Complex Surgical Techniques Research Articles

P-462 Exploring the potential of fertility clinics in the metaverse: opportunities, challenges, and ethical implications

Abstract Study question Could the integration of the metaverse enhance patient care in fertility clinics, and what are its potential challenges and ethical implications? Summary answer Integrating the metaverse into fertility care could enhance assisted reproduction, improving patient and provider experiences. However, it presents challenges in privacy, accessibility, and ethical implications. What is known already The digital transformation in healthcare, accelerated by the COVID-19 pandemic, has underscored the potential of the metaverse in medical fields. Utilising technologies such as virtual reality (VR), augmented reality (AR), and mixed reality (MR), the metaverse offers significant opportunities for enhancing patient care, engagement, medical training, and support. Its applications across various medical disciplines demonstrate its capacity to improve healthcare experiences. However, the specific implementation of the metaverse in fertility clinics, aimed at meeting the distinct expectations of tech-savvy Millennials and Generation Z, and potentially enhancing patient experience, treatment efficacy, and support mechanisms, is yet to be explored. Study design, size, duration Conducted in November and December 2023, this systematic literature review ensured a focused and up-to-date analysis of the current applications and implications of the metaverse in healthcare. This review spanned major databases, leading ART journals, and pertinent industry reports. Over two months, 468 metaverse-related publications, from 2007-2024, were identified, with 81 addressing healthcare (2022-2024). However, only one paper specifically addressed ART in the context of IVF metaverse clinics, indicating a significant research gap. Participants/materials, setting, methods This study involved analysis of academic literature, industry reports, and real-world implementations to assess the metaverse’s current use in healthcare. Research keywords included ‘metaverse’, ‘healthcare’, ‘(in)fertility’ and ‘assisted reproduction’, focusing on present and potential metaverse applications in healthcare provision, advanced patient care technologies, innovative training methodologies, and practical uses in clinical settings. Additionally, it scrutinised challenges and ethical issues associated with metaverse technology and existing platforms, providing a comprehensive overview of its implications in healthcare. Main results and the role of chance Current applications of the metaverse in healthcare are evident in specialties such as urology, mental health, ophthalmology, chronic pain management, cancer, and paediatrics. Innovative technologies, including haptic tools and smart operating theatres, have enabled the development of complex surgical techniques and practices. Metaverse conferences featuring avatar delegates introduced a new dimension to professional interactions. Digital twins are used to simulate patient scenarios, enabling personalised treatment plans that improve the accuracy of diagnoses and treatments. In medical and nursing education, VR offers immersive, hands-on learning experiences. In the context of ART, the metaverse holds promise for enhancing telemedicine through AI-driven avatars, advanced patient monitoring, and haptic simulation training for procedures like egg collections, embryo transfer, and ICSI. Patients may experience immersive virtual tours of typically restricted laboratory areas, interact with digital representations of their embryos, and engage in immersive online support communities. However, significant challenges persist, including the maintenance of patient privacy, addressing technological disparities, and managing billing complexities in virtual environments. The study emphasises the critical importance of data privacy and security, particularly concerning the sensitivity of fertility-related information. Additionally, it raises questions about the authenticity of patient-provider interactions in a virtual setting and the potential for deepening digital divide. Limitations, reasons for caution The study’s limitations include a scarcity of literature on the metaverse in future fertility clinics, as evidenced by just one online paper addressing IVF metaverse clinics. This gap limits a comprehensive understanding of the metaverse’s applications in ART, and raises concerns about consistent and secure access to these emerging technologies. Wider implications of the findings This research highlights the transformative potential of the metaverse in fertility care, emphasising focused research, ethical considerations, and infrastructure development to harness its benefits. Highlighting the importance of navigating challenges such as data privacy, technological disparities, and regulatory frameworks to ensure optimal patient care in this evolving digital landscape. Trial registration number not-applicable

Revision of Failed Nonanatomic Extensor Retinacular Stabilization of the Unstable ECU Tendon: Surgical Technique and Case Series.

