Consideration In Surgical Planning Research Articles

Strategies for reoperative parathyroidectomy

Reoperative parathyroidectomy presents unique challenges and increased risks compared to initial surgeries. A thorough preoperative assessment is crucial, incorporating history, physical exams, laboratory evaluations, imaging studies, operative notes, pathology reports analysis, and postoperative complication reviews. Ectopic parathyroid glands further complicate reoperative procedures, necessitating careful consideration in surgical planning. Radioguided parathyroidectomy offers a safe and successful option for reoperative cases, and is particularly beneficial for detecting ectopic glands.

Conventional aortic root vs valve-sparing root replacement surgery in aortic dilatation syndromes: a comparison of mortality and postoperative complications

ABSTRACT Introduction Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques. Areas covered This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques. Expert opinion Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodeling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.

Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management.

ObjectiveEndoscopic approaches for sinus and skull base surgery are increasing in popularity. The objective of this narrative review is to characterize risk factors for internal carotid artery injury in endoscopic endonasal surgery (EES), highlight preventative measures, and illustrate key management principles.Data SourcesComprehensive literature review.MethodsRelevant literature was reviewed using PubMed/MEDLINE.ResultsCarotid artery injury in EES is rare, with most studies reporting an incidence below 0.1%. Anatomic aberrancies, wide dissection margins, as well as specific provider and hospital factors, may increase the risk of injury. Multidisciplinary teams, comprehensive preoperative imaging, patient risk assessment, and formal training in vascular emergencies may reduce the risk. Management protocols should emphasize proper visualization of the injury site, fluid replacement, rapid packing, angiography, and endovascular techniques to achieve hemostasis.ConclusionsWhile EES is a relatively safe procedure, carotid artery injury is a devastating complication that warrants full consideration in surgical planning. Important preventative measures include identifying patients with notable risk factors and obtaining preoperative imaging. Multidisciplinary teams and management protocols are ultimately necessary to reduce morbidity and mortality.

P91. How does gravity influence the distribution of lordosis in sagittal malalignment?

<h3>BACKGROUND CONTEXT</h3> Supine imaging reveals the contour of the spine without gravity, a key consideration in surgical planning. Comparing supine to standing radiographs may reveal differences in regional flexibility in adult spinal deformity (ASD). <h3>PURPOSE</h3> To determine differences in regional flexibility of the lumbar spine in patients with ASD. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> Fifty-six patients with sagittal ASD (SRS-Schwab Type N, no previous fusion) and 119 asymptomatic volunteers. <h3>OUTCOME MEASURES</h3> PI-LL, L1-L4, and L4-S1 alignment. <h3>METHODS</h3> Asymptomatic volunteers underwent full length standing radiographs, ASD patients had standing and supine radiographs taken for preoperative planning. The standing alignment of the asymptomatic volunteers (50.7±17 years, PI 52±11.4°) was analyzed using linear regression in order to calculate PI-based formulas for normative, age-adjusted standing PI-LL, L4-S1, and L1-L4. These formulas were applied to the ASD cohort and compared to their standing and supine alignment. Given the potential for confounding by ASD patients with stiff lumbar spines, analyses were repeated in a cohort of 25 patients with at least 5° of flexibility (defined as the difference between supine and standing lordosis) and 5 degrees of offset from regional alignment norms. <h3>RESULTS</h3> Linear regression in the asymptomatic cohort resulted in the following PI based formulas: PI-LL= -38.3 +0.41*PI +0.21*Age, L4-S1= 45.3 -0.18*Age, L1-L4= -3 + 0.48*PI). The ASD cohort had a mean age of 65±14 years, BMI 29±7 kg/m2, standing PI-LL 14±22°, T1PA 22±11°). Eighty-seven percent of patients had a lordotic apex between the L3-L4 inferior endplates. PI-LL improved with supine positioning (mean 8.9±18.7°, p<0.001), though not enough to correct to age-matched norms (mean offset 12.2±16.9°). Compared to mean normative alignment at L1-L4 (22.1±6.2°), L1-L4 was flatter on standing (7.2±17.0°, p<0.001) and supine imaging (8.5±15.0°, p<0.001) while L4-S1 was comparable (norm 33.6±2.6 vs standing 30.9±12.9, p=0.325; vs supine 34.5±10.3, p=1.000). Subgroup analysis of subjects with L1-S1 flexibility >5° demonstrated a more dramatic effect—the standing loss of lordosis (32.6±1.7° norm vs 25.5±12.7° standing, p=0.031) at L4-S1 corrected on supine imaging (33.9±11.1°, p=1.000), while L1-L4 alignment did not (23.0±6.2° norm vs 2.2±14.4° standing, p<0.001; vs 7.3±12.9° supine, p<0.001). <h3>CONCLUSIONS</h3> When the effect of gravity is removed, the distal portion of the lumbar spine (i.e., below the apex of lordosis) corrects, suggesting that deformity is contained in the proximal lumbar region. These findings illuminate the etiology of lumbar hypolordosis and may influence selection of fusion levels. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Achieving an Optimal Outcome in Immediate Breast Reconstruction.

