Counter Traction Research Articles

Experimental study of magnetic hydrogel assisted magnetic anchorguided endoscopic submucosal dissection in colonic tumors.

Endoscopic submucosal dissection (ESD) is a well-established treatment for gastrointestinal tumors and enables en bloc resection. Adequate counter traction with good visualization is important for safe and effective dissection. Based on magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD), we would like to explore the feasibility of magnetic hydrogel as an internal magnetic anchor that can be injected into the submucosa through an endoscopic needle to assist colonic endoscopic submucosal dissection. This prospective trial was conducted on 20 porcine colons ex vivo. We injected magnetic hydrogel into submucosa of the porcine colons ex vivo for MAG-ESD to evaluate the traction effect and operation satisfaction. Magnetic hydrogel assisted ESD was successfully performed on 20 porcine colons ex vivo. Adequate counter traction with good visualization was successfully obtained during the procedure of dissection. Magnetic hydrogel assisted MAG-ESD is feasible and effective.

Comparison of standing, side bending and awake supine manual traction dynamic radiographs for predicting spinal flexibility with postoperative correction rate in adolescent idiopathic scoliosis

Abstract Background: The aim of the study was to compare awake supine manual traction radiograph with standing side bending radiograph in adolescent idiopathic scoliosis (AIS) patients and to analyze, which one among them is the best predictor of spinal flexibility index in varying degrees of AIS curves with minimal to severe Cobb angle. Materials and Methods: AIS patients, who underwent surgery during the period from 2015 to 2018, were retrospectively analyzed. Supine manual traction anteroposterior radiograph were taken with the patient in the supine position, with traction applied by a person with the head halter at the chin and counter traction applied with pelvic belt, leg straps. Patients were divided into three groups A, B, and C based on Cobb angle of the major structural curve. Patients with Cobb angles between 40° to 65°, 65° to 90°, and more than 90° were included in Groups A, B, and C, respectively. Flexibility indices obtained from both traction and bending radiographs were correlated with percent change in Cobb angle correction post-surgery. Statistical analysis was done to find Pearson correlation coefficient (r) between variables and results were tabulated. Results: There were 36, 16, and 16 patients in Group A, B, and C, respectively. The mean age of the cohort was 13.38 years. Group A had a positive correlation to traction radiographs (r = + 0.188, P = 0.455). Group B had a statistically significant positive correlation to bending radiographs (r = + 0.729, P = 0.04). A statistically significant positive correlation with traction radiographs (r = + 0.769, P = 0.016) was seen in Group C. Conclusion: Awake supine manual traction radiographs reveal better flexibility index in severe stiff (Cobb more than 90°) curves. In moderately stiffer curves (Cobb 65°–90°) standing side bending radiographs provide a better flexibility index than traction radiographs. Supine manual traction radiographs should always accompany bending radiographs in evaluating AIS patients, especially with severe stiff curves.

Cervical conization with endoCUT mode applying gastrointestinal endoscopic polypectomy technique.

To show how endoCUT mode can be safely managed with cervical conization. Demonstration of the technique and explanation of endoCUT and soft coagulation mode with narrated video footage. Cervical conization is a therapeutic and diagnostic procedure performed for the diagnosis of cervical intraepithelial lesions and cervical cancer. Specific. include cold scalpel, ultrasonically activated device and laser, and loop electrosurgical excision procedure (LEEP), which involves transpiration and partial excision. The endoCUT mode and soft coagulation in VIO3® (ERBE, Tübingen, Germany) were used to perform cervical conical resection safely and at low cost. The endoCUT mode was originally developed for polypectomy in gastrointestinal endoscopy, where no counter traction can be applied. The endoCUT mode approach to cervical conization with several key strategies to minimize blood loss and ensure safety: 1) incisions can be made in close contact; 2) resection can be performed with minimal contact with the lesion; 3) control of bleeding from the resected transection by soft coagulation; and 4) low running cost of endoCUT mode. Conventionally, cervical conical resection has been performed by using a device capable of making a close incision (cold scalpel, ultrasonically activated device and laser, and LEEP etc.), but there have been issues with bleeding control and cost. Here, we present a new technique using the endoCUT mode and several strategies for safe and effective resection.

