Details Of Surgical Technique Research Articles

Laparoscopic ovarian tissue harvesting and orthotopic ovarian cortex grafting for fertility preservation: less is more

To describe our surgical techniques for laparoscopic ovarian tissue harvesting and orthotopic ovarian cortex grafting (LOOCG). This video article uses surgical cases to demonstrate the detailed surgical techniques. Institutional Review Board approval was not required for this video presentation. University hospital. Patients presenting with indication for fertility preservation by means of ovarian tissue harvesting and orthotopic ovarian cortex grafting (in case of setting up a high risk of gonadotoxicity treatment or patients presenting with a pathology with risk of premature ovarian failure). Ovarian tissue harvesting: The entire ovary is harvested by placing an EndoGIA stapler to ensure the control of infundibulopelvic ligament and then, after reloading, the section of the mesovarium. LOOCG one-step procedure: A large and superficial incision of the peritoneum is performed to create a peritoneal pocket. The fragments of ovarian cortex are secured with the use of nonresorbable surgical wire (Prolene 5.0) and introduced into the peritoneal pocket. The peritoneum is not closed after placing the graft. Value and feasibility of LOOCG. Restoration of endocrine function and fertility results. Thirty-four patients were included from November 2011 to October 2017. LOOCG restored ovarian endocrine activity in 88.2% of cases. Ten patients had become pregnant (29.4%), and the same number gave birth to at least one child. Our surgical approach is simple, safe, and reproducible and seems to be as effective as previously described techniques. It deserves to be proposed to patients eligible for ovarian cortex grafting.

Fibular osteotomy strategies and techniques: A survey of the limb lengthening and reconstruction society membership

Context: Fibular osteotomy is a necessary element of most tibial procedures, but there is no consensus on the ideal location, orientation, or technique for the procedure. Aims: We surveyed limb reconstruction surgeons to learn how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Settings and Design: A cross-sectional survey was sent to all members of the Limb Lengthening and Reconstruction Society – North America, as well as experienced international limb reconstruction surgeons. Subjects and Methods: The survey contained 12 questions regarding fibular osteotomies in the setting of limb reconstruction surgery. Responses were not specific to any particular procedure. Data were collected on how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Statistical Analysis Used: Statistical tests employed include Kruskal–Wallis, Mann–Whitney U, Chi-square, and Fisher's exact tests where appropriate. Results: A total of 149 surveys were returned. Most surgeons perform fibular osteotomy at the junction of middle and distal thirds or in middle third, 36.9% and 31.5%, respectively. The least common location for osteotomy was in the proximal third of fibula (4%). The most common method for creating fibular osteotomy was with an oscillating saw (48.3%), followed by drilling holes and using an osteotome (45.0%). The average reported time for the completion of osteotomy was 13 ± 7.2 min, with shortest average time reported for surgeons who perform osteotomy in the distal third (11.3 ± 6.4 min) and longest for those at proximal third (14.6 ± 10.3 min). The most common closure technique was that of layered closure (97%). Conclusions: Most surgeons perform a transverse osteotomy occurring at the junction of the middle and distal thirds of the fibula. The osteotomy is most commonly performed at the beginning of the case using either an oscillating saw or multiple drill holes and osteotome. Continued research is needed to determine the specific indications for performing a fibular osteotomy, if the anatomic location of the fibula osteotomy is important, and when a segment of the fibula should be removed.

Importance of Fenestration Size for Definitive Treatment of a Quadrigeminal Arachnoid Cyst: Endoscopic Inspection of the Cyst and Surrounding Anatomy: 2-Dimensional Operative Video.