Performing immediate breast reconstruction requires careful consideration of preoperative, intraoperative, and postoperative factors. One of the fundamental necessities is a well-coordinated multidisciplinary team to achieve successful reconstruction. Clear and effective communication between the oncological surgeon and plastic surgeon is imperative. The treatment plan must take into account any potential neoadjuvant and adjuvant therapies. Surgical planning and incisional approach must be carefully considered to optimize a safe oncologic surgery and ensure a viable reconstructive outcome. Furthermore, there are fundamentals to immediate breast reconstruction that must be met to obtain an aesthetically pleasing and structurally durable breast reconstruction. The goal of this article was to highlight important considerations in surgical planning and execution of immediate breast reconstruction so that an optimal outcome can be accomplished after either autologous or implant-based breast reconstruction.

Finite element analysis of stress distribution on reconstructed mandibular models for autogenous bone grafts.

There are several challenges in terms of mandibular reconstruction. The defect size, graft materials, and plate combinations should be taken into consideration in surgical planning. The aim of this study was to evaluate the effect of different reconstruction variations on the stress distribution of segmental resected mandibles with two different defect sizes using finite element analysis (FEA). Computerized tomography images of a human mandible, fibula, and iliac crest were used as references to build three-dimensional (3D) models on a PC. The virtual plates and screws were used to simulate reconstruction of the mandibular defects. The models were divided into two groups based on the longitudinal defect size. Different osteosynthesis variations and autogenous graft material combinations were used to reconstruct the mandibles. In all models, higher von Mises stress values occurred on the mandibles reconstructed with the fibula than those with the iliac crest. Fixation of the bone grafts with a reconstruction plate for the 10-mm defects and using a mini-plate in addition to the reconstruction plate for the 30-mm defects decreased stresses on the grafted bones. Mandibular reconstruction with the iliac grafts is biomechanically superior to that with the fibular grafts. In addition, osteosynthesis methods and the defect size affect the stress distribution.

Ophthalmic and orbital considerations in the evaluation of skull base malignancies.

The orbital contents, afferent and efferent visual pathways, and the cranial nerves involved in eye movement, corneal sensation and eyelid closure traverse the skull base, a region bounded by the intracranial cavity, the paranasal sinuses, and the deep spaces of the face and head. As such, tumors from above or below have potential to affect some aspect of the visual system. We discuss here the clinical ophthalmologic and orbital considerations in the evaluation of patients with these tumors, as well as the ophthalmic sequelae of treatment with radiation or surgery (or both). And for the surgeon, we discuss the ophthalmic and orbital considerations in surgical planning, the role of the orbital surgeon in skull base surgery, and briefly discuss transorbital approaches to the skull base. Ophthalmic and orbital dysfunction may be the main source of disability in patients with skull base malignancy; it is thus incumbent on those who manage patients with tumors of this region to be aware of the ophthalmic, neuro-ophthalmic and orbital manifestations, so as to best tailor therapy and monitor treatment outcomes.

Retrospective Review of Immediate Restoration of Lordosis in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Comparison of Static and Expandable Interbody Cages.

Sagittal alignment is an important consideration in spine surgery. The literature is conflicted regarding the effect of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) on sagittal parameters and the role of expandable cage technology. To compare lordosis generated by static and expandable cages and to determine what factors affect postoperative sagittal parameters. Preoperative regional lordosis (RL), segmental lordosis (SL), and posterior disc height (PDH) were compared to postoperative values in single-level MI-TLIF performed using expandable or static cages. Patients were stratified based on preoperative SL: low lordosis (<15 degrees), moderate lordosis (15-25 degrees), and high lordosis (>25 degrees). Regression analyses were conducted to determine factors associated with postoperative SL and PDH. Of the 171 patients included, 111 were in the static and 60 in the expandable cohorts. Patients with low preoperative lordosis experienced an increase in SL and maintained RL regardless of cage type. Those with moderate to high preoperative lordosis experienced a decrease in SL and RL with the static cage, but maintained SL and RL with the expandable cage. Although both cohorts showed an increase in PDH, the increase in the expandable cohort was greater. Preoperative SL was predictive of postoperative SL; preoperative SL, preoperative PDH, and cage type were predictive of postoperative PDH. Expandable cages showed favorable results in restoring disc height and maintaining lordosis in the immediate postoperative period. Preoperative SL was the most significant predictor of postoperative SL. Thus, preoperative radiographic parameters and goals of surgery should be important considerations in surgical planning.

