Additional Incision Research Articles

Total breast reconstruction with a fat-augmented latissimus dorsi flap: A comparative study between muscle and myocutaneous flaps

The fat-augmented latissimus dorsi myocutaneous flap can overcome the volume insufficiency of latissimus dorsi flaps by immediate fat grafting into the flap. When breast skin supplementation is unnecessary, latissimus dorsi flaps can be harvested as a muscle flap to avoid an additional back incision. Here, we compared the efficacy of fat-augmented latissimus dorsi myocutaneous and muscle flaps in total breast reconstruction. We retrospectively reviewed 94 cases of unilateral total breast reconstruction using fat-augmented latissimus dorsi flaps (muscle: 40, myocutaneous: 54) at our hospital from September 2017 to March 2022. The muscle flap group had a significantly shorter operative time than the myocutaneous flap group (p<0.0001). Mastectomy specimen weight did not differ between the 2 groups, but total flap weight in the muscle flap group was significantly lower (p<0.0001). Conversely, total fat graft volume, fat graft volume to the latissimus dorsi flap, and fat graft volume to the pectoralis major muscle were significantly greater in the muscle flap group (p<0.0001, p<0.0001, and p=0.02, respectively). The percentage of cases requiring additional fat grafting was significantly higher in the muscle flap group, but postoperative esthetic evaluation did not significantly differ between the 2 groups. Both groups scored high on each BREAST-Q item, but the muscle flap group scored significantly higher for "Satisfaction with Back." Although the frequency of additional fat grafting was higher than with fat-augmented latissimus dorsi myocutaneous flaps, total breast reconstruction with fat-augmented latissimus dorsi muscle flaps is a viable technique with a short operative time and high patient satisfaction.

Arthroscopic Meniscus Repair Using an All-Inside, All-Suture, Knotless Device

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair.

A uniport subxiphoid approach with a modified sternum retractor is safe and feasible for anterior mediastinal tumors.

Minimally invasive surgery has been used to treat anterior mediastinal tumors. This study sought to describe a single team's experience of uniport subxiphoid mediastinal surgery using a modified sternum retractor. Patients who underwent uniport subxiphoid video-assisted thoracoscopic surgery (USVATS) or unilateral video-assisted thoracoscopic surgery (LVATS) from September 2018 to December 2021 were retrospectively enrolled in this study. A 5-cm vertical incision approximately 1-cm caudal to the xiphoid process was usually made followed by the installment of a modified retractor, which was able to raise the sternum by 6-8 cm. Next, the USVATS was performed. In the unilateral group, 3 1-cm incisions were usually made, among which, 2 are made in the 2nd or 3rd and 5th intercostal anterior axillary line, and the 3rd was made in the 5th intercostal midclavicular line. In some instances, an additional subxiphoid incision was made to remove the large tumors. All the clinical and perioperative data, including the prospectively recorded visual analogue scale (VAS) score, were analyzed. In total, 16 patients who underwent USVATS and 28 patients who underwent LVATS were enrolled in this study. With the exception of tumor size (USVATS 7.9±1.6 cm vs. LVATS 5.1±2.4 cm, P<0.001), the baseline data of the patients in the 2 groups were comparative. Blood loss in surgery, conversion, draining duration, postoperative stay, postoperative complications, pathology and tumor invasion were similar between the 2 groups. Although the operation time was significantly longer in the USVATS group than the LVATS group (115±19 vs. 83±30 min, P<0.001), the VAS score at 1st postoperative day (1.9±1.1 vs. 3.1±1.1, P<0.001) and moderate pain level (a VAS score >3) (6.3% vs. 32.1%, P=0.049) were better in the USVATS group than the LVATS group. Uniport subxiphoid mediastinal surgery is a feasible and safe procedure, especially for large tumors. Our modified sternum retractor is especially helpful during uniport subxiphoid surgery. Compared to lateral thoracic surgery, this approach has the advantages of less injury and lower postoperative pain, which may lead to a faster recovery. However, its long-term follow-up outcomes need to be observed.

