Blunt Dissection Research Articles

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

Sublingual Dermoid Cyst in Young Child

A dermoid cyst is a benign congenital lesion of ectodermal origin that can arise in any region of the body, though occurrence is rare. A young girl aged 2 years 4 months was referred to our hospital because of a painless mass in the floor of the mouth. Intraoral examination findings revealed a painless movable elastic soft mass on the floor of the mouth measuring approximately 15 mm in diameter. Magnetic resonance imaging indicated a cystic lesion, with low signal intensity shown in T1-weighted and extremely high signal intensity in T2-weighted images. These clinical findings indicated the presence of a dermoid cyst and removal was planned. Under general anesthesia with nasal intubation, surgical removal was performed through an incision on the floor of the mouth. Blunt dissection exposed the integrity of the cyst capsule, which was weakly attached to adjacent tissue. The excised mass was 19 mm × 14 mm × 11 mm in size. Histological examination findings confirmed a diagnosis of dermoid cyst. The operation was successfully completed without any complications and the postoperative course was good. It is important to properly evaluate cysts in children and provide proper treatment with appropriate timing.

Laparoscopic Ultrasound-Guided R1 Vascular Liver Resection for Colorectal Liver Metastases at Caval Confluence.

Patients with tumors involving the hepatic vein (HV) at the caval confluence (CC) usually receive major hepatectomies or HV grafting. For colorectal liver metastases (CLM), tumor-vessel detachment (R1vasc) has proven to be oncologically adequate.1-3 However, parenchyma-sparing R1vasc surgery has usually been confined to the open approach. The technical tricks for accomplishing this kind of surgery in laparoscopy are disclosed. A patient with a CLM in contact with the middle HV (MHV) and left HV (LHV) at the CC underwent liver resection. No signs of vascular invasion were observed at preoperative imaging. On the basis of the low rate of tumor-vesselregression after chemotherapy,4 technical feasibility, and low tumor burden, patient was considered for upfront surgery. Surgery consisted in: (1) left liver mobilization with full exposure of the CC; (2) identification of the common trunk's root and its encirclement by tape; (3) the use of ultrasound to rule out HV invasion and to define a resection area favoring a transection plane smoothly approaching the point of vascular contact; and (4) careful vascular detachment by blunt dissection in a caudocranial fashion to separate the lesion from HVs. A limited resection of segments, four superior and two with MHV-LHV detachment, was performed. Operation time was 285min, with 52min of cumulative Pringle time and 20ml of blood loss. Postoperative course was uneventful. The in-hospital stay was 6days. Similarly to open surgery, laparoscopic R1vasc surgery for CLM at CC is feasible and represents an alternative to major hepatectomy. HV control by tape is recommended to manage any bleeding that may occur during tumor-vessel detachment.

Distribution of the tensor of the vastus intermedius.

The tensor of the vastus intermedius (TVI) was first described by Grob et al. in 2016. It originates from the anteroinferior greater trochanter and inserts into the upper patella and receives blood and nerves independently of other muscles. It has been overlooked, but since micro-surgery and detailed rehabilitation treatments are being developed, more research on it is warranted. Here we report on the TVI in a Korean cadaveric study. A total of 58 cadavers (41 males and 17 females) were included. Thighs were examined using a standardized dissection protocol. The quadriceps femoris muscle was identified and its components were defined by blunt dissection. A total of 116 lower limbs were dissected. In 40 of them, there was a separately innervated TVI muscle belly between the fasciae of the vastus lateralis (VL) and the vastus intermedius (VI) muscles. TVIs were classed as independent (ID), VI, and VL types according to the relative relationship between the TVI, VL, and VI, and subdivided into two parts: Part 1 was the proximal muscular portion of the TVI attached to the VL or VI, and part 2 was the distal aponeurotic area. TVIs were analyzed in detail via 58 Korean cadavers. We subdivided them on the basis of their location and association with related muscles. A larger study is needed to clarify the function and prevalence of the TVI.

Facial masculinization surgery

Facial masculinization surgery

Reconsideration of Sharp Dissection in Gynecological Surgery.