Nonanatomic surgical stabilization of the unstable extensor carpi ulnaris (ECU) tendon (where the subluxing tendon is re-routed away from the bony groove in the distal ulna) utilizes a flap of extensor retinaculum to create a new retaining sheath that will stabilize the tendon during forearm rotation movements. When this surgery fails, the extensor retinaculum tissue does not regenerate with sufficient structural strength to be used again. Previously, a different approach has then been needed for revision surgery, often using more complex surgical techniques with a substantially greater impact on recovery. We describe a highly reliable yet simple method of using local soft tissue to adequately restabilize the subluxing ECU tendon in cases where an extensor retinacular flap has already been used. We report the results of this technique in 4 patients, all of whom returned to jobs/hobbies where ECU instability was a considerable functional risk.

Surgical scar management - an evaluation of surgical techniques.

The purpose of this narrative review is to analyze surgical techniques for removing scar tissue and minimizing them. A considerable proportion of the population have scars that are related to a traumatic event that they remember accurately, this being especially true for scars on the face, but also on the rest of the body if they are of significant size. The negative consequences of the esthetic damage are felt mainly in the family and at professional level, without losing sight of the fact that any person suffers as a result of the awareness of unsightly wounds or scars. To be successful, an aesthetic intervention must represent the optimal balance between science, the art of plastic surgery and the patient's expectations. Good communication between surgeon and patient is also needed. We must state that there is no method of total removal of scars; even in the case of complex surgical techniques, the scar cannot be completely excised, but a much more aesthetic appearance can be obtained. Scars cannot be completely removed from the skin, they can improve their appearance by fading or thinning, initially by conservative treatment, later, if necessary, by surgical scar reduction techniques. Improving the appearance of a scar depends on the type of scar, its severity, its surface and location, the causing factors, the time elapsed from production to the application of specialized treatment.

Impact of body fat location and volume on incisional hernia development and its outcomes following repair.

Obesity is known to increase the likelihood of developing abdominal wall hernias, body mass index (BMI) alone does not provide detailed information about the amount and location of body fat. The aim of this study was to investigate the link between various adipose tissue parameters and the incidence of incisional hernias (IHs), as well as the outcomes of hernia repair. We conducted a comprehensive review of the existing literature to examine the relationship between various body fat parameters and the occurrence of IHs after abdominal surgeries, as well as the outcomes of hernia repair. Thirteen studies were included for analysis. Eight trials evaluated the IH development after abdominal surgeries via specific fat parameters, and five studies evaluated the postoperative outcomes after IH repair. The findings of this study suggest that an increase in visceral fat volume (VFA or VFV) and subcutaneous fat (SFA or SFV) are linked to a higher incidence of IHs after abdominal surgeries. Higher levels of VFV or VFA were associated with more challenging fascia closure and greater postoperative recurrence rates following repair. Whereas BMI did not demonstrate a significant association. Measuring visceral and subcutaneous fat composition preoperatively can be a useful tool for assessing the risk of IH, and is more reliable than BMI. Elevated levels of these fat parameters have been linked to increased recurrence of IH following hernia repair, as well as the use of complex surgical techniques during repair.

Transferring laparoscopic skills to robotic-assisted surgery: a systematic review.

Robotic-Assisted Surgery (RAS) is experiencing rapid expansion, prompting the integration of robotic technical skills training into surgical education programs. As access to robotic training platforms remains limited, it is important to investigate the transferability of laparoscopic skills to RAS. This could potentially support the inclusion of early years laparoscopic training to mitigate the learning curve associated with robotic surgery. This study aims to assess the transferability of laparoscopic skills to robotic surgery. A systematic search was conducted using the PRISMA checklist to identify relevant articles. PubMed, MEDLINE, Embase, and Cochrane databases were searched, and inclusion and exclusion criteria were applied to collate eligible articles. Included were original articles comparing the performance of comparable tasks on both laparoscopic and robotic platforms written in English. Non-peer reviewed papers, conference abstracts, reviews, and case series were excluded. Seventeen articles met the inclusion criteria. Among these, 10 studies (59%) demonstrated skill transferability from laparoscopic surgery (LS) to robotic surgery (RS); while one study (5.8%) showed no significant transferability. Four studies highlighted the positive impact of prior laparoscopic training on robotic skill, whereas six papers suggested no significant difference between laparoscopic novices and experienced laparoscopists when utilizing a robotic simulator. Five studies evaluated advanced surgical skills such as intracorporeal knot tying and suturing, revealing superior robotic performance among experienced laparoscopists compared to novice learners. Laparoscopic skills appear to be transferrable to robotic surgery, particularly in complex surgical techniques. Robotic simulators demonstrate a significant reduction in the learning curve for surgical novices, albeit to a lesser extent for experienced laparoscopists.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences.