Three-Port Laparoscopic Splenic Flexure Colectomy for Descending Colon Cancer with Intracorporeal Colocolic Anastomosis and Transvaginal Natural Orifice Specimen Extraction

Introduction: Transanal and transvaginal natural orifice specimen extraction (NOSE) are viable alternatives to transabdominal specimen retrieval after laparoscopic colorectal surgery in selected patients without increasing morbidity or compromising oncologic outcomes.1 Conventional laparoscopic colorectal surgery is performed using one camera port, two operator ports, and one or two assistant ports. Three-port surgery is feasible2 and complementary to NOSE for laparoscopic colorectal cancer surgery to reduce surgical trauma to the abdominal wall.3 Transanal NOSE avoids an additional vaginal incision, however, the transvaginal route is preferable for larger tumors because of the elasticity of the vagina.3 Although dyspareunia and rectovaginal fistulae are theoretical concerns following transvaginal NOSE, these fears are thus far unfounded.1,3 Placement of a transvaginal wound protector protects against the risk of tumor seeding. Transvaginal NOSE following three-port laparoscopic D3 right hemicolectomy4 and three-port laparoscopic anterior resection5 have been previously demonstrated. Compared with other locations within the large bowel, cancers of the splenic flexure are relatively uncommon.6 Splenic flexure colectomy preserves bowel and is safe and oncologically comparable with a subtotal colectomy or formal left hemicolectomy.7,8 However, segmental resection and anastomosis for tumors in this area can be technically challenging. Methods: A 69-year-old patient with a descending colon cancer and body mass index of 29.2 kg/m2 presented for resection. Preoperative bowel preparation with 2 L polyethylene glycol was administered. A 12-mm transumbilical camera port was used, with a 12- and 5-mm right iliac fossa and right flank working ports, respectively. The splenic flexure was mobilized from medial to lateral. The inferior mesenteric artery was identified, and the left colic artery was ligated at its origin, with adequate distal mesenteric division to ensure satisfactory lymph node harvest. Proximal and distal bowel transection were performed intracorporeally with a linear stapler. An isoperistaltic side-to-side colocolic anastomosis was fashioned, with a two-layer closure of the colonic defect. The uterus was hitched to the anterior abdominal wall with a transabdominal suture. The vagina was cleansed before a posterior vaginotomy was created with the help of a transvaginal sizer. A double ring wound protector was inserted transvaginally with one ring completely within the abdominal cavity and the other ring opened against the perineum to shorten the channel for specimen delivery. The wound protector was removed and the vaginotomy was closed using a barbed suture. Results: Operative time was 3 hours 15 minutes, with 20 mL intraoperative blood loss. There was minimal postoperative pain with return of gastrointestinal function on the first postoperative day. The patient was discharged uneventfully on postoperative day 2. Histology was pT4N1 and 27 lymph nodes were harvested. Adjuvant chemotherapy was administered, with no evidence of disease recurrence at 6 months follow-up. Conclusion: The reduced port technique is feasible and synergistic with NOSE for splenic flexure colectomy in selected patients, augmenting the minimally invasive nature of laparoscopy. No competing financial interests exist. Runtime of video: 5 mins 49 secs Patient Consent: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Modification of Rotation-Advancement Split Pectoralis Major (RASP) Turnover Flap Technique for Median Sternotomy Wound Dehiscence.

Pectoralis major muscle flap was used alone or mostly combined with rectus muscle or omentum to cover the whole sternal defect.[1] [2] [3] Disadvantages are additional abdominal incisions, herniation of bowel, introducing infection to abdominal cavity. D. A. Staffenberg introduced “Rotation-Advancement Split Pectoralis (RASP) major muscle turnover flap” technique for median sternotomy wound dehiscence.[4] In his technique, one-side split pectoralis major muscle flap was turned over based on internal mammary artery perforators and the other side pectoralis muscle flap advanced to the defect based on thoracoacromial pedicle. In our technique, we modified the split pectoralis muscle upper flap that was islanded based on the thoracoacromial pedicle to achieve more mobilization, less bulging contour deformity, and use the dominant blood supply.