PO-01-028 LEAD HELIX FAILS TO RETRACT DURING LEFT BUNDLE BRANCH AREA PACING IMPLANT

Left bundle branch area pacing has emerged as the preferred method of conduction system pacing due to the lead stability and the stable low thresholds. The leads are lumenless leads or stylet driven leads The long term impact of these leads has not been well established. In this case, we describe removing a stylet driven lead in the left bundle branch area for repositioning N/A A 76 year old male presented for pacemaker implant for sick sinus syndrome. It was decided to implant a dual chamber pacemaker with left bundle branch area pacing. Using a stylet driven lead (Biotronik Solia S60, SE & Co, Berlin, Germany), and Selectra 3D sheath (Biotronik, SE & Co, Berlin, Germany), site was found on the right ventricular septum to advance lead into left bundle branch area. Helix deployed. Lead was driven into the septum with one to one lead body turns with lead helix turns (Figure A). Left bundle branch area pacing was demonstrated. Lead sensing and pacing parameters were acceptable. Sheath was split and decrease in sensing with increase in threshold was seen. It was decided to remove the lead to reposition. Counter clockwise turns were applied to the helix mechanism. Helix would not retract. Counter clockwise turns applied to the lead body and the lead would not release from the septum. Counter traction was applied to the lead and helix was noted to stretch on fluoroscopy. With further traction, lead was removed from the body in one piece. On gross inspection of the lead, a stretched helix was noted with probably a piece of the tricuspid valve apparatus. A standard right ventricular septal pacing lead was implanted, and the dual chamber pacemaker was completed. Post operative echo did not show any significant tricuspid regurgitation. Left bundle area pacing has emerged given its physiological pacing with stable position and lead parameters. The long term implications of these leads driven deep into the septum have not been established. Our case demonstrated potential pitfall of stylet driven leads for left bundle branch area pacing, which is the helix. This draws concern that future helixes of left bundle branch area leads may break off in the septum. Further long term evaluation of these leads is warranted.

Pilot study on a new endoscopic platform for colorectal endoscopic submucosal dissection.

The endoscopic submucosal dissection (ESD) is a technically demanding and time-consuming procedure, with an increased risk of adverse events compared to standard endoscopic resection techniques. The main difficulties are related to the instability of the operating field and to the loss of traction. We aimed to evaluate in a pilot trial a new endoscopic platform [tissue retractor system (TRS); ORISE, Boston scientific Co., Marlborough, MA, USA], designed to stabilize the intraluminal space, and to provide tissue retraction and counter traction. We prospectively enrolled all consecutive patients who underwent an ESD for sigmoid/rectal lesions. The primary outcome was the rate of technical feasibility. Further technical aspects such as en-bloc and R0 resection rate, number of graspers used, circumferential incision time, TRS assemblage time, submucosal dissection time, and submucosal dissection speed were provided. Clinical outcomes (recurrence rate and adverse events) were recorded as well. In all, 10 patients (M/F 4/6, age: 70.4 ± 11.0 years old) were enrolled. Eight out of 10 lesions were located in the rectum. Average lesion size was 31.2 ± 2.7 mm, and mean lesion area was 1628.88 ± 205.3 mm2. The two sigmoid lesions were removed through standard ESD, because the platform assemblage failed after several attempts. All rectal lesions were removed in an en-bloc fashion. R0 resection was achieved in 7/8 (87.5%) patients in an average procedure time of 60.5 ± 23.3 min. None of the patients developed neither intraprocedural nor postprocedural adverse events. TRS-assisted ESD is a feasible option when used in the rectum, with promising result in terms of efficacy and safety outcomes. Nevertheless, our pilot study underlines few technical limitations of the present platform that need to be overcome before the system could be widely and routinely used.

A Survey of Transoral Robotic Mechanisms: Distal Dexterity, Variable Stiffness, and Triangulation.

