Direct Vision Research Articles

Intraoperative Direct Vision of Transversus Abdominis Plane (TAP) Block versus Ultrasound Guided Transversus Abdominis Plane (TAP) Block for Pain Control after Caesarean Section (CS). A Randomized Controlled Clinical Trial

Background Adequate postoperative analgesia following CS hastens post-operative mobilization, decreases maternal morbidity and facilitates bonding with the newborn. Aim of the Work to assess pain scores at (rest and movement), and need for opioids in women receiving intraoperative direct vision of transversus abdominis plane (TAP) Block versus women receiving ultrasound guided transversus abdominis plane (TAP) Block following cesarean section in first 24H. Study Design Randomized controlled clinical trial was conducted on Patients undergoing lower segment Cesarean section under spinal anesthesia with intra thecal hyper baric bupivacaine 0.5%. Patients were randomized to study group that received intraoperative direct vision transversus abdominis plane (TAP) Block and control group received ultrasound guided transversus abdominis plane (TAP) Block. Postoperative pain score was recorded using visual analog scale (VAS) score and analgesic consumption recorded from patient medication chart. Result A total of 220 eligible women planned to undergo elective lower segment caesarean section were recruited in the current trial, and were randomly allocated into one of the two groups, there were no significant differences between women of both groups regarding age, parity or BMI. No significant differences between the studied group regarding patient pain perception (VAS Score) during rest and movement at different times of follow up (6,8,12,24 H) postoperatively. The dose and the first time of analgesic requirement was non-significantly different among studied groups. Conclusion USG and surgical TAP blocks were safe and had similar efficacy in providing postoperative analgesia in pregnant women following cesarean section under spinal analgesia. Surgical TAP block is an efficacious, safe and rapid technique, particularly in patients in whom USG TAP block is technically challenging (obese women), and where the ultrasound isn’t available in operative theater.

Initial experience of visualized biliary cannulation during ERCP.

BACKGROUND : Selective biliary cannulation is the most challenging step in endoscopic retrograde cholangiopancreatography (ERCP) because only indirect radiographic images can be obtained. Therefore, we developed a novel endoscopic retrograde direct cholangioscopy (ERDC) technology to facilitate visible biliary cannulation. METHODS : In this case series, we used ERDC to treat 21 patients with common bile duct stones who were enrolled consecutively between July 2022 and December 2022. The procedure details and complications were recorded, and all patients were followed up for 3 months after the procedure. The learning curve effect was analyzed by comparing the early and later cases. RESULTS : Biliary cannulation was successful in all patients, and the stones were removed completely. The median (interquartile range [IQR]) time for cholangioscopy-guided biliary cannulation was 240.0 (10.0-430.0) seconds, and the median (IQR) number of cannulation procedures was 2 (1-5). Despite there being one episode of post-ERCP pancreatitis, one of cholangitis, and three patients developing asymptomatic hyperamylasemia, all of the patients recovered after symptomatic treatment, being discharged and with no serious adverse events occurring during the 3-month follow-up period. Compared with the early cases, the number of intubations and the use of guidewire guidance decreased in later cases. CONCLUSION : Our research confirms that ERDC is a feasible technology for biliary cannulation under direct vision.

Divided method of intercostal nerve block reduces ropivacaine dose by half in thoracoscopic pulmonary resection while maintaining the postoperative pain score and 4-h mobilization: a retrospective study

PurposeThis study investigated whether the divided method of multi-level intercostal nerve block (ML-ICB) could reduce the ropivacaine dose required during thoracoscopic pulmonary resection, while maintaining the resting postoperative pain scores.MethodsThis retrospective, single-cohort study enrolled 241 patients who underwent thoracoscopic pulmonary resection for malignant tumors between October 2020 and March 2022 at a cancer hospital in Japan. ML-ICB was performed by surgeons under direct vision. The differences in intraoperative anesthetic use and postoperative pain-related variables at the beginning and end of surgery between group A (single-shot ML-ICB; 0.75% ropivacaine, 20 mL at the end of the surgery) and group B (divided ML-ICB, performed at the beginning and end of surgery; 0.25% ropivacaine, 30 mL total) were assessed. The numerical rating scale (NRS) was used to evaluate pain 1 h and 24 h postoperatively.ResultsIntraoperative remifentanil use was significantly lower in group B (14.4 ± 6.4 μg/kg/h) than in group A (16.7 ± 8.4 μg/kg/h) (P = 0.02). The proportion of patients with NRS scores of 0 to 3 at 24 h was significantly higher in group B (85.4%, 106/124) than in group A (73.5%, 86/117) (P = 0.02). The proportion of patients not requiring postoperative intravenous rescue drugs was significantly higher in group B (78.2%, 97/124) than in group A (61.5%, 72/117) (P < 0.01).ConclusionThe divided method of ML-ICB could reduce the intraoperative remifentanil dose, decrease the postoperative pain score at 24 h, and curtail postoperative intravenous rescue drug use, despite using half the total ropivacaine dose intraoperatively.

