Contralateral Anterior Superior Iliac Spine Research Articles

Laparascopic management of non-palpable testis

We present a new approach to high intraabdominal testis (IAT) for elongation of the testicular vessels without division. The technique entails fixation of the testis to a point one inch above and medial to the contralateral anterior superior iliac spine for 12 weeks. Subdartos orchiopexy is then done as the second stage. Both stages are laparoscopically assisted. The a new approach to high intraabdominal testis, two-stage laparoscopic traction-orchiopexy, is useful and resulted in significant elongation of the testicular vessels without atrophy. It is a safe and valid alternative to the two-stage laparoscopic Fowler–Stephens technique, which entails division of the main testicular vessels.

The Iliofemoral Bounce Test: Identifying Hip Capsular Insufficiency

Background: Insufficiency of hip capsular structures has recently gained recognition as a cause of pre-arthritic hip pain, leading to hip joint instability and progressive chondrolabral injury. An accurate evaluation of capsular integrity can help orthopedic surgeons plan capsular management prior to hip arthroscopy. Indications: The proposed iliofemoral bounce test is meant to be applied preoperatively for identification of hip capsular integrity when microinstability is suspected or in the setting of revision hip arthroscopy. Technique Description: After induction of general anesthesia and complete muscle relaxation, the patient is placed in a supine figure-four position by placing the foot of the pathologic hip on the contralateral knee. Two examination techniques are performed: (1) The examiner places one hand on the patient’s contralateral anterior superior iliac spine and applies consecutive downward pressure in a “rocking” manner to the pelvis; (2) the examiner applies a preload and release force to the flexed knee (examined hip), with the contralateral pelvis stabilized, and observes the response of the knee to this loads. Results: Technique 1: The expected physiologic response in a preserved joint is a “bounce” of the contralateral hip (examined hip), evidenced by an up-and-down movement of the knee in response to the rocking movement applied. This movement reflects the integrity and functionality of the hip capsule ligaments’ elastic recoil forces, allowing the hip to remain in a stable state in response to destabilizing forces. In contrast, when capsular insufficiency is present, a lack of bouncing will be observed due to unrestricted external rotation of the hip to constrain the hip joint. Technique 2: In a preserved joint capsule, the knee will return to its preload position, while in capsular insufficiency, no bouncing of the knee will be observed. Discussion/Conclusion: The iliofemoral bounce test is a novel, dynamic, and reproducible examination technique for clinicians to evaluate patient’s true hip capsular integrity and for preoperative identification of the proper capsular management, either with a less invasive capsulotomy or performing a capsular closure, plication or even reconstruction, when necessary.

Early Clinical Outcome of Staged Laparoscopic Traction Orchidopexy for Abdominal Testes.

To assess the short-term clinical outcome of the novel Shehata technique of laparoscopic traction-lengthening for abdominal testes in a single center over a 12-month period (January-December 2014). An ethics approval of the study and appropriate consents were obtained for all patients before inclusion in our study. A total of 47 consecutive boys presented with impalpable testes in the ipsilateral hemiscrota, 3 of them were bilateral summing up to a total of 50 U of impalpable testes to a single center over 12 months (January-December 2014). Those boys underwent a preoperative ultrasound (US) Doppler scan for the ipsilateral and contralateral testes. They then proceeded to a first-stage laparoscopic exploration for the testes in which the cranial testicular artery and the caudal vas deferens were traced to their meeting point to locate the abdominal testes that were either found (peeping at the internal inguinal ring [IIR] or more cranially) or otherwise vanishing (intraabdominally blind-ending vas and vessels or extra-abdominally passing through the IIR). All 50 testes failed to stay at the contralateral IIR when brought there mandating a preliminary lengthening of the testicular vessels by lateral dissection, traction, and fixation to a point 1-2 cm superolateral to the contralateral anterior superior iliac spine (ASIS), essentially a mobile traction point. After 12 weeks, all underwent a second-stage laparoscopic-assisted ipsilateral subdartos orchidopexy for the testes under traction. Occasional slippage of the testis under traction mandated an otherwise second-stage retraction and a third-stage orchidopexy. All underwent US Doppler scan 3 and 6 months after orchidopexy. The 47 cryptorchid boys presented at a mean age of 3 years 2 months (range: 6 months-8 years). Out of the 50 impalpable testes, 9 were nonvisualized on preoperative US Doppler scan and 16 were vanishing on laparoscopic exploration: 5 abdominally (in utero vascular accident) and 11 scrotally (perinatal torsion). The remaining 34 testes were fixed loosely near the contralateral ASIS in the first-stage laparoscopic exploration. Out of which, 3 had slipped traction at the second stage. The 12-week traction interval went uneventfully and a predefinitive US Doppler scan confirmed viability of all testes under traction. All 34 elongated testes were mobilized and fixed in the ipsilateral hemiscrota inside a created subdartos pouch (of de Netto). All 34 fixed testes were confirmed viable on US Doppler scan 1, 3, and 6 months after orchidopexy. The novel Shehata technique of staged laparoscopic traction-lengthening for abdominal testes is safe, easy, and convenient as evidenced by our limited early experience. Neither internal herniation complicated the traction period nor testicular atrophy (by undue tension) complicated the traction or follow-up periods. We believe it is a good alternative to the Fowler-Stephens staged orchidopexy that entails risky division of the testicular vessels.

Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis

IntroductionMany men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length. AimTo present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis. MethodsA transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. Main Outcome MeasuresPrimary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction. ResultsA total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes. Clinical ImplicationsThis technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad. Strengths & LimitationsThis unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up. ConclusionsSuprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection.Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333–337.

Course of pelvic lift during total hip arthroplasty.

The position of the cup makes a major contribution to the success of total hip arthroplasty (THA). In conventional implantation of the prosthesis without navigation, the surgeon relies on the spatial position of the pelvis. However, iatrogenic manipulation of the pelvis during different surgical steps constantly changes the position of the pelvis during the operation. The position of the pelvis is substantial for the correct placement of the cup. The objective of this study was to investigate and visualize the course of this pelvic lift and correlate it to certain surgical steps. Pelvic lift was measured in 67 patients during implantation of a THA. This was done by measuring acceleration using the SensorLog app on a smartphone. It was placed on the patient's contralateral anterior superior iliac spine and recorded the movement of the pelvis throughout the whole surgical procedure. The position of the pelvis was allocated to each of eight relevant surgical steps during the operation. These surgical steps were normed over the time axis and transferred to a diagram. We found an average pelvic lift displacement of up to 14.9° upon placement in the figure-of-four position. This lift is particularly critical when exposing the acetabulum, as the true cup position can be unconsciously influenced. Average values of between 5.6° and 6.9° were found here. When implanting a THA in supine position, the pelvis is not fixed on the operating table. Rather, the side to be operated on is lifted to a greater or lesser degree, depending on the surgical step to be performed. The retractor traction immediately before cup implantation should be minimized. Nevertheless, it should be taken into account that anteversion of the cup implant in relation to the table plane is systematically higher than in relation to the pelvic entry plane.

Understanding the Active Straight Leg Raise (ASLR): An electromyographic study in healthy subjects

The Active Straight Leg Raise (ASLR) is an important test in diagnosing pelvic girdle pain (PGP). It is difficult to understand what happens normally during the ASLR, let alone why it would be impaired in PGP. In the present study, healthy subjects performed the ASLR under normal conditions, with weight added above the ankle, and while wearing a pelvic belt. Activity of the abdominal muscles, rectus femoris (RF), and biceps femoris (BF) was recorded with surface electromyography (EMG), and transversus abdominis (TA) with fine wire EMG. RF was ipsilaterally active, BF contralaterally, and the abdominal muscles bilaterally. All muscle activity was higher with weight, and abdominal muscle activity was lower with the pelvic belt. In both these conditions, TA and obliquus abdominis internus (OI) were more asymmetrically active than obliquus externus. The abdominal muscles engage in multitasking, combining symmetric and asymmetric task components. Hip flexion causes an unwanted forward pull on the ipsilateral ilium, which is counteracted by contralateral BF activity. To transfer this contralateral force toward ipsilateral, the lateral abdominal muscles press the ilia against the sacrum (“force closure”). Thus, problems with the ASLR may derive from problems with force closure. Also abdominal wall activity counteracts forward rotation of the ilium. Moreover, contralateral BF activity causes transverse plane rotation of the pelvis, often visible as an upward movement of the contralateral anterior superior iliac spine. Such transverse plane rotation is countered by ipsilateral TA and OI. The present study facilitates the understanding of what normally happens during the ASLR.

Pedicled anterolateral thigh flap for contralateral groin composite defect

Pedicled anterolateral thigh flap has been well described for ipsilateral groin defects. Its versatility depends on the intact femoral vessels. When the external iliac and the femoral vessels are absent, especially secondary to wide surgical tumour ablations in the groin region, ipsilateral ALT flap is not an option. Free flaps also are difficult because of lack of recipient vessels. We report a case of composite groin defect following wide resection of recurrent liposarcoma along with encased vessels which was covered with a pedicled anterolateral thigh flap from the opposite thigh. The technique of lengthening the vascular pedicle and medializing the pedicle, to effectively increase its reach to the contralateral anterior superior iliac spine without vascular compromise, is described.

Pedicled anterolateral thigh flap for contralateral groin composite defect

ABSTRACTPedicled anterolateral thigh flap has been well described for ipsilateral groin defects. Its versatility depends on the intact femoral vessels. When the external iliac and the femoral vessels are absent, especially secondary to wide surgical tumour ablations in the groin region, ipsilateral ALT flap is not an option. Free flaps also are difficult because of lack of recipient vessels. We report a case of composite groin defect following wide resection of recurrent liposarcoma along with encased vessels which was covered with a pedicled anterolateral thigh flap from the opposite thigh. The technique of lengthening the vascular pedicle and medializing the pedicle, to effectively increase its reach to the contralateral anterior superior iliac spine without vascular compromise, is described.

Surgical Techniques: Surgery to Correct Hidden Penis

Many men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length.To present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis.A transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump.Primary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction.A total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes.This technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad.This unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up.Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection.Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333–337.