Robot-assisted technologies are being investigated to overcome the limitations of the current solutions for transoral surgeries, which suffer from constrained insertion ports, lengthy and indirect passageways, and narrow anatomical structures. This paper reviews distal dexterity mechanisms, variable stiffness mechanisms, and triangulation mechanisms, which are closely related to the specific technical challenges of transoral robotic surgery (TORS). According to the structure features in moving and orienting end effectors, the distal dexterity designs can be classified into 4 categories: serial mechanism, continuum mechanism, parallel mechanism, and hybrid mechanism. To ensure adequate adaptability, conformability, and safety, surgical robots must have high flexibility, which can be achieved by varying the stiffness. Variable stiffness (VS) mechanisms based on their working principles in TORS include phase-transition-based VS mechanism, jamming-based VS mechanism, and structure-based VS mechanism. Triangulations aim to obtain enough workspace and create adequate traction and counter traction for various operations, including visualization, retraction, dissection, and suturing, with independently controllable manipulators. The merits and demerits of these designs are discussed to provide a reference for developing new surgical robotic systems (SRSs) capable of overcoming the limitations of existing systems and addressing challenges imposed by TORS procedures.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

7458 Approach to the Fertility-Preserving Surgical Management of a Unicornuate Uterus with a Noncommunicating, Functional Rudimentary Horn

<h3>Study Objective</h3> To demonstrate how a unicornuate uterus with a functional non-communicating rudimentary horn in a patient desiring fertility can be safely managed with a robotic approach <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> A tertiary academic hospital <h3>Patients or Participants</h3> A healthy 22-year-old presenting with complaints of cyclic dysmenorrhea and desire for future fertility. <h3>Interventions</h3> A robotic-assisted laparoscopic approach to the resection of a functional non-communicating rudimentary horn with several key strategies to minimize blood loss, damage of normal tissue, and prevention of adhesion formation. 1. Placing a stay suture through the tissue of the rudimentary horn to aid with traction and counter traction necessary for enucleation of the horn in the correct tissue cleavage plane. 2. Minimizing blood loss by dilute vasopressin injection at planned incision site along with care to stay within the fibrotic tissue layer connecting the rudimentary horn to the unicornuate uterus. 3. Removing canalized fallopian tube attached to rudimentary horn to prevent rudimentary horn pregnancy. 4. Combination cold dissection with careful and deliberate use of electrosurgery following principles to minimize thermal injury to surrounding normal myometrium. 5. Two-layer non-locking suture to restore tissue integrity, ensure hemostasis, and prevent adhesion formation. 6. Surgical treatment (excision preferred) of all endometriosis at the time of surgery. <h3>Measurements and Main Results</h3> Final pathology confirmed a rudimentary horn with functioning endometrial tissue, endometriosis implants, and endometriosis of the appendix. <h3>Conclusion</h3> This technique allows for the surgical removal of a non-communicating rudimentary horn with: Restoration of anatomy, prevention of rudimentary horn pregnancy, removal of endometriosis, and optimization of future fertility.

8402 Two-Port Total Laparoscopic Hysterectomy and Excision of Simple Endometriosis in a Transgender Male Patient.

<h3>Study Objective</h3> To provide an overview of a two-port total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in a transgender male patient and to demonstrate the feasibility of excision of simple endometriosis by this approach. <h3>Design</h3> Surgical video. The American College of Obstetricians and Gynecologists recommends vaginal approach to hysterectomy, whenever feasible; however, in the transgender male patient, the vaginal approach to hysterectomy may pose technical challenges due to limited vaginal access: vaginal atrophy (when on testosterone therapy), lack of uterine descensus due to nulliparity that is common, and often times infrequent or no vaginal intercourse. Moreover, the frequent desire for salpingo-oophorectomy in this population can make the vaginal approach a challenging one. When patients have history of dysmenorrhea and/or pelvic pain, laparoscopy offers an adequate intrabdominal survey to diagnose and treat endometriosis, which is precluded with vaginal access alone. <h3>Setting</h3> Academic hospital with a referral-based practice for the transgender male patient who desire gender affirming surgery. <h3>Patients or Participants</h3> 35-year-old nulligravid trans male with gender dysphoria and history of severe dysmenorrhea prior to beginning testosterone therapy, who desires gender affirming surgery by hysterectomy and bilateral salpingo-oophorectomy. <h3>Interventions</h3> A 5 mm umbilical trocar is used for a 30-degree camera to maximize visualization. A 5 mm suprapubic trocar for the single operative instrument is placed above the level of the uterus fundus. Success of a two-port hysterectomy is achieved by having excellent uterine manipulation to generate appropriate counter traction on the uterus. The hysterectomy is completed in the standard fashion, and the excision of simple endometriosis is completed with a single instrument by using blunt and sharp dissection. The vaginal cuff is closed vaginally. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> A two-port laparoscopic approach avoids placement of ancillary trocars on the appropriate patient. This technique can be also used in the appropriate cis-gendered patients. Excision of simple endometriosis can be feasible with the two-port approach.

