Deep Excision Research Articles

Diffuse infiltrative basal cell carcinoma of the eyelid in an adolescent; a rare entity and its atypical presentation

Basal cell carcinoma (BCC) is the most common malignancy of the eyelids in the West; however, BCC is less common among Asians (11%–65%). Although it is prevalence among the elderly, it is rare in adolescents. Herein, we report a case of a 17-year-old boy who presented with a diffuse, irregular mass on the right lower eyelid, persisting for one year, with no associated ocular complaints. Further clinical evaluation revealed a diffuse, infiltrating lesion involving the lower lid and palpebral conjunctiva, an inflamed ocular surface, and a pigmented lesion along the lateral border of the lower eyelid, accompanied by the loss of lid architecture and cilia. The lesion was associated with symblepharon medially and fixation to the underlying tissue. Systemic examination was clinically unremarkable. An incision biopsy confirmed the diagnosis of basal cell carcinoma. The lesion was further managed by excision biopsy with a 4 mm margin, which revealed conjunctival extension on histopathological examination. A tumor-free margin was obtained after a deep excision, followed by further histopathological analysis. The defect was covered with an amniotic membrane graft, and no signs of recurrence were noted after an 8-month follow-up.

Diode Laser for Juvenile Recurrent Respiratory Papillomatosis: A Case Series of 13 Patients.

Juvenile recurrent respiratory papillomatosis (JRRP) is the most common benign tumor in the larynx. It is uncommon; however, it is potentially life-threatening because it compromises the respiratory tract and required several surgeries to manage recurrences. Currently, the carbon dioxide laser is the treatment of choice. There are no studies about the role of the diode laser which is easy to use and has lower usage cost. This case series presentation reported on the therapeutic effects and recurrence rate of JRRP when using Diode laser. This is a case series presentation of 13 children, who were diagnosed with JRRP and operated for laryngeal papillomatosis with Diode laser in Otorhinolaryngology and Head and Nick Surgery Department et al. Mouwasat Hospital, Damascus, Syria between 2015 and 2022. 13 children required 56 surgeries at a rate of 1-2 surgeries/year, mean number of surgeries for each child was 4.31. That suggests that Diode laser might have a role in reducing the number of surgeries compared to a study used cold instrument and CO2 laser. The complications rate was 30.8%, which is considered a high rate compared to the other studies. In conclusion, we encourage using it when the CO2 laser device is not available. However, we suggest, reducing the power as low as possible and avoiding of two opposing raw surfaces, especially at the anterior commissure and deep excision. Further longitudinal studies are recommended to validate these results.

Adjunctive hyperbaric oxygen therapy with reconstruction of lower eyelid for basal cell carcinoma: A case series

IntroductionBasal cell carcinoma (BCC) is among the most widespread non-melanoma skin cancers, with an incidence of around 80 % worldwide. Surgery is the main therapy of choice. High-pressure oxygen is used in hyperbaric oxygen therapy (HBO) to treat hypoxic tissue conditions. By using this technique, the tissue oxygen tensions increase. This is used to treat a wide range of diseases and disorders brought on by hypoxic states, circulation issues, inadequate tissue oxygenation due to vascular damage, tissue damage from infections or accidents, and impairment of tissue healing. Cases presentationThis paper presents five cases of HBO used in the healing BCC surgery. All patients underwent wide and deep excisions with eight adjunctive sessions of HBO therapy. Clinical discussionThe five cases of post-surgery wound healing improved significantly with HBO. ConclusionBCC is a condition that is frequently identified in the outpatient department. Prerequisites for a better prognosis include early diagnosis based on sound information and prompt, structured, and sufficient therapy. Our study reveals the benefit of HBO in increasing wound healing and preventing complications after surgery for BCC.