Distinguishing skill levels with haptic simulation in restorative dentistry: Myth or reality?

This study aims to validate that haptic simulator assistance could distinguish skill levels with haptic simulation in restorative dentistry. This work was carried out with 93 first-year, 87 third-year and 44 fifth-year dental students. The promotions of first- and fifth-year dental students made one session to represent the negative and the positive controls, respectively. The third-year dental students were the studied population. Whatever the group, the maximum time for each reparation was restricted to 3 min. All students have to perform the same three exercises. The third-year dental students performed four sessions spread over the whole university year. For each test, the total score provided by the simulator was recorded and analysed. The exercises are not discriminating in direct vision while the exercise in indirect vision is very interesting to distinguish the levels of the learners. The results underline that the exercises in indirect vision could distinguish different profiles of student having different preclinical and clinical levels, while making it possible to follow the acquisition of clinical competence.

Role of Flexible Bronchoscopy using Biopsy Forceps as the Initial Attempt for Headscarf Pin Aspiration Extraction.

Flexible bronchoscopy is a less invasive procedure for extracting foreign bodies from the airways. However, studies on the extraction of headscarf pins are still very limited to determine the efficacy and safety of headscarf pin extraction using flexible bronchoscopy with biopsy forceps. This retrospective study was conducted at Persahabatan Hospital, Jakarta, Indonesia, on patients who had been treated in this hospital for headscarf pin extraction between January 2013 and February 2023. Fibreoptic bronchoscopy was performed under general anaesthesia. The pin was removed using Radial Jaw 4 mm single-use pulmonary biopsy forceps. The impacted sharp tip of the pin was freed first, and the proximal part of the pin body was gripped using biopsy forceps. Once a firm hold of the sharp end or the proximal part of the pin was secured, the bronchoscope and forceps were both slowly withdrawn under direct vision. Thirty-two cases with headscarf pin aspiration were managed by fibreoptic bronchoscopy. A total of 12 patients (37.5%) came without any respiratory complaints; however, an equal number complained of cough and 6 cases (18.7%) of haemoptysis. All the cases in which the pins were visible in the airway were found with the round head down and the sharp tip oriented superiorly in the airway and impacted in the mucosa. Fibreoptic bronchoscopy extraction succeeded in 31 cases (96.8%). Only one case was converted to surgery. There were no major complications. Fibreoptic bronchoscopy with biopsy forceps under general anaesthesia is safe and effective for the removal of headscarf pin aspiration.

Comparison of Clinical Performance of C-MAC Video Laryngoscope Guided vs Blind Placement of I-Gel® in Paediatric Patients: A Randomized Controlled Open-Label Trial.

Placement of the supraglottic airway devices under direct vision has been shown to decrease the incidence of malposition in adults. This study was designed to compare the clinical performance of C-MAC guided and blind placement of i-gel® in paediatric patients. The present prospective, randomized controlled study was conducted on 102 paediatric patients scheduled to undergo elective infraumbilical surgeries under general anaesthesia. Patients were randomly divided into group "B" (blind) and group "C" (C-MAC) based on the technique used for placement of i-gel®. The primary objective of the study was to compare the incidence of malposition based on the fiberoptic bronchoscope (FOB) score of the glottic view. Oropharyngeal leak pressure (OPLP), hemodynamic parameters, and insertion characteristics (time taken to insert and the number of attempts) were secondary objectives. Categorical data were presented as ratio or percentage and continuous data were presented as mean ± standard deviation or median [95% confidence interval (CI)]. The incidence of malposition (Brimacombe score 1 or 2) was significantly lower in group C compared to group B (7.8% vs 49% respectively) (P < 0.001); implying a relative risk reduction of 2.42 (95% CI 1.72 to 3.40) with C-MAC. On FOB assessment, the median (interquartile range) Brimacombe score was significantly better in group C [4 (4-4)] compared to group B [3 (2-3)] (P < 0.001). The OPLP was significantly higher in group C compared to group B. Other insertion characteristics were comparable in both the study groups. Compared to blind placement, C-MAC guided placement ensures proper alignment of i-gel® with periglottic structures and proper functioning of i-gel®.