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

ТАКТИКА ЛЕЧЕНИЯ ТЯЖЕЛОЙ РЕФРАКТЕРНОЙ АРТЕРИАЛЬНОЙ ГИПЕРТЕНЗИИ У ПОДРОСТКА С ГИПОПЛАЗИЕЙ БРЮШНОЙ АОРТЫ И СТЕНОЗАМИ ПОЧЕЧНЫХ АРТЕРИЙ: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ

Renovascular arterial hypertension (AH) is one of the most common and prognostically most serious secondary hypertensions in children, however, descriptions of renal artery stenosis as part of middle aortic syndrome are quite rarely described Worldwide, and the etiology of this syndrome remains unclear in more than half of all the cases. Treatment approaches include a combination of complex conservative and surgical endovascular techniques that require constant monitoring of effectiveness. A clinical case observation and treatment tactics for refractory hypertension in an adolescent patient with hypoplasia of the abdominal aorta, stenosis of both renal arteries, a progressive decline in the function and volume of the left kidney (a picture of shrinkage of the left kidney on scintigraphy, an increase in hyperazotemia) and left ventricular (LV) hypertrophy is presented. Due to the ineffectiveness of drug antihypertensive therapy, the patient subsequently underwent aortoaortic bypass surgery of the abdominal aorta with prosthetics and implantation of the left renal artery into the shunt, balloon vasodilation with the installation of stents in the lower pole artery of the left kidney and the right renal artery. Over time, there was an improvement in the velocity parameters of the vessels of both kidneys, a decrease in blood pressure to values close to normal and regression of LV hypertrophy. Conclusion: the treatment tactics for a patient with renovascular hypertension and hypoplasia of the abdominal aorta, including drug methods in combination with two-stage surgical correction - the application of an aortoaortic shunt and endovascular treatment - turned out to be the most effective in terms of controlled hypertension.

Short dental implants

Short dental implants have been successfully used to support single and multiple fixed reconstructions in atrophic jaws, despite an increased crown-to-implant ratio. The use of short dental implants allows the treatment of patients for whom complex surgical techniques cannot be performed for medical, anatomical, or financial reasons. Furthermore, the use of short dental implants in clinical practice reduces morbidity, cost, and treatment time and reduces the need for complex surgery. The aim of this review is to evaluate the survival rates of short and extra-short dental implants and to discuss the impact of an increased crown-to-implant ratio on biologic and technical complications.

Technical Implications for Surgical Resection in Locally Advanced Pancreatic Cancer

Pancreatic ductal adenocarcinoma remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries. Currently, surgical resection in combination with systemic chemotherapy offers the only chance of cure or long-term survival. However, only 20% of cases are diagnosed with anatomically resectable disease. Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Although there are multiple surgical techniques described in the literature to improve outcomes in LAPC, the comprehensive view of these strategies remains underdeveloped. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.

The San Antonio kidney transplant model: validity evidence and proficiency benchmarks

Simulation has become an increasingly important tool in training complex and high-stake surgical techniques, including kidney transplantation. While several kidney transplant models have been described, there remains a need for a low-cost model with established proficiency targets. We developed a low-cost kidney transplant model to simulate a renal vein to iliac vein end-to-side anastomosis, and a proficiency-based curriculum to prepare and evaluate trainees. This low-fidelity model utilizes a constrained space and adjustable depth to simulate the iliac fossa, with replaceable Penrose drains as vascular conduits. 18 novices (PGY1), 19 junior intermediates (PGY 2–3), 7 senior intermediates (PGY 4–5) and 6 experts (faculty transplant surgeons) each performed anastomoses on the model. Three metrics were used to rate each performance—completion time, a scoring rubric, and a composite technical score (CTS) formula. Messick’s validity framework was used to evaluate the model and scoring rubric to provide evidence for content alignment, response process validity, internal structure validity, and construct validity. Resident participants reported the model was easy to set up (8.6/10) and added value to their surgical education (9.8/10). Transplant surgery faculty reported the model realistically simulated an end-to-side renal vein anastomosis (8.3/10), supporting content alignment. One-way ANOVAs for each of the three metrics was statistically significant across all skill levels (p < 0.001), supporting construct validity. Response process validity was achieved using blinded raters to review the video performances. Finally, inter-rater reliability was obtained with an intraclass correlation coefficient of 0.896 (< 0.001), supporting internal structure validity. We utilized Messick’s validity framework to provide validity evidence for a low-cost, low-fidelity kidney transplant model and a scoring rubric. Furthermore, we provided proficiency benchmarks for trainees to train towards. This model is well suited for preparing surgical trainees to perform in vivo kidney transplants.