Просторове обгрунтування лінійних параметрів біоптату в гістологічному дослідженні пігментних новоутворень шкіри у дітей

Usually the lower part of melanocyte nevi is at a depth of not more than 1–2 mm or more, which is typical for congenital nevi, as well as for large pigmented tumors that protrude significantly above the skin surface and have a pronounced intradermal part. Incomplete removal of pigmented nevi occurs during their superficial removal with insufficient capture of healthy tissues. When excision of pigmented nevi by acute method means in the vast majority of cases of incomplete removal can be avoided, and primarily because the suturing of the edges of the postoperative wound requires much deeper excision of tissues. Рurpose – to increase the effectiveness of surgical treatment of pigmented skin tumors in children by using a mathematical model. Materials and methods. The study was conducted on the basis of the oncohematology department of Vinnytsia Regional Children’s Clinical Hospital, a mathematical model for calculating the parameters of operational access was conducted on the Microsoft Excel platform. Results. Using the proposed mathematical model, the following parameters of the operating material were calculated: the area of the resection edges of the operating material; the area of the base of the operating material; the total area of morphological examination of the surface of the surgical material; determining the difference in the volume of surgical material to be histologically examined by different methods of its collection. In all cases, the tumor for three-dimensional histological examination was excised in the form of an ellipse with a safety zone (healthy tissue around the tumor). The surgical direction of the incision was formed with an inclination to the surface of the skin towards the tumor with the formation of an acute angle with it, while the upper part of the dermis was cut less than its lower part. This approach to the formation of the profile of the surgical wound improves the conditions for further reconstructive wound defect closure. Conclusions. Comparative mathematical calculation according to the proposed spatial geometric model of the biopsy in the form of a truncated elliptical cone convincingly shows an increase in the useful volume of surgical material in the planned histological examination compared with the cylindrical elliptical configuration of the biopsy due to involvement in the field of microscopic structures «residual structures» (processes) corresponding to melanocyte nevi, under the guise of which the development of the initial stages of melanoma may occur. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: children, melanocyte nevi, operative accesses.

Fluorescence in situ Hybridization (FISH) in the Microbiological Diagnostic of Deep Sternal Wound Infection (DSWI).

PurposePostoperative mediastinitis after cardiac surgery is still a devastating complication. Insufficient microbiological specimens obtained by superficial swabbing may only detect bacteria on the surface, but pathogens that are localized in the deep tissue may be missed. The aim of this study was to analyze deep sternal wound infection (DSWI) samples by conventional microbiological procedures and fluorescence in situ hybridization (FISH) in order to discuss a diagnostic benefit of the culture-independent methods and to map spatial organization of pathogens and microbial biofilms in the wounds.MethodsSamples from 12 patients were collected and analyzed using classic microbiological culture and FISH in combination with molecular nucleic acid amplification techniques (FISHseq). Frequency of and the time to occurrence of a DSWI was recorded, previous operative interventions, complications, as well as individual risk factors and the microbiologic results were documented.ResultsTissue samples were taken from 12 patients suffering from DSWI. Classical microbiological culture resulted in the growth of microorganisms in the specimens of five patients (42%), including bacteria and in one case Candida. FISHseq gave additional diagnostic information in five cases (41%) and confirmed culture results in seven cases (59%).ConclusionMicrobial biofilms are not always present in DSWI wounds, but microorganisms are distributed in a “patchy” pattern in the tissue. Therefore, a deep excision of the wound has to be performed to control the infection. We recommend to analyze at least two wound samples from different locations by culture and in difficult to interpret cases, additional molecular biological analysis by FISHseq.

Rectal Shaving for Bowel Endometriosis by Laparoscopic Reverse Submucosal Dissection for Easier, Safer and More Complete Excision of Disease