In surgical fields, sharp dissection is a basic surgical technique, and the prognosis and oncological outcomes are known to be affected by the technique of dissection. Even in gynecologic surgery, we believe that the basic surgical technique is sharp dissection. We herein present our technique and discuss its significance. Sharp dissection should entail the removal of a single thin line between the residual tissue and the excised tissue. If this line becomes multiple or thicker, it is not sharp dissection but blunt dissection. The accumulation of this thin line of sharp dissection can form surgical layers. What is important is moderate tissue tension and how to use monopolar. One can sharply cut the loose connective tissue assisted by moderate tissue tension. With regard to the use of monopolar, it is essential that it not be applied directly to the tissue, but rather be used with or without touching the tissue. Inadvertent blunt dissection should be minimized, as most surgical procedures can be performed with sharp dissection. We usually perform sharp dissection for open surgery as well as minimally invasive surgery. We obstetricians and gynecologists should reconsider the significance of sharp dissection and practice it in gynecological surgery.

Easy and Standardized Technique for the Dissection of Severe Pouch of Douglas Obliteration Mainly by Blunt Dissection in Total Laparoscopic Hysterectomy for Deep Infiltrating Endometriosis.

Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, Saitama, Japan Address for correspondence: Dr. Kenro Chikazawa, Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma, Omiya, Saitama 330-8503, Japan. E-mail: [email protected] Received October 31, 2022 Received in revised form December 11, 2022 Accepted December 26, 2022

Congenital lingual cyst: an unusually large presentation without obstruction

Congenital lingual cysts are rare tumours that present in variable sizes and locations within the tongue. We report the case of an infant whom we received at two weeks for a mass protruding from the oral cavity. On physical examination, the neonate had a good general condition. There was no respiratory or feeding difficulty. There was a large mucosa-covered, pink, soft tissue oral mass, occupying and expanding the oral fissure. The mass extended about 5 cm anterior to the fissure, and the lingual dorsum was identifiable intra-orally at its superior left surface. Head and neck computerized tomography scan showed an intra-lingual cystic mass, with mass effect on surrounding structures and no bone erosion. The diagnosis of a congenital cyst of the tongue was made. Surgical excision was planned at six months, with very close monitoring for feeding or breathing abnormalities. The procedure consisted of a lateral right mucosal incision along the edge of the tongue, followed by meticulous blunt dissection and separation of the cyst from the surrounding tissues. The cyst was excised completely. It had an approximate volume of 180 ml. The mucosa was closed by interrupted stitches. The procedure was well tolerated and post-operative outcome was good. The patient was addressed to the odontostomatologist for management and eventual correction of occlusal abnormalities. Diligent assessment and management of the airway shared by the surgeon and anaesthetist was capital.

The outcome of 100 patients with achalasia cardia following laparoscopic Heller myotomy with blunt dissection technique.

Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique (BDT). Only a few studies have assessed long-term outcomes and relief of dysphagia following LHM. The study reviews our long-term experience following LHM by BDT. This retrospective study was analysed from a prospectively maintained database (from 2013 to 2021) of a single unit of the Department of Gastrointestinal Surgery at G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. The myotomy was performed by BDT in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered treatment failure. A total of 100 patients underwent surgery during the study period. Of them, 66 patients underwent LHM, 27 underwent LHM with Dor fundoplication and 7 underwent LHM with Toupet fundoplication. The median length of myotomy was 7 cm. The mean operative time was 77 ± 29.27 min and the mean blood loss of 28.05 ± 16.06 ml. Five patients had intraoperative oesophageal perforation. The median length of hospital stay was 2 days. There was no hospital mortality. The post-operative integrated relaxation pressure (IRP) was significantly lower than the mean pre-operative IRP (9.78 vs. 24.77). Eleven patients developed treatment failure, of which ten patients presented with recurrence of dysphagia. There was no difference in symptom-free survival amongst various types of achalasia cardia (P = 0.816). LHM performed by BDT has a 90% success rate. Complication using this technique is rare, and recurrence post-surgery can be managed with endoscopic dilatation.

Anatomic variations in retaining ligaments during minimally invasive resection of subcutaneous lipomas.