Arachnoid cysts are fluid-filled sacs, located between the brain or spinal cord and the arachnoid membrane. Their prevalence in children is between 1% and 3%. Quadrigeminal arachnoid cysts represent 1% to 10% of them and are often associated with hydrocephalus, mostly by an obstructive mechanism, explained by compression of the tectum of the midbrain. When an indication for treatment is retained, 3 surgical options are available: microsurgical excision/fenestration, endoscopic fenestration, and shunt placement. Endoscopic treatment is considered the best compromise of definitive treatment with least surgical morbidity, especially because quadrigeminal cysts are located close to the midline, in intimate relationships with basal cisterns and ventricles. We here present the endoscopic treatment of a prenatally diagnosed quadrigeminal arachnoid cyst type III1 with right lateral extension into the middle cerebral fossa, and associated hydrocephalus, treated at the age of 18 mo.Step-by-step detail of surgical technique is presented in original anatomic conditions. Restoration of better cerebrospinal fluid pathways being the objective of this surgery, ventriculocystic, and cyst-cisternal fenestrations were made. Secondary obstruction of the cyst occurred a few months later, requiring further endoscopic treatment to obtain a larger fenestration that allowed good long-term clinical and radiological outcome. The key point of this video is to compare the 2 procedures, stressing the importance of the dimension of fenestrations, to ensure a long-term patency of both stomas.The patient being a child, both parents gave their consent for publication and signed a form.

The middle fossa approach with self-drilling screws: a novel technique for BONEBRIDGE implantation

BackgroundBone conduction implants can be used in the treatment of conductive or mixed hearing loss. The BONEBRIDGE bone conduction implant (BB-BCI) is an active, transcutaneous device. BB-BCI implantation can be performed through either the transmastoid or retrosigmoid approach with their respective limitations. Here, we present a third, novel approach for BB-BCI implantation.ObjectiveDescribe the detailed surgical technique of BB-BCI implantation through a middle fossa approach with self-drilling screws and present preliminary audiometric outcome data following this approach.MethodsA single institution, retrospective chart review was completed for patients implanted with the BB-BCI via the middle fossa approach. Preoperative planning and modelling were performed using 3D Slicer. Audiological testing was performed pre- and post-operatively following standard audiometric techniques.ResultsForty patients underwent BB-BCI implantation using the middle fossa approach. Modelling techniques allowed for implantation through the use of external landmarks, obviating the need for intraoperative image guidance. The surgical technique was refined over time through experience and adaptation. Mean follow-up was 29 months (range 3–71 months) with no surgical complications, favourable cosmesis, and expected audiometric outcomes. An average functional gain of 39.6 dB (± 14.7 SD) was found.ConclusionThe middle fossa technique with self-drilling screws is a safe and effective option for BONEBRIDGE implantation. As a reference for other groups considering this approach, an annotated video has been included as a supplement to the study.

Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes

BackgroundRemoval of the penile prosthesis reservoir can be technically challenging because of its difficult locations either deep in the pelvis or high in the abdominal wall. AimTo describe a detailed surgical technique for reservoir removal through a penoscrotal approach. MethodsWe describe our preferred method for removal of prosthetic reservoir and present a retrospective review of patient outcomes after reservoir removal. Main Outcome MeasurePrimary outcomes included immediate or late complications. Secondary outcomes included operative time. Results34 patients underwent reservoir removal with the use of our described technique. 23 patients (67.6%) had reservoirs removed because of device malfunction and 11 (32.4%) because of infection. A total of 18 reservoirs (52.9%) were found in the space of Retzius (SOR), whereas the other 16 (47.1%) were in an alternative/ectopic space. 2 cases (5.9%) required a counterincision to remove the reservoir. Mean overall operative time was 96.2 minutes (range 35–175). There were no complications in this series. There was no statistical difference in operative time between reservoirs removed because of malfunction when compared with infection (P = .283). However, there was a difference in operative time between reservoirs removed from the SOR when compared with those removed from an ectopic space, with mean operating room times of 104.5 and 75.4 minutes, respectively (P = .001). Clinical ImplicationsReservoir removal through a penoscrotal incision is feasible and safe. Strength & LimitationsThis is the first report, to our knowledge, describing surgical techniques and outcomes for reservoir removal. Limitations include its retrospective nature and lack of validated questionnaires to assess patient satisfaction. ConclusionAlthough removal of a reservoir deep in the SOR or placed in alternate/ectopic locations can be challenging, the use of a lighted retractor, meticulous dissection, and a few technical maneuvers described allow for safe removal of the reservoir completely intact while avoiding complications. Our technique for a secondary incision in particularly difficult cases is also described.Clavell-Hernández J, Aly SG, Wang R, et al. Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes. J Sex Med 2019;16:146–152.

Endoscopic transorbital surgery for Meckel's cave and middle cranial fossa tumors: surgical technique and early results.