Impact of Comorbid Disease on Length of Hospitalization in Spine Fusion Patients: An HCUP-US-NIS Study

Introduction: The following is a study of the impact of comorbid conditions on hospital length of stay following spinal fusion. Methods: Surgeries were identified from the 2016 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-US-NIS) by Medicare Severity Diagnosis Related Group (MS-DRG) codes and subdivided for analysis by fusion location and procedure approach. Length of stay was evaluated in relation to comorbid disease status, fusion location, and surgical technique. Comorbidities of interest included hypothyroidism, diabetes mellitus, hypertension, hyperlipidemia, anxiety, obesity, chronic obstructive pulmonary disease, osteoarthritis, rheumatoid arthritis, major depression, coronary atherosclerosis, arrhythmia, congestive heart failure, osteoporosis, stroke, and transient ischemic attack. Patients hospitalized longer than two months were excluded from this analysis. Results: 185,216 patients undergoing an inpatient spinal fusion were identified (Cervical 32,753, Cervicothoracic 2,633, Thoracic 2,817, Thoracolumbar 4,761, Lumbar 32,316, Lumbosacral 17,326). Each comorbid disease was found to significantly increase the length of hospital stay for at least one procedure location (p<.05), with transient ischemic attack (8.5 days in cervicothoracic cases), arrhythmia (5.4 days in thoracic cases), and chronic heart failure (4.8 days in cervicothoracic cases) associated with substantially increased duration of hospitalization. Chronic heart failure (β 2.85, SE 0.11, p <.001), stroke (β 3.05, SE 0.08, p <.001), and osteoarthritis (β 2.12, SE 0.41, p <.001) demonstrated strong positive association with increases in length of peroperative hospitalization. Conclusion: Preoperative comorbidities contribute variably to the length of post-spinal fusion hospital stay. With increasing trends towards predictive modeling in healthcare outcomes these conditions represent important factors for consideration in surgical planning.

Implications of Facial Asymmetry in Rhinoplasty.

Diagnostic, IV.

Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness

Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

1206 ABDOMINOPLASTY IN PRUNE BELLY SYNDROME, MODIFICATIONS IN TECHNIQUE TO ADDRESS THE VARIABLE PATTERNS OF ABDOMINAL WALL WEAKNESS

You have accessJournal of UrologyPediatrics: Reconstructive Surgery - Diversion, Endourology & Transplantation, Trauma1 Apr 20121206 ABDOMINOPLASTY IN PRUNE BELLY SYNDROME, MODIFICATIONS IN TECHNIQUE TO ADDRESS THE VARIABLE PATTERNS OF ABDOMINAL WALL WEAKNESS Edwin Smith, Arun Srinivasan, Andrew Kirsch, Hal Scherz, and Bruce Broecker Edwin SmithEdwin Smith Atlanta, GA More articles by this author , Arun SrinivasanArun Srinivasan Atlanta, GA More articles by this author , Andrew KirschAndrew Kirsch Atlanta, GA More articles by this author , Hal ScherzHal Scherz Atlanta, GA More articles by this author , and Bruce BroeckerBruce Broecker Atlanta, GA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1473AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Abdominoplasty is an important component of the management of children with prune-belly syndrome. Surgical tailoring of the abdominal wall results not only in an improved cosmetic appearance, but may also yield benefits of improved pulmonary, bowel and bladder function. While some features of the abdominal defect that are common to all patients, each patient possesses unique features that require consideration in surgical planning. We propose to our present our experience with this rare surgery and lessons we have learned. METHODS Patient information of children with prune-belly syndrome who underwent abdominoplasty in our institution between years 2001 to 2011 were collected. Indications for intervention, procedural details including incisions, adjunct procedures done and technique for dealing with the umbilicus were documented. Length of operative time, blood loss, complications and length of hospital stay were also collected. RESULTS 11 patients with prune-belly syndrome, ages 3 to 7 years of age underwent abdominoplasty using either the Ehrlich/Monfort techniques. In 9 patients, modifications in these techniques were applied to precisely address the pattern of abdominal wall laxity and properly position the umbilicus. These modifications included creation of a neoumbilicus, repositioning of the umbilicus using infraumbilical fascial tuck and differential tightening of the supraumbilical and infraumbilical components. In 1 patient, laparoscopy was used to assist repair. Abdominoplasty was performed concommittantly with other genitourinary procedures in 8 patients. Mean operative time is 251 minutes and mean hospital stay is 8 days. Immediate post operative outcome was satisfactory in all but one patient who had skin flap necrosis which improved in weeks. 2 children redeveloped supraumbilical abdominal reprotuberance and in 1 of them we felt this was due to progressive urinary tract dilation. After a median follow up of 5 years, 9 patients had stable satisfactory long term outcomes. CONCLUSIONS Abdominoplasty in prune-belly syndrome patients is not a single defined surgical procedure but rather a pot pourri of techniques that are modified to individual patient needs. Initial accurate assessment of morphological abnormalities and designing the intervention based on this assessment is the key to success. Infraumbilical Heinecke-Mikulicz technique of reconstruction is our favored method for repositioning umbilicus. Recurrent protuberance is a recognized complication and can occur years after repair. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e488 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Edwin Smith Atlanta, GA More articles by this author Arun Srinivasan Atlanta, GA More articles by this author Andrew Kirsch Atlanta, GA More articles by this author Hal Scherz Atlanta, GA More articles by this author Bruce Broecker Atlanta, GA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Accuracy of the Combination of Mammography and Sonography in Predicting Tumor Response in Breast Cancer Patients After Neoadjuvant Chemotherapy