Limb Reconstruction System Assisted Reduction and Internal Fixation for Intra-Articular Calcaneal Fractures: A New Application.

Minimally invasive reduction and fixation of intra-articular calcaneal fractures poses great challenges for orthopaedic surgeons. The aim of the present study was to report the technical points, evaluate the efficacy of minimally invasive reduction and internal fixation assisted by the temporary limb reconstruction system (LRS) external fixator for intra-articular calcaneal fractures, and propose the indications of our protocol. In this retrospective study, a series of 34 consecutive closed and displaced intra-articular calcaneal fractures involving the articular surface were treated by this technology between June 2016 and April 2018. X-ray and computed tomography (CT) scans were performed before and after surgery to measure Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot. Postoperative complications were recorded. Imaging and clinical outcomes were comprehensively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system. After testing the normality of the data, Bohler's angle and the length of calcaneus were compared using the Wilcoxon signed-rank test. The height, width of the calcaneus, and the mechanical axis of the hindfoot were compared using the Paired-Samples t-test. Thirty-two fractures were followed up for an average of 20.66 months (from 12 to 32 months). All fractures achieved stable reduction and bony union. The articular surface was reduced and fixed with direct vision through the sinus tarsi incision. No failure of internal fixation or loss of reduction was detected during follow-up. There were no soft tissue complications. Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot improved significantly. The AOFAS scores averaged 84.12 points; seven cases were rated excellent, 20 good, four fair, and one poor. For intra-articular calcaneal fractures, minimally invasive surgery assisted with temporary LRS external fixation can reconstruct the calcaneal shape and the sub-talar articular surface. This simple surgical modality with limited complications may be helpful in the surgical treatment of most type II and III calcaneal fractures except comminuted fractures of the calcaneal tuberosity.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Evaluation of bronchoscopic direct vision glottis anesthesia method in bronchoscopy.

Fibrobronchoscopy is a common adjunct tool that requires anesthesia and is widely used in the diagnosis and treatment of various respiratory diseases. However, current anesthesia methods, such as spray, nebulized inhalation, and cricothyroid membrane puncture, have their own advantages and disadvantages. Recently, studies have shown that bronchoscopic direct-view glottis anesthesia is a simple and inexpensive method that shortens the examination time and provides excellent anesthetic results. To evaluate the effectiveness of bronchoscopic direct vision glottis anesthesia for bronchoscopy. The study included 100 patients who underwent bronchoscopy during thoracic surgery. A random number table method was used to divide the patients into control and observation groups (50 patients each). The control and observation groups were anesthetized using the nebulized inhalation and bronchoscopic direct vision glottis method, respectively. Hemodynamic indices [systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SpO2) before (T1), 5 min after anesthesia (T2), and at the end of the operation (T3)] serum stress hormone indices [norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), and cortisol (Cor) before and after treatment] were compared between the 2 groups. Adverse effects were also compared between the two groups. At T2 and T3, SBP, DBP, and HR were lower in the observation group than the control group, whereas SpO2 was higher than the control group [(119.05 ± 8.01) mmHg vs (127.05 ± 7.83) mmHg, (119.35 ± 6.66) mmHg vs (128.39 ± 6.56) mmHg, (84.68 ± 6.04) mmHg vs (92.42 ± 5.57) mmHg, (84.53 ± 4.97) mmHg compared to (92.57 ± 6.02) mmHg, (74.25 ± 5.18) beats/min compared to (88.32 ± 5.72) beats/min, (74.38 ± 5.31) beats/min compared to (88.42 ± 5.69) beats/min, (97.36 ± 2.21)% vs (94.35 ± 2.16)%, (97.42 ± 2.36)% vs (94.38 ± 2.69%], with statistically significant differences (all P < 0.05). After treatment, NE, E, ACTH, and Cor were significantly higher in both groups than before treatment, but were lower in the observation group than in the control group [(68.25 ± 8.87) ng/mL vs (93.35 ± 14.00) ng/mL, (53.59 ± 5.89) ng/mL vs (82.32 ± 10.70) ng/mL, (14.32 ± 1.58) pg/mL vs (20.35 ± 3.05) pg/mL, (227.35 ± 25.01) nmol/L vs (322.28 ± 45.12) nmol/L], with statistically significant differences (all P < 0.05). The incidence of adverse reactions was higher in the control group than in the observation group [12.00% (12/50) vs 6.00% (3/50)] (P < 0.05). The use of bronchoscopic direct vision glottis anesthesia method for bronchoscopy patients is beneficial for stabilizing hemodynamic indices during bronchoscopy and reducing the level of patient stress, with good safety and practicality.