Tumors involving Meckel's cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel's cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach. Between September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel's cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded. Gross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa "peeling" technique, and full visualization of Meckel's cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak. The eTOA affords a direct route to access Meckel's cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.

Intraoperative Decision-Making and Technical Aspects of Parathyroidectomy in Young Patients With MEN1 Related Hyperparathyroidism.

One in 5,000 to 1 in 50,000 births have multiple endocrine neoplasia type 1 (MEN1). MEN1 is a hereditary syndrome clinically defined by the presence of two of the following endocrine tumors in the same patient: parathyroid adenomas, entero-pancreatic endocrine tumors and pituitary tumors. Most commonly, patients with MEN1 manifest primarily with signs and symptoms linked to primary hyperparathyroidism. By age 50, it is estimated that 100% of patients with MEN1 will have been diagnosed with primary hyperparathyroidism. These patients will need to undergo resection of their hyperfunctioning glands, however there is no clear consensus on which procedure to perform and when to perform it in these patients. In this original study we describe and explain the rational of our peri-operative approach and management at MD Anderson Cancer Center of MEN1 patients with hyperparathyroidism. This protocol includes preoperative evaluation, intraoperative decision-making and detailed surgical technique adopted for these patients' care. Additionally we review follow-up and disease management in instances of recurrent primary hyperparathyroidism in patients with MEN1 syndrome.

Penile Size Restoration With Nondegloving Approach for Peyronie’s Disease: Initial Experience

IntroductionThe sliding technique (ST), commonly done with a subcoronal circumcising incision with penile degloving, has been used to restore penile size in patients with severe Peyronie’s disease (PD) and erectile dysfunction, but with a potential risk of ischemic injury to the glans penis. AimTo provide detailed surgical techniques regarding the nondegloving ventral incision and report our initial experience with this approach to perform the ST and penile prosthesis placement in patients with severe PD. MethodsThis was a retrospective review of patient outcomes after penile prosthesis placement with penoplasty for severe PD and erectile dysfunction from January 2015 to December 2017. Main Outcome MeasuresPrimary outcomes included straightening rates, penile measurement, along with immediate and late complications. Secondary outcomes include operative time and overall patient satisfaction. Results12 Patients had significant penile atrophy and/or curvature >60 degrees and underwent inflatable penile prosthesis placement with grafting procedure. Significant penile atrophy was determined by a combination of the patient’s subjective report and the surgeon’s objective assessment through stretched penile length. 7 (58.3%) of those patients underwent ST, of which the last 5 had the procedure performed through a nondegloving ventral incision. Mean degree of curvature prior to ST was 66 degrees (45–90 degrees). Mean penile length gain was 2.6 cm (2.0–3.0 cm). At a mean follow-up of 15.5 months (3–31 months), only 1 patient had minimal residual curvature of 15 degrees. There were no vascular complications. Clinical ImplicationsThis nondegloving technique theoretically maintains blood flow continuity to the glans penis by preserving the continuity of the skin, dartos fascia, and neurovascular bundle. Strengths & LimitationsStrengths of this study include the novel nature of this approach, no incidence of vascular complications, and adaptability to other grafting procedures during penile prosthesis placement. Limitations include the use of 5-item International Index of Erectile Function scores to assess preoperative erectile function on PD, small population, longer incision, and a possible steep learning curve. ConclusionWhile ischemic complications of ST and penile prosthesis implantation are rare, there are reports of ischemic injury in patients undergoing a subcoronal circumcising incision with penile degloving. The non-degloving technique with ventral incision provides for an alternative method for ST and penile prosthesis placement to maintain dartos and skin continuity to the glans penis while still allowing for adequate surgical exposure.Clavell-Hernández J, Wang R. Penile Size Restoration With Nondegloving Approach for Peyronie’s Disease: Initial Experience. J Sex Med 2018;15:1506–1513.

Retrospective multicenter study of post-operative stenosis after stapled colorectal anastomosis.