Lipomas are common, benign tumors usually located in the subcutaneous tissue. The "one-inch method" is a minimally invasive technique for resecting large subcutaneous lipomas through a one-inch incision after blunt dissection of the lipoma from its peripheral retaining ligaments. The limitations of this method are currently unclear. We assessed twenty-five patients with large lipomas, defined as a tumor diameter greater than 5 cm. The location of the lipoma was at the shoulder in fifteen patients, the extremity in six patients, and the torso in four patients. The mean operative time for all lesions was 28.3 minutes, with a mean time of 25.9 minutes for lipomas at the shoulder, 21.8 minutes for the extremities, and 47.0 minutes for the torso. We classified patients into three groups according to operative time: the short group (10-29 min), middle group (30-49 min), and long group (50-70 min). For lipomas of the shoulder, there were eleven patients (73%) in the short group, three patients (20%) in the middle group, and one patient (7%) in the long group. For lipomas of the extremity, the groups contained five patients (83%), one patient (17%), and no patients (0%), respectively. For lipomas of the torso, the groups contained one patient (25%), no patients (0%), and three patients (75%), respectively. Lipomas of the torso require a longer operative time than those of the shoulder or extremity; this difference could be due to the number of retaining ligaments present, which is reportedly higher in the back than in the anterior or side body. Lipomas of the back are less amenable to the one-inch method, and posterior shoulder lipomas may take more time than those at other parts of the shoulder or at the extremities.

A novel simulation model for tube thoracostomy.

Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine. This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues. The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt. We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.

Effects of Topical Cyclosporin A Application on Preventing Epineural Scar Formation in Rats: Experimental Study

The aim of this study is to evaluate macroscopic, histopathologic and immunohistochemical effects of topical cyclosporin administration on prevention of epineural scar formation in rats.This experimental study was performed in two groups, each consisting of ten rats. Sciatic nerve was opened bilaterally. Tibial and peroneal components were set apart with blunt dissection. Abrasion injury was achieved by repetitive rubbing over biceps femoris muscle. In the control group saline sucked cotton peds were administered over opened sciatic nerve region bilaterally, whereas cyclosporin sucked peds were administered in the second group for five minutes duration. Eight weeks after surgery both groups were sacrificed and nerve complexes were evaluated microscopically, histopathologically and immunohistochemically. No side effects were observed after 5 minutes single dose topical cyclosporine administration in our study. Cutaneous, muscular and deep fascial repairment were almost completed according to Petersen’s numerical grading system (p<0.05). Nerve adherence was significantly decreased (p<0.001) in the ones treated with cyclosporin than the control group. FGF expression was demonstrated and individual evaluations of the control and the study groups immunhistochemically. The ratio of fibroblast/fibrosit number showed that both groups results were parallel. Single dose topical cyclosporin administration is shown to be successfull in preventing epineural scar formation after peripheric nerve neurolysis.

Novel Application of Hydrodissection in Laparoscopic Cholecystectomy for Gangrenous Gallbladders

IntroductionLaparoscopic cholecystectomy (LC) for gangrenous gallbladders (GGBs) can be challenging and represent a significant number of LC cases, necessitating more efficacious surgical techniques. Currently, the standard treatment for GGBs is blunt dissection which can have high iatrogenic complication rates. To our knowledge, this is the first large retrospective study conducted on the novel application of hydrodissection (HD) in LCs for GGBs. MethodsIn this retrospective study of 386 LCs, data were collected for patient demographics, medical comorbidities, operating time (OT), anesthesia time (AT), length of stay (LOS), estimated blood loss, conversion to open procedures, 30-day readmissions, and mortality. Patients were categorized into four groups: (1) Vyas employing HD for GGBs (VHG), (2) non-Vyas group of five surgeons not employing HD for GGBs (NVG), (3) Vyas treating non-GGBs, and (4) non-Vyas group of five surgeons treating non-GGBs. Control groups were age-matched and sex-matched. Statistical analysis used descriptive statistics, Mann–Whitney U testing, and chi-squared testing (α = 0.05). ResultsThis study demonstrated significantly decreased (P < 0.05) OT (P = 0.001), AT (P < 0.001), LOS (P = 0.015), and conversion to open procedures (P = 0.047) between the VHG and NVG groups, with HD reducing OT by 35.5% compared to blunt dissection. This study did not demonstrate significantly decreased (P > 0.05) estimated blood loss (P = 0.185) and 30-day readmissions (P = 0.531) between the VHG and NVG groups, but they were trending toward significant. There were no mortalities in this study. ConclusionsHD is associated with improved surgical outcomes of LCs for GGBs demonstrated by reduced OT, AT, LOS, and conversion to open procedures. Further multi-institutional studies are needed to validate HD implementation and further dissemination.