To demonstratefull-thickness excision of the affected muscularis along the submucosal plane. Stepwise demonstration of LRSD technique with narrated video footage. LRSD takes advantage of the submucosal layer of the bowel wall and uses it as an easier line of excision for rectal endometriosis compared with the very difficult traditional line of excision of irregular disease-muscularis interface. The expansion of the submucosal layer by the injection separates the affected muscularis away from the mucosa, making it safer to excise the lesion with less chance of entering the bowel lumen. Excision of disease is more complete with LRSD because the full-thickness excision of the muscularis layer includes the healthy deep muscularis, which will form the disease-free deep excision margin. This video will highlight anatomic and technical aspects of LRSD including the following key steps: 1. Mobilization of diseased bowel segment 2. Submucosal injection 3. Circumferential incision of the muscularis 4. Submucosal dissection along the submucosal plane 5. Bowel wall integrity test 6. Muscularis defect repair CONCLUSION: Rectal shaving by LRSD appears to be easier, safer, and more complete in excision of bowel endometriosis than the classical rectal shaving technique. This modification requires further evaluation to confirm its potential in the surgical management of rectosigmoid deep infiltrative endometriosis.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique.

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2–S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

The effectiveness of cold-knife conization (CKC) for post-menopausal women with cervical high-grade squamous intraepithelial lesion: a retrospective study

BackgroundThe effectiveness of surgery of high-grade squamous intraepithelial lesion in post-menopausal women needs to be investigated. This study evaluated the clinical significance of cold-knife conization in the diagnosis and surgery of cervical high-grade squamous intraepithelial lesions in post-menopausal women.MethodsWe conducted a retrospective analysis of post- and pre-menopausal patients with high-grade squamous intraepithelial lesion. All patients received cold-knife conization as the primary therapy.ResultsThe satisfactory rate of colposcopy was significantly lower in the post-menopausal group than in the pre-menopausal group (38.33 vs. 71.25%; χ2 = 36.202, P < 0.001). The overall positive margin rate of cold-knife conization (25.83 vs 12.50%; χ2 = 10.106, P = 0.001) and rate of positive endocervical cone margins (16.67 vs. 4.58%; χ2 = 14.843, P < 0.001) were significantly higher in the post-menopausal group. Moreover, 49 post- and 60 pre-menopausal women underwent subsequent surgical treatment (40.83 vs. 25.00%). Residual rate of positive and negative margins in patients before and after menopause was significantly different (χ2 = 5.711, P = 0.017; χ2 = 12.726, P < 0.001, respectively). The recurrence rate in post-menopausal women remained 3.85%.ConclusionsCold-knife conization can be performed as a primary procedure for diagnosis and surgery of post-menopausal patients with high-grade squamous intraepithelial lesions. Sufficient deep excisions are necessary to avoid positive endocervical margins, which can reduce the residual and recurrence of postoperative lesions.

New species of the genera Cranae and Lucretilis (Orthoptera: Acrididae) from Indonesia with taxonomic notes on the tribe Cranaeini

Three species are described from Indonesia, namely Cranae lolobatensis sp. nov. (Halmahera Island), C. ferwillemsei sp. nov. (New Guinea Island) and Lucretilis balikpapan sp. nov. (Borneo Island = Kalimantan). Position of the genera Lucretilis Stål, 1878 and Cranae Stål, 1878 in the modern classification of grasshoppers is discussed. First genus belongs to the nominative tribe of the subfamily Oxyinae. The genera Cranae, Cranaella Ramme, 1941, Craneopsis C. Willemse, 1933, Opiptacris Walker, 1870, Paracranae C. Willemse, 1931, Phalaca I. Bolívar, 1906, Philicranae C. Willemse, 1955 are placed in the tribe Cranaeini Brunner von Wattenwyl, 1893, stat. resurr. This tribe is transferred here from Oxyinae to the subfamily Hemiacridinae based on following characters: ventral genicular lobes of hind femora without spine; epiphallus bridge-like, not divided into two symmetric halves; zygoma apically with deep excision; valves of penis completely divided into basal and apical ones, and flexure between them absent.