Anastomotic stenosis after colorectal surgery is usually considered low-rate complication and often is under-reported in most studies. Few data are available on management strategies. The aim of the study was to assess the prevalence of stenosis after stapled colorectal anastomosis, performed either in elective or emergent setting, for benign or malignant disease, and to evaluate treatment profiles. This retrospective study was a survey conducted in a large Italian North-Eastern area including three regions (Triveneto), over a 12-month period (January-December 2015). Patients' characteristics and surgical technique details were recorded, along with data on the prevalence of stenosis and its treatment. Patients with mid or low rectal resection and/or neoadjuvant chemo-radio therapy and/or diverting stoma were excluded. The study was promoted by the Italian Association of Hospital Surgeons (ACOI) and the Society of Surgeons of the Triveneto Region. Twenty-eight surgical units were enrolled in the survey, accounting for over 1400 patients studied. Fifty percent of the units performed laparoscopically > 70% of the colorectal resections and 7.5% of the procedures were emergent. Less than 60% of the units planned regular endoscopic follow-up after colorectal resection. Anastomotic stricture was recorded in 2% of the patients; 88% of the stenoses were diagnosed within 6months from surgery. Only one anastomotic stricture required re-do surgery. The CANSAS study confirms that colorectal anastomotic stenosis is low-rate-but still present-complication. Treatment strategies vary according to surgeons' and endoscopists' preferences. Commonly endoscopic dilatation is preferred, but re-do surgery is required in some cases.

Robot-assisted Partial Adrenalectomy for the Treatment of Conn's Syndrome: Surgical Technique, and Perioperative and Functional Outcomes

BackgroundIn the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series. ObjectiveTo detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes. Design, setting, and participantsData of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported. Surgical procedureRAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration. MeasurementsBaseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed. Results and limitationsAll cases were completed robotically. Median nodule size was 18mm (interquartile range [IQR] 16–20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2–3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19–42), neither symptoms nor imaging recurrence was observed. ConclusionsWe demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community. Patient summaryRobot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future.

Surgical Pericardiectomy for Constrictive Pericarditis: A Single Tertiary Center Experience.

Although surgery is the sole therapeutic option for patients with constrictive pericarditis (CP), reports on high postoperative mortality rates have led to hesitant surgery referral. The aim of this study was to report the short- and long-term outcomes of surgical pericardiectomy (SP) from a large tertiary center. Between January 2005 and January 2017, 55 consecutive patients underwent SP after comprehensive echocardiography, computed tomography, and hemodynamic studies. Detailed clinical, imaging, surgical techniques and follow-up outcomes were recorded. The most common etiology was idiopathic (n = 27, 49%) and 33 patients (60%) were in functional class 3/4. Sixteen patients (29%) underwent concomitant interventions during SP, and cardiopulmonary bypass (CPB) was used in these, as well as in four additional cases. Complete resection, independent of CPB, was achieved in 96%. One patient died during the index hospitalization, and four (7%) needed re-explorations due to bleeding. While 12 patients (22%) died during a mean follow-up of 52 ± 39 months, only 1 death was due to right heart failure. Functional class significantly improved (with a p-value < 0.001), diuretics were discontinued in all, and significant reductions of right atrial pressures were recorded. None of these outcomes differed as a result of concomitant interventions at the time of SP. Short- and long-term outcomes of SP, performed either alone or concomitantly with other procedures, indicate high safety and favorable clinical and hemodynamic efficacy for the treatment of CP.

Fertility preservation in pediatric female cancer patients

To describe and demonstrate ovarian tissue cryopreservation (OTC) as an emerging fertility preservation technique DESIGN: Video presentation. University hospital. A 6 year-old female patient diagnosed with aplastic anemia with plan for bone marrow transplantation underwent laparoscopic unilateral oophorectomy in conjunction with surgical procedure for port placement by the pediatric surgeon, followed by cryopreservation of ovarian tissue. Laparoscopic unilateral oophorectomy followed by ovarian decortication in the operating room, and ovarian tissue freezing prior to undergoing bone marrow transplantation. To present principle surgical techniques of ovarian tissue harvesting prior to OTC in pediatric patients, and different surgical techniques for ovarian auto-transplantation of cryobanked ovarian tissue after completion of gonadotoxic treatment and when the patient is ready to conceive. This video demonstrates the detailed surgical technique for ovarian tissue harvesting. This harvesting can be performed laparoscopically or via mini-laparotomy and can involve a complete oophorectomy versus removing a portion of the ovary (a procedure also known as ovarian decortication). In the prepubertal child, due to the small size of the ovaries, we recommend oophorectomy rather than decortication owing to the small size of prepubertal gonadal tissue. Many young cancer patients can be offered the option of ovarian tissue freezing. This tissue contains immature primordial follicles that can be stored. OTC requires surgical ovarian harvesting followed by cryopreservation of strips of ovarian tissue. The increased number of eggs in prepubertal children underscores the fact that smaller ovarian size in this population does not preclude OTC. At this time, ovarian auto-transplantation is the only option to utilize this stored tissue for fertility preservation. OTC is a relatively new procedure within the area of ART. The overall data from OTC is reassuring and further suggests that cryopreservation of ovarian tissue has the potential to become an established fertility preservation method in the near future.