Minimizing Risks of Spillage during Laparoscopic Cystectomy

<h3>Study Objective</h3> Demonstrate cystectomy performed over an endocatch bag inserted through a posterior colpotomy. <h3>Design</h3> Video. <h3>Setting</h3> Hospital operating room. <h3>Patients or Participants</h3> 29yo G0 who presented with spotting at time of ovulation, found to have two ovarian dermoid cysts <h3>Interventions</h3> The patient had a laparoscopic cystectomy which was performed over an endocatch bag inserted through a posterior colpotomy. <h3>Measurements and Main Results</h3> The cystectomy was successfully performed via sharp and blunt dissection, along with a traction counter traction technique. The cysts were successfully removed without any spillage. <h3>Conclusion</h3> Inserting an endocatch bag vaginally is a minimally invasive technique to ensure that any spillage that occurs during a cystectomy is contained. It is a safe and feasible intervention.

INTRA-ARTICULAR LIGNOCAINE AS ANALGESIA DURING MANUAL REDUCTION OF ACUTE ANTERIOR SHOULDER DISLOCATION: AN OBSERVATIONAL STUDY.

Background:Acute anterior shoulder dislocation needs prompt reduction to provide pain relief. The ideal reduction method should be simple, fast, effective and non- traumatic, with minimal pain, and should not cause further injury to the affected shoulder. Intra-articular lignocaine has been advocated as a means of providing analgesia and subsequent relaxation to the patient.Aim: To assess the efciency of intraarticular lignocaine for reduction of anterior shoulder dislocations. Patients s &amp; Methods: Thirty cases of acute anterior shoulder dislocation were reduced using intraarticular local lignocaine injection as a method of analgesia by Rockwood's traction and counter traction method. Ten to Fifteen ml of 1% lignocaine was injected into the glenohumeral joint through a 20 gauge, 35-mm needle. Approximately ten to fteen minutes were allowed for the local anaesthetic to take effect before any manipulation of the shoulder was attempted. Results: The mean age was 37.2years±18.23 SD with majority of patients in age group of 20 to 40 years. 80% of patients were females. Among thirty patients studied 28 (93.3 %) had primary dislocation and in 18 patients (60 %) dominant shoulder was dislocated. Majority of the dislocations were reduced within 6 hours of injury. Pain assessed through application of a Visual Analog Scale during the maneuver revealed scores ranging from two to eight with mean score of 4.39 ± 1.46 SD (p value 0.049). Conclusion: We conclude method is not only safe and effective but also reduces hospital stay and has negligible adverse effects making it a popular choice for most orthopedists.

Single-Port Endorobotic Rectal Mucosa Harvest For Urethral Reconstruction.