A Preclinical Feasibility Study of Single-Port Robotic Subcostal Anatomical Lung Resection and Subxiphoid Thymectomy Using the da Vinci® SP System.

Despite the recent introduction of technologically advanced single-port (SP) robotic systems, their use in the field of thoracic surgery has been rarely explored. Here, we report our preclinical experience concerning SP robotic thoracic surgery using the da Vinci® SP system. The da Vinci® SP system was used to perform subcostal anatomical lung resection and subxiphoid thymectomy in three cadavers. The operative settings that best met the surgeon's requirements for each resection were also determined. Four subcostal anatomical lung resections and two subxiphoid thymectomies were completed. While both procedures did not require additional incisions, the use of an observation port in the intercostal spaces was strongly recommended to safely create subcostal access. Dissection of hilar structures and mediastinal lymph nodes was feasible. However, due to the current unavailability of a robotic stapler, a handheld stapling instrument was required to perform a transection of vital structures. When the stapling process proved to be difficult, the table surgeon temporarily removed a robotic arm to acquire the necessary space to complete the procedure. Our data represent a promising preclinical step in understanding the feasibility of using the da Vinci® SP system to perform an SP subcostal anatomical lung resection and a subxiphoid thymectomy.

Fragmented Glass Foreign Body in the Pre-auricular Region: Computer-assisted Radio Monitoring-guided Retrieval in a 3-year-old Child

Craniomaxillofacial region represents a complex region with anatomical boundaries that has difficult accessibility and slippage of foreign bodies into deeper planes challenging the surgical retrieval. Removal of embedded foreign bodies from the craniofacial region poses an additional risk of facial scars, particularly in the aesthetic zones. Most often for easy localisation and retrieval of these foreign bodies, an additional incision might be required over the site where it is embedded. Here, we report a case where a fragmented glass foreign body was localised and retrieved from the pre-auricular region of a 3-year-old child precisely using an intraoperative computer-assisted radio monitoring (C-arm) technique without additional incisions. We made use of an existing facial wound which was away from the actual location of the foreign body. Image-guided surgery is a technical refinement towards surgical exploration in anatomically complex regions. C-arm can be used routinely to aid surgical procedures as it is easy to use in operating rooms, technique friendly as well as cost-effective.

Trans - 6R Portal Repair of Superficial TFCC Tears; A Modified Arthroscopic Outside-in Technique

Different arthroscopic repair techniques have been described for various tear types. Several series have reported successful outcomes for arthroscopic repair of superficial tear of the triangular fibrocartilage complex (TFCC) tears using the outside-in technique. Described techniques entail usage of special instruments for passage of sutures and/or use of many incisions. We describe an arthroscopic technique for repair of superficial part of TFCC through the 6R portal by single hypodermic needle, with no additional skin incisions or special equipment.

Endovascular laser coagulation in varicose vein relapses in the lower extremities

Objective. To study the effectiveness of endovascular laser coagulation in patients with recurrent varicose veins in their lower extremities.Material and methods. Outcomes after the treatment of 54 patients with varicose vein relapses in the lower extremities were analyzed. Under the tumescent anesthesia, endovascular laser coagulation was made: in 5 patients – stump of the great saphenous vein; in 22 patients – recanalized, residual and preserved subcutaneous venous trunks; in 27 patients – insufficient communicating veins of the thigh and lower leg.Results and discussion. In average, surgery lasted for 31 ± 0.6 minutes; intensity of the postoperative pain syndrome was 3.4 ± 0.4 points. Early postoperative complications were registered in 1 (1.8 %) patient, side effects in the form of hyperpigmentation and paraesthesia – in 4 (7.4 %). In 12 months, all operated patients demonstrated an improvement in all parameters of their quality of life by 29.2– 40 %; cosmetic outcome after surgery was 7.8 points out of a ten-point scale. The long-term observation revealed the relapse in varicose veins only in 1 (1.8 %) patient.Conclusion. The justified use of endovasal laser coagulation in patients with relapses of varicose veins in the lower extremities allows to avoid manipulations in the area of scar-altered tissues, to reduce tissue damage and duration of surgery, to improve patients’ quality of life, to avoid additional incisions as well as to improve cosmetic outcomes after surgery.