Treatment of Anterior Dislocation of the Sacroiliac Joint via the Lateral-rectus Approach: Surgical Techniques and Preliminary Outcomes.

Anterior dislocation of the sacroiliac joint (ADSIJ) is caused by strong violence, and because of its low morbidity, there are no standardized diagnostic and therapeutical guidelines at this moment. This study aims to explore the surgical techniques and preliminary outcomes of the lateral-rectus approach (LRA) for treating ADSIJ. A retrospective study was conducted of 15 patients with ADSIJ from January 2016 to January 2021. The patients' age ranged from 1.8 years old to 57 years old (37 ± 18 years old). All patients underwent open reduction and internal fixation (ORIF) through the LRA. Eight patients were combined with lumbosacral plexus injury and underwent neurolysis during operation. Patients' fracture type, mechanism of injury, associated injuries, operation time and intraoperative bleeding volume were accessed by reviewing medical history. Quality of fracture reduction was evaluated with the Matta score. At 1-year follow-up, the functional rehabilitation was evaluated by the Majeed rehabilitation criteria. For those with lumbosacral plexus injury, the neuromotor function was evaluated using muscle strength grading proposed by the British Medical Research Council (BMRC) and recovery was recorded. All 15 patients underwent the operation successfully. The surgical time ranged from 70 to 220 min (126 ± 42 min), and the intraoperative blood loss ranged from 180 to 2000 mL (816 ± 560 mL). Eighty percent of the cohort (12/15) were rated as excellent and good in the Matta score for fracture reduction quality after operation without surgical incision-related complications. At 1-year follow-up, the overall excellent and good rate was 73.3% (11/15) according to the Majeed criteria, the neuromotor function recovered completely in six cases and partially in two cases according to the BMRC muscle strength grading, and the recovery of sensory function was evaluated as excellent in six cases, good in one case and poor in one case, with an overall excellent and good rate of 87.5%. The LRA can well expose the surrounding structures of the sacroiliac joint from the front, which helps surgeons reduce and fix the anterior dislocation of the sacroiliac joint under direct vision and effectively decompress the entrapment of the lumbosacral plexus to achieve better clinical efficacy.

Early Cpap and Large Volume Minimal Invasive Surfactant Administration (Ecalmist)

Large volume surfactant administration in premature infants less than 35 weeks using minimally invasive surfactant therapy (MIST). Background: Surfactant in small volume preparations can be successfully administered to premature infants using a narrow-bore vascular catheter inserted into the trachea under direct vision. It was not known if surfactant in large volume preparations could be administered effectively to spontaneously breathing premature infants while maintaining them on nasal continuous positive airway pressure (nCPAP). Objective: To evaluate the feasibility of administering a large volume of surfactant (5 ml/kg) in spontaneously breathing premature infants on nCPAP using a vascular catheter. Methods: Single-arm interventional trial in two level III nurseries in Canada. Spontaneously breathing premature infants between 24- and 34-weeks’ gestation, born between July 4th, 2012 and September 5th, 2012 were eligible for the trial in the first 24 hours of life. A 16-gauge vascular catheter was inserted under direct vision through the vocal cords to administer 5 ml/kg of surfactant while maintaining the infants on nCPAP. Results: Twenty-one premature infants were enrolled. The mean gestational age was 29 ± 3 (range 24 to 34 weeks) with mean birth weight of 1474 ± 575 g. Surfactant was successfully administered in 20 infants (95 %). There was a clear effect after surfactant administration with a decrease in oxygen requirement from 0.34 ± 0.111 before the procedure, to 0.26 ± 0.08 after the procedure (p = .001), and a decrease in nCPAP pressure from 7.2 ± 0.5 cm H2O before the procedure to 5.9 ± 0.5 after the procedure (p &lt; .0001). The mean duration for surfactant administration was 8.3 ± 3.4 minutes. The procedure was temporarily stopped in three cases due to bradycardia and/or apnea with desaturations that spontaneously recovered without intervention. Coughing and reflux of the surfactant were transiently observed in four cases (19 %). Conclusion: It is feasible to administer large volumes of surfactant without interrupting nCPAP via a vascular catheter, to premature infants less than 35 weeks’ gestation. Further trials are needed to confirm the safety and efficacy of this method compared to other methods of surfactant administration.