An ex-vivo model for the biomechanical assessment of cement discoplasty.

Percutaneous Cement Discoplasty (PCD) is a surgical technique developed to relieve pain in patients with advanced degenerative disc disease characterized by a vacuum phenomenon. It has been hypothesized that injecting bone cement into the disc improves the overall stability of the spinal segment. However, there is limited knowledge on the biomechanics of the spine postoperatively and a lack of models to assess the effect of PCD ex-vivo. This study aimed to develop a biomechanical model to study PCD in a repeatable and clinically relevant manner. Eleven ovine functional spinal units were dissected and tested under compression in three conditions: healthy, injured and treated. Injury was induced by a papain buffer and the treatment was conducted using PMMA cement. Each sample was scanned with micro-computed tomography (CT) and segmented for the three conditions. Similar cement volumes (in %) were injected in the ovine samples compared to volumes measured on clinical PCD CT images. Anterior and posterior disc heights decreased on average by 22.5% and 23.9% after injury. After treatment, the anterior and posterior disc height was restored on average to 98.5% and 83.6%, respectively, of their original healthy height. Compression testing showed a similar stiffness behavior between samples in the same group. A decrease of 51.5% in segment stiffness was found after injury, as expected. The following PCD treatment was found to result in a restoration of stiffness—showing only a difference of 5% in comparison to the uninjured state. The developed ex-vivo model gave an adequate representation of the clinical vacuum phenomena in terms of volume, and a repeatable mechanical response between samples. Discoplasty treatment was found to give a restoration in stiffness after injury. The data presented confirm the effectiveness of the PCD procedure in terms of restoration of axial stiffness in the spinal segment. The model can be used in the future to test more complex loading scenarios, novel materials, and different surgical techniques.

Robot-assisted partial nephrectomy with calicolithotomy

The combination of renal cell carcinoma and urolithiasis in the same kidney is rare. The management of patients who have two such diseases simultaneously is primarily determined by renal cell carcinoma as the dominant disease. To date, modern diagnostic and surgical technologies make it possible to perform partial nephrectomy with simultaneous removal of a calculus from the pelvicalyceal system using minimally invasive endovideosurgical methods.&#x0D; This study aimed to demonstrate the possibility of performing robot-assisted nephrectomy with calicolithotomy in a patient with abnormalities of renal vessels.&#x0D; This work presents a clinical case of a 36-year-old man hospitalized with a neoplasm of the right kidney measuring 38 35 35 mm, detected during multislice computed tomography. In the lower group of calices of the kidney, a 5 4 mm calculus with a density of 1200 HU was found. The presence of anomalies of the renal vessels served as the basis for a three-dimensional (3D) reconstruction of the right kidney using the 3D Slicer modeling program. The patient underwent a robot-assisted kidney resection with calicolithotomy on a da Vinci SI robot. Intraoperatively, an ultrasound examination of the kidney was performed using an intracavitary sensor BK Flex Focus 800.&#x0D; The console operating time of the operating surgeon was 110 min. Blood loss was approximately 100 ml. The warm ischemia time was 20 min. The postoperative period proceeded without complications. At 3 weeks postoperatively, nephrogenic arterial hypertension disappeared. Laboratory studies conducted 3 months after surgery indicated an increase in the glomerular filtration rate compared with preoperative results.&#x0D; 3D reconstruction allows rational planning of the scope of surgical intervention during preoperative preparation. Kidney resection with calicolithotomy is optimally performed using the da Vinci robot, which allows complex surgical techniques to be performed using endovideosurgical methods.

Creating a Spaced Repetition Model to Supplement Education in Plastic Surgery.

