of sensory symptoms at the time of presentation was a statistically significant factor for recurrence (P = .016). We suggest that addressing spinal ABC in pediatric patients with a 4-step approach is a safe technique that may decrease long-term recurrence and reoperation rates compared to the traditional technique of intralesional curettage and bone grafting. 4.

Ultrasound Liver Map Technique for Laparoscopic Liver Resections.

Laparoscopic liver resection (LLR) is reported as a safe procedure with potential advantages over open surgery albeit with inherent limitations, such as loss of haptic perception and spatial orientation. Ultrasound is considered the best tool to identify anatomic landmarks and the transection plane during liver surgery. The aim of this study was to analyse the outcomes of LLR performed with a standardized US guidance technique. We have standardized a 4-step technique for ultrasound-guided LLR: (1) compose a 3-D mind map by studying relationships among lesions and surrounding anatomic structures, (2) sketch the map on the liver surface, (3) check, and (4) correct the transection plane in real time. Between 01/2006 and 12/2016, 190 consecutive patients treated with US-guided LLR were analysed. The indications for LLR included malignant tumours in 148 patients (81.8%). The procedures were classified according to a difficulty scale. There were 18 major hepatectomies (9.9%), 80 anatomic bi- and monosegmentectomies (44.2%), and 101 non-anatomic resections (55.8%). Redo resection was performed in 17 patients (9.4%), and multiple liver resections were performed in 25 patients (24.7%). Median intraoperative blood loss was 100 ± 154mL. Overall and major morbidity rates were 14.9% and 1.6%, respectively. Mortality was nil. Ultrasound liver map technique enables planning and real-time guidance during laparoscopic liver resections.

Translumenal applications of a novel EUS-guided lumen apposition stent

Introduction: Tubular stents designed for ductal drainage have been used for endoscopic translumenal drainage of the gallbladder, pseudocysts, and extraintestinal fluid collections. Limitations are the potential for leakage, migration, and trauma to the surrounding tissue. Purpose: To evaluate a novel lumen apposition stent (LAS) for the following translumenal applications: 1) gallbladder drainage; 2) gastro-enteric bypass; 3) creation of a NOTES port. Methods: LAS devices were implanted in acute and survival animals (swine) under general anesthesia. The LAS is made of braided nitinol wire and fully coated to prevent tissue ingrowth, leakage, and enable removability. Dual-flanged anchors provide lumen-to-lumen apposition. Fully expanded, the flange & body diameters measure 20mm and 10mm, respectively. The LAS is constrained onto a 10.5Fr delivery catheter and deployed with a proprietary handle that luer-locks onto the inlet port of a 3.7mm channel echoendoscope. A standardized 4-step technique was used: 1) Lumen access with 19G needle; 2) Tract dilation with 4mm balloon; 3) LAS deployment across the tract; 4) LAS lumen dilation with a 10mm balloon. Translumenal endoscopy using an ultraslim 5.9mm gastroscope was performed across the deployed LAS. Survival animals underwent endoscopy at weekly intervals. Results: Devices were successfully deployed under EUS-guidance from the stomach lumen into each of the following target lumens: 1) gallbladder; 2) colon; 3) peritoneum. After dilation, the gastroscope could be easily advanced through the LAS into the target lumen. The LAS stabilized the endoscope for translumenal interventions. Gallbladder: mucosa inspected, cystic duct identified. Bowel: mucosa inspected, advancement into afferent and efferent limbs, retroflexion view of LAS possible. NOTES port: biopsies obtained from organ surfaces, small bowel grasped with forceps and pulled into the stomach through the LAS. Follow-up for 5 weeks: the LAS remained stable, patent, and the covering intact without tissue ingrowth or overgrowth. One device was removed with a snare at 4 weeks. Gross necropsy showed the devices were well-tolerated by the surrounding tissue. Conclusion: 1. EUS-guided deployment of the LAS is feasible and safe. 2. The LAS enables a robust, reliable, and removable lumen approximating conduit for translumenal endoscopic procedures.

Cricoid ring integrity: Implications for cricothyrotomy

Study objectives: The rapid 4-step technique for cricothyrotomy was originally described as making use of a single traction hook on the cricoid ring. However, it is possible that such hook placement could lead to damage of the cricoid ring. As an alternative, a double-hook device was developed to augment the rapid 4-step technique by dispersing forces applied to the cricoid ring. The objectives of this study were to compare the requisite forces for intubation and the structural tolerances of the cricoid ring between the single- and double-hook techniques. Methods: We randomized 56 human cadaver specimens to undergo either cricothyrotomy with intubation followed by cricoid ring breakage or cricoid ring breakage alone. We randomized those cadaver specimens undergoing cricothyrotomy with intubation with respect to the initial hook technique used and then crossed over to the alternate technique for repeat intubation and subsequent cricoid ring breakage. We performed all cricothyrotomies in a similar manner with a consistent technique. We measured the intubation and breakage forces for the single- and double-hook techniques and calculated 95% confidence intervals (CIs). Results: The mean force to intubate with the single-hook technique was 18 N (95% CI 14 to 22 N), and the mean force to intubate with the double-hook technique was 23 N (95% CI 17 to 29 N). There was a significant difference between the mean forces required to break the cricoid ring with the single-hook technique (54 N; 95% CI 47 to 62 N) versus with the double-hook technique (101 N; 95% CI 89 to 113 N; difference in means 47 [95% CI 34 to 60 N]). Conclusion: When applying the rapid 4-step technique for cricothyrotomy, the force required to intubate with either the single- or double-hook technique is small. The cricoid ring, however, tolerates significantly more force without breakage when the double-hook technique is used. [Ann Emerg Med. 2003;41:331-337.]

Comparison of 2 Cricothyrotomy Techniques: Standard Method Versus Rapid 4-Step Technique

Study objective: To compare the success rate, complication rate and time required for the rapid 4-step technique versus the standard technique for cricothyrotomy. Methods: We conducted a prospective, randomized crossover study. Twenty-seven emergency medicine interns, 1 junior medicine resident, and 4 senior medical students, without prior cricothyrotomy experience, were randomly divided into 2 groups. Group 1 was initially instructed in and then performed the standard technique; group 2 was initially instructed in and then performed the rapid 4-step technique. Each group was then instructed in and performed the alternate method. Cricothyrotomies were performed on preserved human cadavers. Results: A surgical airway was established in 28 of 32 attempts with the use of the rapid 4-step technique (88%); the average time elapsed before tube placement was 43 seconds. Thirty of 32 attempts involving the standard technique (94%) were successful; the average time to tube placement was 134 seconds (95% confidence interval for a difference of 91 seconds, 63 to 119; P<.001). Complications were identified in 12 attempts involving the standard technique (38%; 1 considered major) and in 12 involving the rapid four-step technique (38%; 3 considered major). The incidence of major complications was 6% higher for the rapid 4-step technique (95% confidence interval, –9% to 21%). Conclusion: In a group of inexperienced subjects working on a preserved human cadaver model, the rapid 4-step technique for cricothyrotomy was performed in about one third the time required for performance of the standard technique. This finding was both clinically and statistically significant. Although the 2 techniques had similar success and complication rates, we noted a trend toward more severe complications in the rapid 4-step technique.[Holmes JF, Panacek EA, Sakles JC, Brofeldt BT: Comparison of 2 cricothyrotomy techniques: Standard method versus rapid 4-step technique. Ann Emerg Med October 1998;32:442-447.