Colorectal mucosal grafts for substitution urethroplasty are alternatives for patients when buccal mucosa is not adequate for long urethral strictures. This study presents the first cases of single-port endorobotic rectal mucosa harvesting for urethral reconstruction. The patients are 43- and 57-year-old men with medical histories of lichen sclerosis. The urethrograms demonstrated panurethral strictures requiring long mucosal grafts. The single-port robot was docked under general anesthesia in the modified lithotomy position. The procedure began with a submucosal injection of a lifting agent. After achieving an adequate lift of the mucosa, the dissection was started 2 cm proximal to the sphincter complex with a hook and continued cephalad. The semiflexible robotic platform eased and facilitated the dissection providing the required traction and counter traction. The injecting needle and aspiration device were directed with the help of a silk knot at the tip of the tools to create a handle for robot arms. The procedure was continued with a spatula tip thinner than the hook, which delivers less energy to the dissection field and creates a precise cut. The harvested graft was provided to the urology team after pinning it for measurement. The urologists prepared and completed the reconstruction of the urethra with the autograft. The patient had no complications related to his rectal mucosa harvest. We report the first 2 cases of single-port robotic rectal mucosal harvesting for long panurethral strictures with single-port endorobotic submucosal dissection technique. The technique seems promising to facilitate the precise submucosal dissection with meticulous control of traction and delivered energy.

Retrieval of a Fractured Marathon Microcatheter Entrapped in Onyx Using a Novel Stentriever-Assisted Technique.

Endovascular embolization using Onyx has been a major advancement in the treatment of cerebrovascular malformations. Microcatheter entrapment in Onyx is a procedural complication which can pose a thromboembolic risk to patients. There have been 4 retrieval techniques for intact microcatheters entrapped in Onyx previously described in the literature, which are summarized in this report. We present the first case using a novel stentriever-assisted technique to successfully and safely retrieve a fractured microcatheter entrapped in Onyx. An adult patient with a Cognard IIa + b dural arteriovenous fistula (dAVF) underwent Onyx embolization. The microcatheter became entrapped and fractured while initially attempting removal. A stentriever was used off label to capture the fractured microcatheter and then a larger caliber microcatheter was railroaded over it. Retrieval of the fractured microcatheter by the stentriever was then facilitated by counter traction on the Onyx cast using the larger microcatheter. This novel stentriever-assisted technique is a safe and effective rescue maneuver for retrieving a fractured microcatheter trapped in Onyx during embolization of dAVF. There is a need for further research and development of novel devices for retrieval of entrapped microcatheters.

155 Fracture of Pubic Rami During Hip Fracture Fixation - a Rare Case of Traction Table Related Injury

Abstract Background Traction tables form the mainstay of closed reduction techniques for lower limb fracture and in particular hip fractures. They offer a versatile solution to continuous traction required in a variety of operations such as closed intramedullary femoral fixation and hip fixation. Counter traction on the table is provided by the perineal post, this has been associated with significant complications such as neuropraxia, erectile dysfunction, cutaneous necrosis, and urethral injuries. Case presentation We present a case of an elderly and co-morbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intra-operatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Conclusions Closed reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed fixation should be accounted for when managing this complex and often frail group of patients.

Automation System Development for Counter Traction in Laparoscopic Surgery Using Reinforcement Learning

Automation System Development for Counter Traction in Laparoscopic Surgery Using Reinforcement Learning

Lead extractions: dissecting adhesions up to the lead‐tip of the right ventricle: safety and success‐rates

AbstractAimsGoal of Transvenous Lead Extraction (TLE) is complete removal of all targeted leads, without complications. Despite counter traction manoeuvres, efficacy rates are often hampered by broken right ventricle lead (RV‐lead) tips. Mechanically powered lead extraction (Evolution sheath) is effective, however safety of dissection up to the lead tip is unclear. Therefore, we examined the feasibility and safety of RV‐lead extraction requiring dissection up to the myocardium.Methods and resultsFrom 2009 to 2018, all TLE in the Isala Heart Centre (Zwolle, The Netherlands) requiring the hand‐powered mechanical Evolution system to extract RV‐leads (n = 185) were examined from a prospective registry. We assessed 4 groups: TLE with the first generation Evolution (n = 43) with (A1,n = 18) and without (A2,n = 25) adhesions up to the myocardium and TLE with the Novel R/L type (n = 142) of sheath with (B1, n = 59) and without (B2, n = 83) adhesions up to the myocardium. Complete success rate in Group B was significantly higher than group A (96.5 vs 76.7%, p = 0.0354). When comparing the patients with adhesions up to the myocardium, total complete success is higher in the R/L group (61.1% vs 90.5%, p = 0.0067). There were no deaths. Overall major complication rates were low (2/185; 1.1%) and there was no statistically significant difference in major and minor complications between the two groups.ConclusionExtraction strategy with the bidirectional Evolution R/L sheath for right ventricular leads with adhesions up to the myocardium is safe and feasible.