Modified Orbitozygomatic Approach without Orbital Roof Removal for Middle Fossa Lesions.

ObjectiveThe purpose of the present study was to describe an OrBitoZygomatic (OBZ) surgical variant that implies the drilling of the orbital roof and lateral wall of the orbit without orbitotomy.MethodsDesign : cross-sectional study. Between January 2010 and December 2014, 18 patients with middle fossa lesions underwent the previously mentioned OBZ surgical variant. Gender, age, histopathological diagnosis, complications, and percentage of resection were registered. The detailed surgical technique is described.ResultsOf the 18 cases listed in the study, nine were males and nine females. Seventeen cases (94.5%) were diagnosed as primary tumoral lesions, one case (5.5%) presented with metastasis of a carcinoma, and an additional one had a fibrous dysplasia. Age ranged between 27 and 73 years. Early complications were developed in four cases, but all of these were completely resolved. None developed enophthalmos.ConclusionThe present study illustrates a novel surgical OBZ approach that allows for the performance of a simpler and faster procedure with fewer complications, and without increasing surgical time or cerebral manipulation, for reaching lesions of the middle fossa. Thorough knowledge of the anatomy and surgical technique is essential for successful completion of the procedure.

The proximalization of the arch anastomosis.

This viewpoint article and the detailed surgical techniques are demonstrated in our video ( Figure 1 ). Open surgery for total aortic arch replacement is an established operation (2-4), however it has proven technically demanding due to the narrowness of access to such a deep site as the distal arch.

Kidney autotransplantation after nephrectomy and work bench surgery as an ultimate approach to nephron-sparing surgery

BackgroundKidney autotransplantation (KAT) is the ultimate approach for nephron-sparing surgery. It is a rarely used method in renal tumor surgery today as minimal invasive and open techniques for nephron-sparing surgery improve constantly. In this publication, the complication rate and the long-term functional and oncological outcome at a single center are analyzed.MethodsA prospectively constructed database of patients with renal tumors who underwent renal surgery was retrospectively analyzed to identify patients with KAT and describe surgical and oncological outcomes and to obtain long-term follow-up. Data collection included detailed surgical technique, complications (Clavian-Dindo), and hospital stay, as well as functional and oncological outcome and long-term follow-up.ResultsBetween 1976 and 2013, 12 patients (median age 50.5 years) underwent KAT for highly complex renal masses: in five cases for complex renal cell carcinoma (RCC), five cases for complex upper urinary tract carcinoma (UTUC), one case for a renal metastasis, and one case for nephroblastoma. The nephrectomy or nephron-ureterectomy was performed open via a flank or transabdominal. The median surgical time was 360 min (range 270–490 min). Intraoperatively, six cases required blood transfusions (50%). Six patients (50%) developed significant postoperative complications (Clavian-Dindo > 2). In two patients, intermittent hemodialysis for delayed graft function (16.6%) was needed, and in six cases (50%), additional blood transfusions postoperatively were necessary. At discharge from hospital, all patients had functioning grafts. The median hospital stay was 29.5 days (range 18–35).At follow-up (median follow-up of 83.5 ± 40.7 months), six patients had died (50%)—all with functioning grafts (free from hemodialysis). In five cases, recurrence of primary tumor or metastatic disease was recorded. In four cases, the recurrent carcinoma could be resected; in detail, UTUC in three cases and one partial nephrectomy of the autotransplanted kidney was performed. One patient suffered from bone and lung metastasis. Two patients died finally tumor-related. Five patients (41.6%) are presently alive, without evidence of tumor relapse. One patient developed terminal renal failure requiring hemodialysis 105 months after autotransplantation. One additional patient was lost to follow-up; after 69 months, this patient had a functioning kidney and no evidence of disease-recurrence at the last follow-up. A cumulative number of 1424 months without hemodialysis was gained for these 12 patients.In the literature to date, most KAT are performed in benign disease, with minor but frequent complication. Here, we report the largest series of KAT for malignant kidney tumors. The complication rates are similar, compared to the recently reported series for benign indications with an improved graft survival rate. Since KAT requires a complex and challenging surgical approach, it should be performed by experienced kidney transplant surgeons.ConclusionIn very complex cases involving renal tumors and multi-morbidity, patients should be counseled well before KAT is considered. At the same time, KAT should not be abandoned in these very rare cases, especially when a nephron-sparing approach is otherwise not feasible. KAT can maintain renal function and quality of life and extend expectancy of life.