Cutaneous leiomyosarcoma /&#x0D; atypical smooth muscle sarcoma

Relevance: Cutaneous leiomyosarcoma is a rare primary&#x0D; dermal neoplasm, accounting for up to 2-3% of all superficial&#x0D; sarcomas. It can occur at any age, most likely between the ages&#x0D; of 50 and 70 years. This tumor has a high recurrence potential&#x0D; in case of insufficiently deep excision. Recurrent tumors are&#x0D; more aggressive and characterized by subsequent metastasis.&#x0D; The purpose of the study was to demonstrate the results&#x0D; of the histopathological examination of a cutaneous leiomyosarcoma / atypical smooth muscle tumor.&#x0D; Results: Cutaneous leiomyosarcoma was represented by&#x0D; spindle-shaped cells with high cellularity located in bundles&#x0D; and growing expansively, surrounded by a capsule. The nuclei&#x0D; of the cells were elongated, hyperchromic. Cells with atypical&#x0D; abnormal nuclei were present in smaller quantities. The mitoses, including atypical, were numerous. IHC staining for SMA,&#x0D; Desmin, H-Caldesmon – diffusely positive on tumor cells. The&#x0D; reaction for S100, Myogenin – negative.&#x0D; Conclusion: A cutaneous leiomyosarcoma can be finally&#x0D; diagnosed only after a pathomorphological examination of&#x0D; the specimen and differential diagnostics using additional research methods.

Cutaneous leiomyosarcoma/&#x0D; atypical smooth muscle sarcoma

Relevance: Cutaneous leiomyosarcoma is a rare primary dermal neoplasm, accounting for up to 2-3% of all superficial&#x0D; sarcomas. It can occur at any age, most likely between the ages of 50 and 70 years. This tumor has a high recurrence potential&#x0D; in case of insufficiently deep excision. Recurrent tumors are more aggressive and characterized by subsequent metastasis.&#x0D; The purpose of the study was to demonstrate the results of the histopathological examination of a cutaneous&#x0D; leiomyosarcoma / atypical smooth muscle tumor.&#x0D; Results: Cutaneous leiomyosarcoma was represented by spindle-shaped cells with high cellularity located in bundles&#x0D; and growing expansively, surrounded by a capsule. The nuclei of the cells were elongated, hyperchromic. Cells with atypical&#x0D; abnormal nuclei were present in smaller quantities. The mitoses, including atypical, were numerous. IHC staining for SMA,&#x0D; Desmin, H-Caldesmon – diffusely positive on tumor cells. The reaction for S100, Myogenin – negative.&#x0D; Conclusion: A cutaneous leiomyosarcoma can be finally diagnosed only after a pathomorphological examination of the&#x0D; specimen and differential diagnostics using additional research methods

Does the trend toward less deep excisions in LLETZ to minimize obstetric risk lead to less favorable oncological outcomes?

To analyze the relationship between large loop excision of the transformation zone (LLETZ) depth and the persistence of disease and human papillomavirus (HPV) infection in patients with cervical intraepithelial neoplasia grades 2 and 3. A cross-sectional observational retrospective study included women with cervical intraepithelial neoplasia grades 2 and 3 who underwent LLETZ at Hospital Universitario Santa Lucía, Cartagena, Spain, from November 1, 2011, to December 31, 2016. Follow-up of cytology and HPV detection were performed at 6 and 12-18months after surgery. In this study of 256 women, multivariate analysis revealed that conization depth of 10mm or less did not indicate an increase of persistence/recurrence of pathological cytology at 6months (P=0.094) and after 12-18months (P=0.234), or infection by HPV at 6months (P=0.675) and 12-18months (P=0.938) after LLETZ. The affected endocervical margin at 6months is the sole independent risk factor for persistence, both in the lesion (P=0.003) and HPV (P=0.004). Conization depth lower than 10mm at LLETZ did not increase disease persistence or infection by HPV in an 18month monitoring period. Therefore, higher depth conizations would not be justified to ensure favorable oncological results.

"Personalized Excision" of Malignant Melanoma-Need for a Paradigm Shift in the Beginning Era of Personalized Medicine.