Preliminary application of transoral robotic thyroidectomy: experience from an initial 30 cases

Objective: To examine the surgical outcome of transoral robotic thyroidectomy. Methods: Clinic data of total 30 cases of transoral robotic thyroidectomy at the Department of Thyroid and Breast Surgery, the 960th Hospital of People's Liberation Army from May 2020 to December 2020 were analyzed retrospectively. There were 3 males and 27 females, aged (31.5±11.0) years (range: 17 to 55 years), including 6 cases of benign tumor and 24 cases of malignant cancer (all papillary thyroid carcinoma). An inverted U-shaped incision 1.5 cm in length was made over the end of the frenulum of the lower lip. A wide subplatysmal space was created by bluntly passing with a vascular tunneller (8 mm diameter), and a 12 mm trocar was inserted through the lip incision for the camera port. Lateral oral mucosal incisions 8 mm in length were made near both lateral labial commissures, 8 mm robot trocars were inserted through the incisions. An 5 mm trocar was inserted through an incision made along the patient's right axillary fold into the subplatysmal working space and was connected with 5 mm ProGrasp for counter traction during the operation and for later drain insertion. Numerical scoring system (NSS) was used to assess cosmetic effect 1 month post-operation. Results: All the 30 transoral robotic thyroidectomies was successful, no case conversed to open operation. Postoperative hospital stay was (6.3±1.2) days (range: 4 to 10 days). The tumor size of thyroid cancers was (5.3±3.0) mm (range: 2 to 15 mm). Lymph node metastasis was observed in 12 cases. The retrieved central lymph node number was 10.5±4.4 (range: 4 to 20), while the central metastatic lymph node number was 2(2) (range: 1 to 11). Postoperative transient hypoparathyroidism occurred in 2 cases. Permanent hypoparathyroidism and vocal cord palsy didn't occur. Other surgical complications included hematoma, surgical site infection and perforation of chin flap, retrospectively in 1 case. Local regional lymph node recurrence wasn't developed during 1 to 7 months follow-up. All patients were satisfied with the postoperative cosmetic outcomes,NSS was 9.4±0.8 (range: 8.7 to 9.6). Conclusion: Transoral robotic thyroidectomy is safe and effective, suitable for early thyroid cancers without lateral lymph node metastasis, and has superior cosmetic results when the patients are selected carefully.

Robotic Assisted Total Laparoscopic Hysterectomy for Complex Uteri with Cervical Fibroids: Tips and Tricks with an ABC Approach

<h3>Study Objective</h3> Leiomyomatous uteri present as a complex pathology for those women requiring a hysterectomy. Specifically, cervical leiomyomas complicate typically straightforward hysterectomies by anatomically distorting the ureter, uterine arteries, and bladder pillars. A systematic approach is necessary in order to ensure the safety of patients undergoing robotic surgery for benign indications. <h3>Design</h3> N/A. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> This patient is a 40-year-old, African American woman who presents with a 4.6 centimeter cervical fibroid adjacent to the right uterine artery and parametrium on transvaginal ultrasonography. <h3>Interventions</h3> This video proposes the following ABC approach in order to safely perform a robotic-assisted total laparoscopic hysterectomy (RA-TLH) in the setting of known cervical fibroids by imaging: A - Anatomical identification: specifically, the ureters, uterine artery, and colpotomy demarcation B - Build a plane to delineate cervical fibroids: find a tissue plan with judicious use of blunt dissection and short bursts of energy C - Consistent traction/counter traction: push the fibroids up and away from the eventual colpotomy site <h3>Measurements and Main Results</h3> Following the ABC approach ensures patient safety by identifying critical anatomical landmarks within the pelvis. Planes that delineate cervical fibroids help peel and shell these bulky tumors off and away from the eventual colpotomy site, while at the same time minimizing blood loss. Traction and counter traction allows for the cervix and colpotomy site to be set apart and distanced from the transection site, thus avoiding complications. <h3>Conclusion</h3> Cervical fibroids present as a uniquely complex pathology for surgeons attempting a total laparoscopic hysterectomy, whether robotic or via straight stick. This video proposes surgeons to follow the ABC approach for safely performing a hysterectomy with a leiomyomatous cervix. Further ongoing pre- and peri-operative planning will ultimately optimize patient outcomes.