Arthroscopic supraspinatus advancement for retracted rotator cuff tears: a technical note.

Irreparable rotator cuffs with retracted torn ends remain a significant challenge for most shoulder surgeons. Since repairs are preferable to reconstruction or replacement whenever possible, studies for anatomical reductions with minimal tension and secure fixation are important. In this study, the authors introduce an arthroscopic supraspinatus advancement (ASSA) procedure for retracted rotator cuff tears that could not be adequately reduced to the original footprint. Using modified long, narrow, curved Cobb elevators, procedures can be performed through lateral portals without any additional skin incision. Following meticulous stepwise three-compartment elevation procedures based on the supraspinatus insertion anatomy, the supraspinatus muscle could be safely elevated from the fossa and sufficiently advanced laterally. The authors suggest that ASSA could be a useful procedure for management of challenging retracted rotator cuff tears by maximizing lateral excursions that could convert irreparable tears to reparable tears in select patients.

Biomechanical Comparison of a Novel 3-Screw Fixation vs Conventional 2-Screw Fixation of Calcaneal Tuberosity Avulsion Fractures.

Calcaneal tuberosity avulsion fractures are challenging to treat because of the poor bone stock and high risk of fixation failure secondary to the strong Achilles tendon pull. The purpose of this study is to compare the tensile force to failure of 2 different types of screw fixation construct in a cadaveric model of calcaneal tuberosity avulsion fracture. An oblique osteotomy was created in the calcanei of 7 matched pairs of cadaveric specimens to simulate a tuberosity avulsion fracture and one specimen from each pair randomized into one of the 2 groups for comparison. Two cancellous screws were inserted perpendicular to the fracture line at the posteromedial and posterolateral corners of the avulsed fragment for the 2-screw construct. For the second group, an additional stab incision was made at the midline of the Achilles insertional region for a screw placed between the initial 2 screws with a trajectory toward the calcaneocuboid joint in the 3-screw construct. These specimens were then mounted and loaded to failure. The mean force to a predefined failure at 3.0-mm gap for the 3-screw construct was 468.7 ± 267.9 N vs 278.9 ± 164.0 N for the 2-screw construct (P < .001). The addition of a central nonparallel screw in the 3-screw construct significantly increased the force required for fracture gap displacement at all cut-off points (1.0-8.0 mm) when compared to the 2-screw construct (P < .001). Notably, the mean peak tensile force for the 3-screw construct was 499.4 ± 255.4 N occurred at the gap displacement of 4.1 mm for the 3-screw construct whereas the mean peak tensile force for the 2-screw construct was 315.9 ± 162.4 N displacing the gap at 4.3 mm. This study showed that an additional central nonparallel screw in the 3-screw construct provided significant mechanical superiority compared to a 2-screw construct. The present study supported the use of augmented fixation with an additional central off-axis screw to reduce risk of fixation failure in calcaneal tuberosity avulsion fractures.

Effect of delayed distal radius fracture fixation on the difficulty of surgical operation