The premises on which guidelines for the excision of primary cutaneous melanoma are based are illogical and fail to take into account peculiarities of the individual lesion. The horizontal margins of excision continue to be adjusted to the vertical thickness of the neoplasm, and recommended clinical margins do not reflect the histopathologic borders of melanoma. Micrographically controlled surgery has become accepted for acral melanomas and melanomas of the face and neck but not for melanomas on the trunk, arms, and legs, although the latter tend to be more sharply confined. Extending margins of excision for the purpose of removing inapparent metastases is fallacious because the latter are rare, their localization cannot be foretold, and satellite metastases are usually associated with distant metastases, so that patients do not profit from early removal of cutaneous lesions. The only meaningful objective of excision is complete removal of the primary melanoma. The success of excision must be controlled histopathologically. Because of limitations of the method, a histopathologic safety margin should be observed that must depend on the characteristics of the individual lesion. In sharply confined melanomas, a histopathologic margin of at least 1 mm is sufficient. In the case of poor demarcation, with solitary atypical melanocytes extending far beyond the bulk of the lesion, a broader histopathologic safety margin is advisable. Special caution should be exercised in the presence of regression and for desmoplastic melanomas, acral melanomas, and melanomas on the face and scalp. Instead of wide and deep excisions with standardized margins, "personalized excisions" are required for primary cutaneous melanoma. The concept of clinical safety margins is a relic of former times that has no place in modern medicine.

A retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin

Basal cell carcinoma (BCC) is the most common malignancy worldwide. Although rarely a risk to life, they are potentially destructive and disfiguring. Current treatment guidelines are predominantly based on low-risk BCC and make no recommendations regarding the deep excision margin. We aim to clarify the prevalence of high-risk BCC and appropriate surgical management of the deep margin. Data of 556 patients presenting for primary excision of 694 basal cell carcinoma to CUH Plastic Surgery between January 2017 and April 2018 were collected by capture of demographics, surgical notes and histology. We defined the deep surgical margin as numbered anatomical planes, with subcutaneous fat as 0, the first plane under this as 1 and so forth. This allowed comparison of the surgical excision depth, and resulting deep margin histology, across disparate sites. Histological margin clearance was analysed using ordinal regression of age, site, size, histological type and surgical margin. This allowed identification of factors associated with clear, close or incomplete lesion excision. Subgroup analysis was then performed to make recommendations for surgical margins to achieve adequate lesion clearance. Six hundred ninety-four BCCs were identified, 66% were male and the average age of patients was 74 years. Of the BCCs, 49% were nodular but 39% were mixed. An infiltrative component was seen in 24% (mixed infiltrative), but only 4% were purely infiltrative. Mean size, site and patient age were similar across histological types. Deep margin involvement was very rare in nodular or superficial BCCs but occurred in 7% of pure infiltrative and 5% of mixed infiltrative. Peripheral margins were very rarely involved in nodular BCCs but occurred in 9% of mixed infiltrative and 10% infiltrative despite similar surgical margins. A deep margin of the first underlying anatomical plane resulted uninvolved margins in 95% of infiltrative or mixed infiltrative BCC, but subcutaneous fat was sufficient for clearance in 95% of nodular, superficial and mixed non-infiltrative BCC. High-risk BCC was a common finding in our patient population. This was based not only on site and size but also on histological type. Infiltrative and mixed infiltrative BCCs have a higher risk of close or involved deep margins than other types. We recommend that they are excised to the first underlying anatomical plane. Nodular, superficial and mixed non-infiltrative BCC can usually be safely excised with a cuff of fat alone.

Upper Lid Thick Skin Blepharoplasty.

While many of the basic tenants of upper lid blepharoplasty remain constant regardless of skin type, the thick-skinned eyelid patient requires special consideration. The brow may be naturally lower in the thick-skinned patient. These patients are more prone to having the brow pulled downward while attempting to remove redundant skin. There may also be more fat in the medial and central compartments. There may be fat in a lateral compartment overlying the lacrimal gland. Patient's expectations for a deep lid sulcus and complete excision of redundant skin may not be possible. They are more prone to an observable scar, a small dog ear at the lateral wound edge, and prolonged postoperative lid edema. Patients with lifelong upper lid fullness must get some input from significant others because their upper face aesthetic will change. In these patients, the eyelid surgery is not a rejuvenation, but a creation.