INTRAORAL LYPHOMA ON THE MENTAL REGION: A Case Report

Introduction: Lyphoma is a benign tumor of mesenchymal origin composed of mature adipocytes, usually separated by a thin fibrous connective tissue capsule. Lyphomas are rare in the oral maxillofacial region (0.1% to 5%). The clinical presentation of intraoral lyphoma is usually an asymptomatic yellowish mass. Case: This case report present an intraoral lyphoma occurring in the mental region of a 44-years-old man. The patient came with complaints of fullness in his left chin since the last year. Intraoral examination revealed the presence of smooth sessile nodules, moderate in size with yellowish color. Case Management: Surgical excision under general anesthesia is performed to remove the tumor. Discussion: Lyphoma is the most common mesenchymal tumor, but incidence in the oral cavity is rare. The etiology of intraoral lyphoma still unclear, but the possible pathogenesis mechanisms are the “hypertrophy” and “metaplasia” theory. The diagnosis of intraoral lyphoma usually clinical. Techniques such as intraoral radiography, USG, CT and MRI make the diagnosis of these tumors easier. Histopathology remains the gold standard in the diagnosis of lyphomas. Intraoral lyphoma treatment is surgical excision. In this case, the intraoral lyphoma located near to the mental foramen so the mental nerve must be protected during surgery using blunt dissection and careful excision. With this technique no complications seen after the surgery. Conclusion: Intraoral lyphomas are rare, clinicians should be able to recognize this tumor. Through this, adequate surgical excision will be performed and the recurrence rate reduced.

Evaluation of Osteopathic Principles in Cadaveric Specimens Using Radiological Assessment.

Osteopathic manipulative treatment (OMT) of the spine requires the physician to first be able to diagnose with palpation of the spinous processes, transverse processes, and facets, test for movement of the anatomy, and evaluate changes in tissue texture at each level. Physicians should then apply these changes to Fryette's Principles to effectively understand the corresponding somatic dysfunction and provide treatment.Continuing education in osteopathic principles and practices is important throughout an osteopathic physician's training. Diagnosis and treatment require an understanding ofthe complex neuroanatomy and physiology of patients. We sought to evaluate the diagnostic capabilities of osteopathic physicians.This was done by evaluating the accuracy of diagnosis of somatic dysfunction on a cadaver specimen and verifying via fluoroscopy and blunt dissection. Fresh refrigerated cadavers were palpated for lesions in the thoracic spine by residents and attendings, and diagnoses of somatic dysfunction were made. Anterior-posterior X-rays were taken with a C-arm. These levels were then exposed by blunt dissection, and somatic dysfunctions were visualized and recorded. Comparative analyses were conducted to evaluate the accuracy of diagnosis. Results: The accuracy of diagnoses was correct in those who had OMT skills reassessed throughout training and continuing medical education. Osteopathic physicians who routinely kept up with their training were better able to make diagnoses of somatic dysfunction. Continuing osteopathic medical education with an emphasis on the maintenance of palpatory skills is important.Those physicians with the greatest accuracy of somatic dysfunction diagnosis were physicians who routinely underwent reassessment and continuing medical education of osteopathic skills.

Developing a Robotic Surgery Curriculum: Selection of Virtual Reality Drills for Content Alignment

IntroductionDespite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills’ validity through content mapping and the alignment between learning goals and drill content. MethodsThree robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills’ difficulty, usefulness, relevance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity. ResultsThe 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inanimate drills were added to the curriculum to address lacking skill domains. ConclusionsWe identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address identified gaps in drill content.

Vagus nerve stimulator revision in pediatric epilepsy patients: a technical note and case series.

Vagus nerve stimulation (VNS) is an adjunctive treatment in children with intractable epilepsy. When lead replacement becomes necessary, the old leads are often truncated and retained and new leads are implanted at a newly exposed segment of the nerve. Direct lead removal and replacement are infrequently described, with outcomes poorly characterized. We aimed to describe our experience with feasibility of VNS lead removal and replacement in pediatric patients. Retrospective review examined 14 patients, at a single, tertiary-care, children's hospital, who underwent surgery to replace VNS leads, with complete removal of the existing lead from the vagus nerve and placement of a new lead on the same segment of the vagus nerve, via blunt and sharp dissection without use of electrocautery. Preoperative characteristics, stimulation parameters, and outcomes were collected. Mean age at initial VNS placement was 7.6years (SD 3.5, range 4.5-13.4). Most common etiologies of epilepsy were genetic (5, 36%) and cryptogenic (4, 29%). Lead replacement was performed at a mean of 6.0years (SD 3.8, range 2.1-11.7) following initial VNS placement. Reasons for revision included VNS lead breakage or malfunction. There were no perioperative complications, including surgical site infection, voice changes, dysphagia, or new deficits postoperatively. Stimulation parameters after replacement surgery at last follow-up were similar compared to preoperatively, with final stimulation parameters ranging from 0.25mA higher to 1.5mA lower to maintain baseline seizure control. The mean length of follow-up was 7.9years (SD 3.5, range 3.1-13.7). Removal and replacement of VNS leads are feasible and can be safely performed in children. Further characterization of surgical technique, associated risk, impact on stimulation parameters, and long-term outcomes are needed to inform best practices in VNS revision.