PurposeThe effect of delayed distal radius fracture (DRF) fixation by volar locking plates (VLPs) on the operative time, rate of bone graft use and need for additional surgical incisions was analyzed. Short- and mid-term outcomes were compared between early and delayed DRF fixation. MethodsA retrospective cohort review of DRFs treated with VLPs was performed. The effects of delayed fixation were analyzed by 1) comparing intraoperative and radiographic parameters and follow-up outcomes between early fixation (EF, 1–10 days) and late fixation (LF, ≥11 days), 2) predicting the prolonged operative time using linear regression analysis, and 3) predicting the rate of bone graft use and additional incision using odds ratios. ResultsOf 104 patients, 51 and 53 were in the EF and LF groups, respectively. EF showed a significantly shorter operative time, lower rate of bone grafting and fewer additional incisions (94.80 vs. 123 minutes, 3.92% vs. 26.18% and 2% vs. 20.45%, respectively). Radiographic parameters, immediate postoperative pain and wrist range of motion were significantly better in the EF group. However, the visual analog scale (VAS) pain and Patient-Rated Wrist Evaluation (PRWE) scores were not different at the 12-month follow-up. For every day of delay, the operation was prolonged by 2.17 min, the rate of bone grafting increased by 8%, and the chance of additional incisions increased by 8%. ConclusionDelayed DRF fixation affects intraoperative and postoperative outcomes. We encourage internal fixation for DRFs as early as possible to reduce surgical complexity and improve postoperative outcomes.

Circumumbilical incision for neonatal abdominal surgery: additional skin incision when there is difficulty in manipulating the intestine.

This study aimed to evaluate the safety and effectiveness of circumumbilical incision (CUI) for neonates requiring intestinal anastomosis. Seventy neonates requiring intestinal anastomosis at our institution between 2003 and 2020 were included in this retrospective case-control study. Patients were classified into the CUI (25 patients: 36%) and transverse incision (TI) groups (45 patients: 64%). Postoperative complications and surgical outcomes were compared between the two groups. Intestinal perforation at the non-anastomotic site occurred significantly more often in the CUI group than in the TI group (3 patients: 12%, and 0 patients: 0%, respectively (p = 0.042)). There were no between-group differences regarding anastomotic leakages, anastomotic strictures, time to enteral feeding, operative time, and blood loss. Neonatal intestinal surgery employing CUI might be associated with increased intestinal perforation at the non-anastomotic site. Hesitating to enlarge the skin incision to maintain favorable cosmetic outcomes might cause severe injury to the delicate neonatal intestine during the surgical procedure owing to the restricted surgical field. When performing CUI, we suggest that the skin incision should be extended without hesitation whenever there is difficulty in manipulating the intestine.

Feasibility of transoral robotic selective neck dissection with or without a postauricular incision for papillary thyroid carcinoma: A pilot study.

BackgroundThe study aimed to evaluate the feasibility of transoral robotic selective neck dissection (SND) with or without a postauricular incision for papillary thyroid carcinoma (PTC).MethodsWe studied 14 patients with PTC who underwent robotic SND via the transoral or combined transoral and postauricular approaches.ResultsThe transoral approach was performed on 10 patients for dissection of levels III and IV. An additional postauricular incision was made on 4 patients for dissection of level II in addition to levels III, IV, and V. The operation was completed successfully in 13 patients, except 1 patient with the procedure conversion due to uncontrolled bleeding from the internal jugular vein. The mean numbers of removed lymph nodes in the lateral compartment were 23.1 ± 9.4 and 38.3 ± 8.5 in the transoral and combined groups. Transient recurrent laryngeal nerve palsy occurred in 1 patient, transient hypoparathyroidism in 3 patients, and chyle leakage in 1 patient. There were no hematomas, mental nerve injuries, surgical space infections, or CO2 embolisms.ConclusionTransoral robotic SND is feasible with or without a postauricular incision.