Risk factors for recurrence of facial basal cell carcinoma after surgical excision: A follow-up analysis

Several tumour features and surgical factors have been implicated in an increased risk of BCC recurrence after excision; however, there are limited data on facial lesions specifically. This study sought to evaluate risk factors of facial BCC, which may influence future treatment and follow-up regimes. Facial BCCs excised from a single surgeon practice over a 2-year period were included in the study. Data pertaining to patient demographics, lesion depth of invasion, surface area, excision margins, perineural infiltration, location, previous history of recurrence, histological subtype and ulceration were extracted. A search of recurrence was conducted over the following 70-80 months. In total, 331 cases of facial BCC were included, and 10 lesions recurrences (3%) were identified within the observation period. Infiltrative (p=0.02) and micronodular (p=0.04) subtypes as well as incomplete or close (within 1mm) peripheral (p=0.01) and deep excision margins (p=0.04) were significantly associated with tumour recurrence. Five of the 10 recurrent lesions had been re-excised for a recurrence previously, placing them at much greater risk of future recurrence (p=0.00). Incomplete and close excision margins, infiltrative and micronodular subtypes and previous excision are strong risk factors for facial BCC recurrence. Although depth of invasion, perineural infiltration, ulceration and surface area may indicate the aggressive nature of a lesion, the results suggest that with adequate excision margins, these factors may not influence the recurrence rate. The strongest risk factor was a lesion having already recurred after previous excision, and it suggested that these lesions be treated with particular caution and a closer follow-up regime be employed.

Reconstruction de la racine du nez après exérèse carcinologique profonde. Intérêt de combiner implants de titane et greffe de tissu graisseux

The mucosal cylindroma or adenoid cystic carcinoma is the second sinonasal non-epithelial malignant tumor frequency argument. Due to the achievement of the nasal mucosa and a late diagnosis reconstructions are often complex. We report the case of a mucous cylindroma recurrence of nasal septum requiring a wide and deep excision of the root of the nose with nasal reconstruction. A patient aged 66years whose history resection two years ago with a mucous adenoid cystic carcinoma of the right side of the nasal septum, had a local recurrence T2NOM0 imposing a wide excision with amputation nasal septum own bones of nose, the anterior portion of the triangular cartilages. The reconstruction was carried out in three areas: a musculocutaneous forehead flap to the mucosal level, a titanium plate to the bone plane, nasal native skin to skin level. Histological examination confirmed the existence of a recurrence cylindroma infiltrating the bone. The surgical margins were however in sano. Adjuvant radiotherapy to 60Gy dose of the surgical area was indicated after surgery. The consequences of surgery and radiotherapy were simple. However local changes to show a progressive refinement of the nasal skin due to irradiation leading to a small titanium plate exposure revision surgery with coverage by a glabellar flap associated with a time of lipomodeling unexposed areas have improved and trophism of soft tissue. Two further lipomodeling sessions have yielded a good quality and stable skin. From an oncological point of view, no recurrence was detected with a decline of 10years. Aesthetic and functional point of view the results were highly satisfactory. Oncologic resections subtotal nasal pyramid are complex, we will see the benefits and disadvantages of the different techniques used in the different stages. This case report illustrates the difficulties of reconstruction after wide excision of mucosal lesions root of the nose carrying the mucous plan and nasal bones. It stresses the importance of bone reconstruction titanium plate and innovative element, the efficiency of fat transfer to restore the quality and trophicity soft tissue. Fat transfer in addition to reconstructions by titanium plates and splints may thus expand the indications of these types of techniques in complex facial and cranial reconstructions.