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate.

There is an increasing incidence of cesarean scar (CS) defect/niche and its sequelae, probably not entirely explained by better diagnosis or rising cesarean rate. Discussion of possible etiological factors has received scant attention but would be important to formulate preventive strategies. Meaningful informative studies on long-term sequelae of cesarean section are very difficult and none are available for causation of CS defect. Hence, it is crucial to identify key areas in etiology of CS defect for focused research. This practical review proposes an “ischemia and mal-apposition hypothesis for CS niche”, stating that the surgical technique of uterine incision closure is the most important determinant of CS defect formation. Other factors such as cervical location incision, adhesion formation and patient specific factors seem far less important in etiology. Rather than the headline theme of “single versus double-layer closure of uterus”, the finer details of surgical technique which achieve good apposition without inducing tissue ischemia seem more important. Different techniques are discussed and it is proposed that continuous, non-locking absorbable sutures in two layers, without including much of decidua and without undue tight (constricting/devasculaizing) pulling of sutures are likely to result in good healing of uterine scar. Single-layer technique may be best reserved for thin myometrial edges especially during repeat cesareans. Adhesions between uterine isthmus and bladder/abdominal wall seem common associations but not causative for CS niche. It would be desirable to prove these surgical principles by good quality prospective randomized “quantitative” studies but the wait may be very long and this should not hinder the adoption of good surgical principles. Science is much cognitive and not just empirical. To consider a related example, the current recommendation of non-suturing of peritoneal layers during cesarean is mistakenly based on short-term irrelevant surrogate outcomes like analgesic requirements and time-saving, many of which have been already disproven. Evidence is presented recommending simple quick techniques of peritoneal closure to prevent adhesions. More analytical debate in surgical techniques is needed to inspire engaged, critical and insightful practitioners rather than unquestioning dependence on weak evidence/guidance.

Endoscopic partial corpectomy using anterior decompression for cervical myelopathy.

Symptomatic ventral cervical cord compressions have been treated by anterior discectomy with fusion, anterior corpectomy and fusion, discectomy with an artificial disc, and minimally invasive techniques. There are complications associated with the fusion procedure, especially when a long segment fusion is undertaken. Partial removal of the vertebral body without fusion could help in avoiding fusion and its associated complications. We are describing the detailed surgical technique, indications, limitations, and early results of endoscopic partially corpectomy. The detailed endoscopic technique of how to remove minimal portion of the anterior and middle part of the vertebra with the removal of compressing posterior portion is described. To the best of the author's knowledge, this procedure has not been described in the literature till date. This technique has the advantages of preservation of most of the vertebral body and disc. The stability of the spine is maintained without the patient having to undergo the additional procedure of spinal fusion. There is a shorter length of hospital stay. The technique can also be used in special conditions, such as when a migrated disc behind the vertebral body or any bony compression opposite the vertebral body is encountered. It avoids injury to the longus colli muscles and damage to most of the annulus fibrosis. It preserves motion segments at the operated and adjacent segments without any significant decrease in the disc and vertebral height. A relatively short follow-up and the experience in a relatively small number of patients till now, are the limitations to the widespread use of this technique. Although long-term follow-up of this procedure in a large number of patients is not currently available, endoscopic partial corpectomy seems to be an effective and an alternative method for dealing with anteriorly located cervical compression. Long-term follow-up in a large number of patients is required to assess for the safety and effectiveness of the procedure.