Summary:Plastic surgery encompasses a wide spectrum of material involving comprehensive anatomy, physiology, microbiology, biomaterials, complex surgical techniques, and many nonsurgical interventions. The core disciplines overlap extensively with the foundational knowledge of many other surgical specialties. With the ever-expanding knowledge base required to become a competent plastic surgeon, spaced repetition is a means to optimize learning in plastic surgery and help trainees master new concepts while retaining other facts that are easily forgotten. Platforms for spaced repetition are user-friendly and can be synchronized between devices to streamline progress and make efficient use of the limited free time that exists throughout the workday. Flashcard decks can be imported to these platforms to follow a spaced repetition algorithm. Currently, no publicly available comprehensive deck exists for education in plastic and reconstructive surgery. Creation of flashcard decks covering lectures, textbooks, or old examination questions can reinforce the foundational concepts of our field. Additionally, there is potential to improve resident performance on the Plastic Surgery In-service Training Examination. Once created, this comprehensive flashcard deck can be distributed to plastic surgery residency programs to pave the way for a uniform curriculum.

24: IDEAL IMPLEMENTATION OF THE MINIMALLY INVASIVE CERVICAL ESOPHAGECTOMY (MICE), A JAPANESE-DUTCH COLLABORATION

Abstract Background and aim MICE is an innovative Japanese surgical technique, combining a laparoscopic transhiatal and a single port cervical mediastinal dissection in patients operated for esophageal cancer. This complex surgical techniques aims to reduce pulmonary morbidity without compromising oncological radicality by avoiding thoracic access, prevailing pleural integrity and facilitating cervical or abdominal instead of pleural drainage of mediastinal infections in case of anastomotic leakage. Potential drawbacks are an increased risk of recurrent laryngeal nerve injury and learning associated morbidity during the implementation phase. Up to date this technique is not routinely performed in European esophageal cancer patients. Methods In order to explore the feasibility and safe implementation of the MICE procedure in Dutch esophageal cancer patients, the evidence based IDEAL-framework will be followed. This framework describes 6 stages of evolution for new surgical therapeutic interventions: Pre-clinical, First in human, Development, Exploration, Assessment and Long-term Study. Outcomes of the first two phases will be described. Results The Pre-clinical phase consisted of on-site visits to a Japanese expert center, protocol development, prospective risk assessment, instrument collection and extensive cadaveric training on six fresh frozen human bodies. A ‘virtual supervision platform’ has been developed to proceed with the implementation process despite the COVID pandemic. After thorough evaluation with Dutch upper GI surgical experts and esophageal cancer patients, we have proceeded to the ‘First in Human’ phase. Conclusion The IDEAL framework was used as an evidence based tool for safe implementation of the MICE procedure. We will present the results of the ‘pre-clinical’ and ‘first in human’ stage as well as the surgical technique of the MICE procedure.

Urinary tract obstruction: Ultrasound-guided intervention.

Urinary tract obstruction (UTO) is a common clinical problem of which there are many potential causes. The aim of this feature article is to explore the role of ultrasound in diagnosing UTO, during guided interventional procedures and the potential procedural complications.Topic description and discussion: Ultrasound is an integral imaging modality throughout the management pathway of a patient with UTO and is often utilised as a first-line test in diagnosis and treatment. Percutaneous nephrostomy is an interventional technique, usually performed by radiologists or interventional sonographers, as either a short- or long-term management strategy. It can either be used in isolation or to gain access to the renal collecting system prior to more complex interventional or surgical techniques. Ultrasound-guided interventional techniques to relieve UTO can be employed in a number of clinical scenarios each with their own indications, contraindications and complications. Ultrasound plays a unique role in the planning and active stages of intervention with the provision of dynamic imaging which is crucial for providing safe and effective patient management.

Aucune différence dans les résultats cliniques et radiologiques après la fixation de fractures transversales de la rotule avec une fixation par une bandelette ou un cerclage métallique : une étude comparative rétrospective

IntroductionSeveral surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HypothesisThe hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-peration than metallic cerclage but no differences in other clinical outcomes. Patients and methodsA retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months post-operatively to evaluate clinical scores and complications. ResultsA total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at two months post-operatively due to painful prominence. There was no significant difference in reoperation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of reduction throughout the series. At the final clinical follow-up of 18 months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. ConclusionNo significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidenceIII.