Sesamoidectomy for Autografting in First Metatarsophalangeal Joint Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first metatarsophalangeal (MTP) joint is a well established procedure with excellent outcomes for patients with forefoot disorders including hallux rigidus and hallux valgus Routine bone grafting is not typically required, but bone graft may be necessary in the setting of revision surgery, non-union, or erosive bone loss to encourage biologic fusion and fill bone voids. Options for bone graft include either allograft or autograft. Typical locations for autograft harvesting would include calcaneus, distal tibia, or iliac crest. Due to potential harvesting morbidity and time associated with an extra incision, allograft bone is frequently utilized. In this study, we describe the outcomes of an approach to first MTP fusion with simultaneous medial sesamoidectomy with morselizing the bone for utilization as autograft. Methods: A retrospective review of all first MTP arthrodesis cases performed by one fellowship-trained foot and ankle surgeon were identified. Operative reports and radiographs were reviewed identifying patients that underwent simultaneous medial sesamoidectomy for autograft purposes. Routine bone graft was not typically used for primary first MTP fusion. In the setting of nonunion surgery, revisions, or bone loss, autograft bone was harvested as needed to facilitate fusion. Medial sesamoidectomy was performed via the same dorsal approach without use of an additional incision. The bone was morselized and used to fill voids within the first MTP as needed. Supplemental calcaneal autograft was harvested if the harvest was not adequate (i.e. substantial bone voids). Indications for sesamoidectomy harvesting were noted. The primary outcome reviewed was fusion rate. Overall nonunion rates and patient outcomes were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis. Results: During the study period, 74 patients underwent first MTP arthrodesis. Of these, 20 underwent concurrent sesamoidectomy grafting with 11 requiring additional calcaneal grafting. Of the 20, 16 had prior surgeries and 4 had extensive erosive arthritis requiring grafting. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of hallux valgus, 3 nonunions, 3 failed Cartiva implants, 2 cases of avascular necrosis, 3 failed arthroplasties, 1 conversion bunionectomy, and 1 conversion from Keller procedure (Table 1). All 20 patients went on to successful union. In the non- sesamoidectomy group the fusion rate was 92.6% (p=0.57). All patients in the sesamoidectomy group were satisfied with their surgical outcome, and no revisions were required. Conclusion: This study found highly successful fusion rates in a potentially higher risk population (i.e. bone loss and revision cases) with the use of local autografting from the medial sesamoid. The medial sesamoid serves as a cost-effective, freely-available, successful graft material for first MTP arthrodesis that can be done quickly via the same incision, reducing potential need for other painful donor sites and the cost associated with allograft. This technique can be particularly useful in the context of revision arthrodesis, failed implants with conversion to arthrodesis, and in arthrodesis with osteoporotic bone or cases with significant erosive arthritis.

Modified Mercedes Single Incision for Combined Liver Kidney Transplant: A Case Series Report

The traditional approach in combined liver-kidney transplantation involves 2 separate and sequential incisions. We describe a modification of the standard Mercedes incision that allows a single-incision operation while providing and maintaining adequate exposure to enable safe dual-allograft transplantation. Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4 fingerbreadths below the rib edge with a midline, cephalad incision and inferior ± medial ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. Five consecutive patients (3 women/2 men; mean age, 49 years; median body mass index, 29.8 kg/m2) underwent combined liver-kidney transplantation for end-stage liver disease and progressive hepatorenal syndrome via a modified Mercedes single-incision approach (at a median Model for End-stage Liver Disease of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the 5 patients experienced postoperative wound complications, including 1 with delayed wound healing and 1 with superficial dehiscence. All patients have normal dual-allograft function at or beyond 6 months posttransplantation. The modified Mercedes single-incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation. Further studies are needed to prove the theoretical benefits of this technique.

How we do it—the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery

PurposeExtended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects.MethodsAll patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1–8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity.ResultsParietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred.ConclusionsThe use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

A Better Treatment for Moderate to Severe Hallux Valgus: Scarf + Akin Osteotomy Combined with Lateral Soft Tissue Release in a Single Medial Incision.