Tendon Excision Following Distal Semitendinosus Injury in the Elite Athlete: A Surgical Technique.

Hamstring injuries can present in numerous forms, some of which can lead to persistent pain, loss of function, and delay in return to sport. Although most are treated conservatively, proximal and distal tendon avulsion injuries have become more commonly treated with surgery. Distal semitendinosus avulsion injuries have been largely reported in the elite athlete population. While conservative management has been utilized, failure in this group can significantly impact a future career. The purpose of the manuscript is to describe our approach of surgical tendon excision for distal semitendinosus injury in an elite athlete. We highlight a two-incision technique to isolate the avulsed tendon, followed by exteriorization and tendon excision. In addition, we provide insight on clinical and imaging findings to help guide management. This technique provides a reliable and effective surgical option for managing these rare injuries of the distal semitendinosus, along with outlining rehabilitation goals in the postoperative period. In this setting, we present a detailed surgical technique to excise the injured distal semitendinosus tendon to promote recovery and potentially allow for earlier return to play.

Microvascular Decompression for Glossopharyngeal Neuralgia: Clinical Analyses of 30 Cases.

ObjectiveWe present our experience of microvascular decompression (MVD) for glossopharyngeal neuralgia (GPN) and evaluate the postoperative outcomes in accordance with four different operative techniques during MVD.MethodsIn total, 30 patients with intractable primary typical GPN who underwent MVD without rhizotomy and were followed for more than 2 years were included in the analysis. Each MVD was performed using one of four different surgical techniques: interposition of Teflon pieces, transposition of offending vessels using Teflon pieces, transposition of offending vessels using a fibrin-glue-coated Teflon sling, and removal of offending veins.ResultsThe posterior inferior cerebellar artery was responsible for neurovascular compression in 27 of 30 (90%) patients, either by itself or in combination with other vessels. The location of compression on the glossopharyngeal nerve varied; the root entry zone (REZ) only (63.3%) was most common, followed by both the REZ and distal portion (26.7%) and the distal portion alone (10.0%). In terms of detailed surgical techniques during MVD, the offending vessels were transposed in 24 (80%) patients, either using additional insulation, offered by Teflon pieces (15 patients), or using a fibrin glue-coated Teflon sling (9 patients). Simple insertion of Teflon pieces and removal of a small vein were also performed in five and one patient, respectively. During the 2 years following MVD, 29 of 30 (96.7%) patients were asymptomatic or experienced only occasional pain that did not require medication. Temporary hemodynamic instability occurred in two patients during MVD, and seven patients experienced transient postoperative complications. Neither persistent morbidity nor mortality was reported.ConclusionThis study demonstrates that MVD without rhizotomy is a safe and effective treatment option for GPN.

Lateral Lumbar Interbody Fusion and in Situ Screw Fixation for Rostral Adjacent Segment Stenosis of the Lumbar Spine.

ObjectiveThe purpose of this study is to describe the detailed surgical technique and short-term clinical and radiological outcomes of lateral lumbar interbody fusion (LLIF) and in situ lateral screw fixation using a conventional minimally invasive screw fixation system (MISF) for revision surgery to treat rostral lumbar adjacent segment disease.MethodsThe medical and radiological records were retrospectively reviewed. The surgery was indicated in 10 consecutive patients with rostral adjacent segment stenosis and instability. After the insertion of the interbody cage, lateral screws were inserted into the cranial and caudal vertebra using the MISF through the same LLIF trajectory. The radiological and clinical outcomes were assessed preoperatively and at 1, 3, 6, and 12 months postoperatively.ResultsThe median follow-up period was 13 months (range, 3–48 months). Transient sensory changes in the left anterior thigh occurred in 3 patients, and 1 patient experienced subjective weakness; however, these symptoms normalized within 1 week. Back and leg pain were significantly improved (p<0.05). In the radiological analysis, both the segmental angle at the operated segment and anterior disc height were significantly increased. At 6 months postoperatively, solid bony fusion was confirmed in 7 patients. Subsidence and mechanical failure did not occur in any patients.ConclusionThis study demonstrates that LLIF and in situ lateral screw fixation may be an alternative surgical option for rostral lumbar adjacent segment disease.