Residual tumor size after neoadjuvant chemotherapy is an important consideration in surgical planning. We examined the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size. Tumor size was evaluated by physical examination, mammography, and sonography at diagnosis and before surgery in 162 breast cancer patients who received neoadjuvant chemotherapy. Agreement between the predicted and the pathologic responses and the predicted and the pathologic tumor sizes was calculated. The effect of invasive lobular carcinoma, high nuclear grade, hormone receptor positivity, and the presence of an extensive intraductal component on the accuracy of mammography and sonography in predicting pathologic residual tumor size was analyzed. Forty-two patients (25.9%) had a pathologic complete response (pCR). Overall agreement between predicted and pathologic responses was 53% for physical examination, 67% for mammography plus sonography, and 63% for physical examination plus mammography and sonography. The sensitivity of mammography and sonography in predicting pCR was 78.6%, and the specificity was 92.5%; the accuracy was 88.9%. Residual tumor size determined by mammography and sonography correlated with pathologic residual tumor size (r = .662); pathologic tumor size was within .5 cm of predicted in 69.1% of patients. Multivariate analysis showed that pathologic residual tumor size was underestimated for lobular carcinoma and overestimated for poorly differentiated tumors. The combination of mammography and sonography has a high accuracy in predicting pCR after neoadjuvant chemotherapy. Agreement of residual tumor size in mammography and sonography with pathologic residual tumor size was moderate.

Decision making in revision sinus surgery

Success in endoscopic sinus surgery (ESS) occurs in 85 to 95% of patients. Approximately 5 to 15% of patients fail and require revision sinus surgery. Some of the same problems that cause failure for primary ESS could also be a problem for revision surgery. Nasal polyps, extensive disease, and previous surgery are problematic cases. Underlying problems such as cilial abnormalities, immunodeficiency, and cystic fibrosis need to be taken into consideration in surgical planning. The most common symptoms noted in the patient with failure are headache and symptoms of recurrent infection. The most common anatomic problems related to failed surgery are a retained or intact uncinate process and a lateralized or destabilized middle turbinate. Pathophysiology noted on objective evaluation includes anterior and posterior ethmoid disease; frontal recess obstruction or stenosis; an obstructed, blocked, or closed antrostomy; recirculation phenomenon; recurrent or persistent fungal disease; and sphenoid obstruction or closure. Surgical decision making designed to treat these problems is carefully planned and targeted with surgical alternatives ready as back-up. Stereotaxic computerized ESS is very helpful in finding disease and identifying the orbit and skull base. These points of interest are reviewed in an effort to give an overview of what is required for appropriate decision making in ESS.

Cholesteatoma: pathological considerations in surgical planning.

The management of cholesteatoma has been a controversial subject for many years. Advances in technology, magnification and surgical skills have enabled the otologist to deal more effectively with cholesteatoma over the years. However, attention must be paid to the pathological nature of cholesteatoma when planning surgical attack upon it. Rather than simply being skin that has gotten lost and becomes unable to cleanse itself of its epithelial debris, cholesteatoma is an invasive, erosive and destructive process. It feeds upon the bone by invading it with osteoclastic cells and others which are apparently capable of regenerating cholesteatoma matrix. Unless these residua are removed along with the matrix, one cannot be certain of total ablation of disease. Microscopic inspection at the operating table cannot be trusted to make this determination. Therefore, the case is presented for dealing with cholesteatoma in a two-stage operation. One-stage operations which reconstruct the ear at the same time as the removal of cholesteatoma matrix predispose to the recurrence of cholesteatoma in several ways. The neophyte otologist should not feel that extraordinary operations are the standard and should be prepared to utilize the basic mastoid operations as a preliminary to timed reconstruction of the middle ear. Observation of the ear over an interval is the best way to determine that cholesteatoma has been removed in its entirety.