ObjectiveTraditional lateral soft tissue release (LSTR) was conducted by an additional dorsal first web incision, as the malformed thick scar and neuritis were common after surgery. A new method of lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) should be recommended. The objective is to investigate the clinical effectiveness and safety of scarf + Akin osteotomy (SAO) combined with lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) for moderate to severe hallux valgus.MethodsPatients who were performed surgery for hallux valgus from April 2014 to June 2020 were retrospectively reviewed. The visual analog scale (VAS) was recorded before surgery and during follow‐up, as well as the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Patient satisfaction was evaluated at the follow‐up time. The preoperative and follow‐up weightbearing X‐ray were conducted in all patients. The radiological parameters of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured. Tibial sesamoid position (TSP) was also recorded according to seven‐part grading system. The quantitative data were performed as mean ± standard deviation or median ± interquartile range. Student's t test was performed in HVA, IMA, and DMAA. The TSP, VAS, and AOFAS were statistical analyzed by Mann–Whitney U test. p value of <0.05 was considered significant.ResultsThere were 123 feet conducted surgery in 96 patients. The AOFAS score improved a lot which was preoperative 39 to 100 at the follow‐up time and VAS was 4 to 0 (p < 0.001). A total of 63 (51.2%) patients were very satisfied, 47 (38.2%) were satisfied, five (4.1%) were undecided and eight (6.5%) were not satisfied. The HVA, IMA, DMAA, and TSP were all decreased after surgery and were statistically significant (p < 0.001).ConclusionThe SAO combined with a LSTR‐SMI‐DFFM for moderate to severe hallux valgus is effective and safe with pretty good clinical and radiographic results, as well as minimal complications. The corrections of AOFAS and VAS conformed to the minimum clinically important difference (MCID).

ONCOPLASTIC CONE-SHAPED REMOVAL OF MELANOMA IN SITES WITH LIMITED SKIN RESOURCES

Background. According to the existing recommendations of the NCCN, 2-cm margins are optimal for surgical excision of skin melanoma (SM). Objective. A method of cone-shaped oncoplastic surgery of SM in sites with limited skin-plastic resources is presented. Methods. In the study 30 patients (11 men, 19 women) underwent cone-shaped removal of primary SM on arm and shin, epigastria and subclavicular sites. Oncosurgical approach involves the following: primary SM is excised with 2 cm margins around with transforming this round wound into conical using additional incisions; then conical wound is closed by transverse displacement of lateral skin-fatted flap. The postoperative seam looks like hook-shaped line. SM thickness is measured by sonography before surgery. Morphological verification is obtained by cytological examination of smears after superficial scraping biopsy. Results. Postoperative histology confirmed melanomas in all cases with “clear margins” in all surgical specimens, and postoperative staging was as follows: pT2bN0M0 – in 3 patients, pT2bN1-2M0 – 4 patients, pT3bN0M0 – 9 patients, pT4bN0M0 – 7 patients, and pT4bN1-2M0 – in 7 patients. Partial marginal necrosis of displaced flaps was of 4 patients (13.3%). There were no recurrences of melanoma at site of postoperative scar. 3-years disease free survival (DFS) rate was 76.6%, and 5 years DFS rate – 60.0%. Conclusions. Cone-shaped radical excision of primary melanoma is an appropriate surgery for patients with SM on the forearms, shoulders, epigastria and subclavicular sites and legs. The one-step oncoplastic radical surgery without intermediate biopsy prevents local recurrence in site of surgery as well as iatrogenic metastasis to regional lymph nodes.

Laparoscopic Living Donor Nephrectomy—Single-Center Initial Experience

(1) Background: Donor nephrectomy for living donor kidney transplantation using minimally invasive techniques is a safe procedure that has been used for more than 20 years with excellent results. The total laparoscopic approach offers decreased postoperative pain, less incisional morbidity, and a shorter recovery time. (2) Methods: We present the results of a series of 43 laparoscopic donor nephrectomies performed in a single center. The procedures were performed in a systematic approach with transperitoneal access using four ports. The main renal artery and vein were ligated using a linear stapler fixed with an alternate triple row of titanium staples. The specimen was extracted in an endoscopic bag through an additional incision. (3) Results: All procedures were performed laparoscopically without conversion to open surgery. The average warm ischemia time was 4.73 min. In all recipients, immediate kidney allograft function was observed. (4) Conclusions: Total laparoscopic living donor nephrectomy is a safe procedure. It was performed successfully in all cases with a short surgical time, low morbidity, and 0% mortality.