Conservative Management using the Triple Approach and the Rouen Technique in Large Deep Rectovaginal Endometriosis

Background Colorectal resection is performed in numerous patients presenting with large endometriosis of mid and lower rectum; however, it may lead to low anterior rectal resection syndrome. To avoid such outcomes, we propose an original technique combining vaginal excision of infiltrated vaginal cul de sac, laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler: the Rouen technique. Methods The video presents the procedure performed in a 31-year-old nullipara referred with a large endometriotic nodule infiltrating the vaginal posterior cul de sac and the anterior wall of the mid rectum on more than 30 mm length responsible for symptomatic stenosis. The first step of the procedure is represented by the excision of vaginal infiltration using a vaginal approach. The second step includes a laparoscopic deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision is performed from rectal approach, by placing traction parachute sutures on the shaved area. Their traction induces the prolapse of shaved rectal wall that is resected using a semi-circular stapler. Results Operative time was 140 min. Immediate postoperative outcomes were uneventful. One year after the surgery, the patient reported one stool/day, without dyskesia, normal anal continence and no deep dsypareunia. To date, the Rouen technique was successfully carried out in 42 women with large deep endometriosis of the mid and lower rectum. Conclusions The Rouen technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.

Report on immediate irradiation of a rapidly growing sarcoma of the scalp prior to wound closure.

Cutaneous sarcomas are primarily treated with extensive surgery, and occasionally require adjuvant radiation therapy following complete wound healing. Thus, sarcoma surgery leads to large and deep wounds, and the initiation of adjuvant radiation therapy depends on the time required for defect closure. We present the case of a male patient with pleomorphic sarcoma of the temporal skin, which was treated with multiple wide and deep excisions, instant application of an Integra(®) bilayer, and immediate radiation therapy prior to wound closure. The objective was to investigate the usefulness of a dermal substitute (Integra(®) ) in accelerating the effect of adjuvant radiation therapy on scalp defects after tumor surgery. A ring-shaped skin area - at risk for recurrence - around the Integra(®) bilayer was irradiated with a total of 59.4Gy. No necrosis, infection, or major radiotoxicity was observed, and a subsequent split skin graft following radiation therapy remained fully vital until complete healing. In conclusion, a combined procedure consisting of sequential tumor surgery and subsequent application of a dermal substitute in conjunction with immediate initiation of adjuvant radiation therapy is, in principle, possible, and may permit innovative therapeutic options in dermatooncology and dermatosurgery.

Reproductive Outcome Is Favorable After Laparoscopic Resection of Bladder Endometriosis

Study ObjectiveTo assess the reproductive outcome (spontaneous and assisted conception rates) in women who underwent laparoscopic resection of bladder endometriosis. DesignThis was a retrospective, observational study analyzing prospectively recorded data (Canadian Task Force classification II-2). SettingA tertiary referral center. PatientsOver a 9-year period, we identified 69 consecutive women with symptomatic pelvic endometriosis who underwent laparoscopic resection of bladder endometriosis at our center. InterventionsGroup A patients (n = 21) had full-thickness endometriotic invasion of the bladder and underwent laparoscopic partial cystectomy. Group B (n = 48) patients had partial endometriotic bladder penetration and underwent partial-thickness excision of the detrusor muscle. Most patients (over 70%) had additional, nonbladder endometriotic lesions, which were also removed during surgery. Measurements and Main ResultsFertility outcomes were analyzed in patients who wished to conceive (n = 42), and improvements in symptoms were assessed for all patients. The minimum follow-up after surgery was 36 months. Of the 42 patients who wished to conceive, 35 patients (83.3%) conceived: 16 patients spontaneously and 18 patients after IVF treatment. No difference was observed in fertility outcome between group A (partial cystectomy) and group B (partial-thickness excision of the detrusor muscle). For all patients, long-term follow-up revealed that 80% of the patients (55 patients) had no urinary/endometrial symptoms after surgery. ConclusionPregnancy rates after laparoscopic surgery for bladder endometriosis by either partial cystectomy or deep excision of the detrusor muscle are favorable, both for spontaneous pregnancy and conception after IVF treatment. Additionally, urinary symptoms were improved for the majority of patients. Based on our findings, it seems warranted to offer laparoscopic surgical management to symptomatic infertile patients diagnosed with bladder endometriosis, even after IVF failure.