No difference in clinical and radiological outcomes following fixation of transverse patella fractures with either suture tape or metallic cerclage: A retrospective comparative study

IntroductionSeveral surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HypothesisThe hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-operation than metallic cerclage but no differences in other clinical outcomes. Patients and methodsA retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months postoperatively to evaluate clinical scores and complications. ResultsA total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at 2 months postoperatively due to painful prominence. There was no significant difference in re-operation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of fixation throughout the series. At the final clinical follow-up of 18months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. ConclusionNo significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidenceIII.

THREE DIMENSIONAL VIRTUAL PLANNING, MODELLING AND PRINTING IN FIBULA FREE FLAP MANDIBULAR RECONSTRUCTIONS – INITIAL CASE SERIES IN A LIMITED RESOURCE ENVIRONMENT

The most contemporary approach when dealing with extensive head and neck defects post oncological resections is based on virtual computer planning, surgical resection/reconstruction simulation and three dimensional modeling and printing. It is of great benefit, particularly when the maxillo-mandibular area is involved, because of its complex three dimensional form and active functional load, both these features presenting a long-standing reconstructive challenge to the head and neck surgeons. Developing such complex surgical techniques is a very resource dependent undertaking and relies substantially on a strategic support from the given National Health Service system. An overview of the first 3 consecutive cases of entirely digitally planned and lab-to-theatre transferred mandibular resections and simultaneous microvascular fibula flap reconstructions performed in Sofia between August – October 2017 is presented.

Damage control in penetrating duodenal trauma: less is better - the sequel.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of “Less is Better”. Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

Results of laparoscopic and open distal gastrectomies in patients with gastric cancer. Meta-analysis of Russian and European studies.

Objective: to compare the results of laparoscopic and open distal gastrectomy in patients with gastric cancer according to Russian and European studies. Materials and methods: we searched the e-library, the Cochrane Library and PubMed. Literary references, tables of contents of specialized journals and protocols of research not yet completed have been studied. Statistical calculations (mean difference - MD, odds ratios - OR, 95 % confidence interval – 95 % CI) and meta-analysis graphs were performed using RevMan 5.4 software. Results: ten primary sources met the inclusion criteria (4 researches from the Russian Federation and 6 from other European countries). Laparoscopic and open gastric resections did not differ in the number of lymph nodes removed (MD = ‒1.31, 95 % CI from 3.51 to 0.89, p = 0.24). At the same time, laparoscopic operations are accompanied by less intraoperative blood loss (MD = –163, 95 % CI ‒268 to ‒57, p = 0.002), and open operations are shorter (MD = –38, 95 % CI –71 to ‒17, p = 0.004). The period of hospital stay is shorter after laparoscopic resections (MD = –4.1, 95 % CI –8.02 to –0.14, p = 0.04). Differences in mortality are not statistically significant (OR = 0.83, 95 % CI from 0.45 to 1.54, p = 0.55), but significantly lower after laparoscopic operations (2.3 %, 12/516) than after open (3.4 %, 92/2702), as well as the frequency of complications - 31.8 % (153/481) and 35.7 % (935/2658), respectively (OR = 1.05, 95 % CI from 0.84 to 1.37, p = 0.67). The overall five-year survival rate after laparoscopic operations varies from 48.1 % to 63.6 %, after laparotomy - from 43.4 % to 55.7 %. However, scattered and incomplete information on long-term outcomes did not allow a formal meta-analysis on comparative survival at this stage. The high level of performance of technically complex surgical techniques made it possible to significantly reduce the differences in duration between open and laparoscopic interventions (RS = ‒27, 95 % CI from 77 to 22, p = 0.28) and the duration of inpatient treatment after minimally invasive operations (RS = - 8.97, 95 % CI from ‒13.48 to ‒4.47, p &lt;0.0001) in the subgroup of domestic studies. Conclusion: the direct results of laparoscopic subtotal distal gastric resections in Russian and European studies do not differ in terms of the amount of harvested lymph nodes, the number of complications and postoperative mortality. It is difficult to reliably assess the life expectancy of patients due to the lack of sufficient information at this stage, which requires the continuation of further research.