B-PO03-011 COMPLETE HEART BLOCK. . .WHY NOW?

A 40 yo female with a history of hypertrophic obstructive cardiomyopathy (HOCM) s/p myectomy (age 17), LBBB, and VT s/p dual chamber ICD presented with lead abnormalities. RA lead showed chronically high impedance and threshold and RV lead showed noise. She was referred for extraction and re-implant of a subcutaneous ICD (S-ICD). S-ICD was chosen given < 1% historical RV pacing. N/A N/A In the OR, femoral venous access was obtained, and sheaths placed. A loop snare and deflectable EP catheter were advanced to the level of the IVC/RA junction and secured around the RV lead. The RA lead was fractured prohibiting placement of a stylet. A locking stylet was placed in the RV lead. A 14 Fr laser was used to begin to free the RV lead. At the first point of significant traction with the snare and the laser, which remained in the subclavian vein, the patient went in to CHB. Trans-cutaneous pacing was initiated, but unsuccessful, prompting chest compressions and placement of a pacing catheter in the RV. Compressions lasted approximately 2 minutes and were stopped after pacing capture was confirmed. The procedure was resumed and re-attempt at laser removal of the RV lead was made, however, the coil separated and the lead disintegrated. Further attempts were abandoned. Removal of the RA lead was difficult, as it appeared to wrap around the SVC coil. Ultimately, counter traction with a snare from below freed the lead, and it was removed from the groin. Post extraction, the patient remained in CHB. Given her history of rare pacing needs, it was felt her AV conduction would recover and therefore a single chamber ICD was implanted. Our HOCM patient presented with LBBB, no prior pacing needs, and a plan to proceed with S-ICD post extraction. It is unclear as to the exact mechanism of the patient's CHB, as this occurred with mere movement of the lead with a snare and modest traction, prior to any substantial manual traction being applied or removal of the RV lead from the endocardial tissue. The CHB was assumed to be temporary, and therefore a single chamber ICD was implanted with the expectation that her native conduction would recover. At her most recent follow up (8 months), conduction had not recovered, and she underwent upgrade of her single chamber ICD to a dual chamber.

Verbalization, Categorization, and Evaluation of Fundamental Surgical Skills: An Expert Consensus in Open Head and Neck Surgery.

This study aimed to verbalize fundamental surgical skills required for open head and neck surgery (OHNS), to organize them by categorization, and to establish a consensus among surgeons regarding the importance and difficulty of each skill. Improvement of fundamental surgical skills is the core of surgical education; however, surgical skills are not yet organized, and consensus in any surgical field remains uncertain. Fundamental surgical skills during OHNS were collected from surgical textbooks, real surgeries, and expert interviews. The items were analyzed to calculate the frequency of words and were categorized by 2 expert surgeons. After consensus on the importance and difficulty of each item was established by 15 expert surgeons using a Delphi survey, principal component (PC) analysis was performed to integrate importance and difficulty into a single parameter. Sixty skills were verbalized and categorized into 7 categories: "skin flap elevation (n = 6)," "vessel management (n = 9)," "nerve preservation (n = 8)," "instrument handling (n = 11)," "counter traction (n = 7)," "tissue exposure (n = 9)," and "flow and planning (n = 10)." In the Delphi survey, expert consensus was established after 2 voting rounds (Cronbach's α ≥ 0.80). The "counter traction" and "flow and planning" categories had high PC scores, which indicate priority in surgical education. Fundamental OHNS skills were verbalized, categorized, and evaluated via expert consensus. Assessment of surgeons' skills by the structured items hereby developed will help standardize the quality of OHNS and improve patient outcomes.