Novel blunt dissection forceps for tunnel creation during peroral endoscopic myotomy.

Novel blunt dissection forceps for tunnel creation during peroral endoscopic myotomy.

Use of Novel Blunt Dissection Technique for Surgical Unroofing in Myocardial Bridging Patients.

Myocardial bridging (MB) is a congenital anomaly involving the myocardial tissue encasement of a segment of the coronary artery. The purpose of the present study was to assess safety and efficacy of two surgical methods used for treating MB patients at our institute. Off-pump MB unroofing was performed in 45 adult patients between January 2016 and December 2021 by traditional surgical unroofing techniques (conventional group, n = 26) and blunt dissection techniques (blunt dissection group, n = 19). We retrospectively reviewed our patients by examining the baseline clinical characteristics, risk factors, medications, and diagnostic data for coronary artery disease. The Seattle Angina Questionnaire (SAQ) was used to assess angina symptoms both preoperatively and 6 months postsurgery. No significant difference in preoperative clinical characteristics was observed between the two groups. The blunt dissection group had shorter unroofed period (14.69 vs. 18.91 mins, P=0.001), less ventilator time (16.26 vs. 24.62 hours, P < 0.001), and a shorter hospital stay (8.74 vs. 12.89 days, P < 0.001). Although both traditional and blunt dissection techniques significantly improved postoperative SAQ scores including physical limitation due to angina, anginal stability, anginal frequency, treatment satisfaction, and quality of life (P < 0.001), no significant difference was observed between the traditional and blunt dissection techniques for SAQ. No cases of left anterior descending (LAD) injury in the blunt dissection group were observed although seven patients in the conventional group had LAD injuries. In our single-center experience of MB unroofing, the blunt dissection technique is a safe, effective technique that significantly reduces surgical and ventilator time and hospital stay. MB patients with severe angina who underwent the blunt dissection for surgical unroofing experienced significant improvements in anginal symptoms and quality of life six months after the surgery.

Abstract 12958: The Dark Side of Normal Healing: Fibrous Encasement of a Subcutaneous ICD Coil

Introduction: Implantable devices elicit fibrotic and inflammatory responses, which may result in reduced efficacy of the device. Prior literature has addressed thrombus formation and fibrous encapsulation of intravascular leads. This mechanism is at least in part different than subcutaneous fibrosis. However, there have been scarce reports of fibrosis related to subcutaneous leads. Case: A 74 year-old male with long standing ischemic cardiomyopathy and absence of pacing indication met indications for primary prevention S-ICD. After shared decision making, a device was implanted with defibrillation thresholds at 65 joules. He later presented with interventricular dyssynchrony (QRS 160 msec) and symptomatic heart block. Upgrade to a biventricular defibrillator was undertaken with removal of the S-ICD system. S-ICD coil manual traction failed to free the lead from the subcutaneous space of implantation. After extensive blunt dissection and removal of the coil, extensive coil ingrowth and fibrosis was noted (Figure 1). Conclusions: This case describes the occurrence and visually documents extravascular coil fibrosis and ingrowth into the SICD coil, similarly seen in intravascular ICD leads. The S-ICD coil is a necessary component of the shocking vector and extensive fibrosis may contribute to elevated shock impedance and failed defibrillation thresholds. In cases of elevated shock impedance, it is unknown whether failed defibrillation thresholds or elevated high voltage shock impedance is the result of the generator, coil, or both. Further research is warranted to ascertain whether failed defibrillation thresholds and increased shock impedance is due solely from the SICD generator pocket. Advances in coil technology and regenerative medicine may offer insights into mitigation of the inflammatory process.