Retroperitoneal approach for robot living donor nephrectomy: A step-by-step description of technical nuances.

Open, pure or hand-assisted laparoscopic, natural orifice transluminal endoscopic surgical (NOTES) and robotic approaches (Transperitoneal or retroperitoneal) are the described approaches for living donor nephrectomy. We describe the procedural steps of a robotic living donor nephrectomy (RLDN) retroperitoneal (RRLDN) technique using a da Vinci X surgical system and three robotic arms. This is the first reported case with the retroperitoneal robotic approach. The procedure in brief is as follows. First, with the patient placed in full flank position, the camera port is placed at the level of the Petit's triangle apex. Retroperitoneal space is created by turning the index finger in a 180° movement through this port and a gloves balloon. The second 8mm port was inserted, 8 cm far from the first port, The peritoneum is reflected medially and downward off of the transversus abdominis muscle laparoscopically, respectively along the anterior and posterior axillary line; 3-5 cm caudally to the last one, a 12 mm AirSeal® assistant port is placed in the same manner. Only then, the port is placed under direct vision. The robotic ports placement will result in a caudally convex arc. This technique, due to the extensive use of the surgeon index, implies fast access to the retroperitoneum, protects the underlying anatomical structures from damage, and, due to the trocar positioning along an arc, lowers the arm conflict risk.

Role of laparoscopic surgery in gynecology.

Objective: Technological advancements extend the range of indications for gynecological laparoscopy. We are presenting the outcome of our experiences with gynaecological laparoscopies and assessed rate, indications, complications and its benefits in a teaching hospital. Study Design: Retrospective Observational study. Setting: MTI Hayatabad Medical Complex Peshawar. Period: January 2021 to December 2021. Material &amp; Methods: we performed laparoscopic procedure for a total of 222 patients and all were included in the study. Laparoscopic surgeries were performed under general anesthesia. Successful creation of the pneumoperitoneum was done with the help of Veress needle, mostly by closed access technique and occasionally with the open method. Secondary ports were introduced under direct vision. After completing the surgery laparoscope and secondary ports were removed under direct vision to minimize any iatrogenic insult. Results: During the study period, 908 major gynaecological operations including 222 laparoscopies were performed. This gave the rate of 24.45% laparoscopies per 100 operations. Diagnostic laparoscopies were performed in 195 (87.84%) cases and operative were in 27 (12.16%) cases. Complications were only in 5 of the cases, two being of major nature. A ureteric ligation occurred during laparoscopic hysterectomy resulting in conversion of laparoscopic surgeries into open surgery and another was during cystectomy due to excessive bleeding. Conclusion: Laparoscopic surgery propounds unique benefits including definite diagnosis, mobilization and speedy recovery, minimal complications, less cost and shorter hospital stay. In young patients, laparoscopy helps in preserving their fertility with better prognosis in contrast to open surgery.

Minimally invasive cardiac surgery in low-resource settings: right vertical infra-axillary mini-thoracotomy without peripheral cannulation - the first 100 cases.

Literature is scarce on minimally invasive cardiac surgery in adults with a right vertical infra-axillary thoracotomy approach without using peripheral cannulation. This study aimed to analyze the perioperative, early outcomes of minimally invasive cardiac surgery with direct vision using central aortic-venous cannulation through a right vertical infra-axillary thoracotomy, vs. standard cardiac surgery with median sternotomy. This retrospective study included the first 100 adult patients who were operated on via right vertical infra-axillary thoracotomy and central aortic and venous cannulation. The control group comprised 100 adult patients who underwent cardiac surgery through a median sternotomy and central aortic and venous cannulation. The thoracotomy group was associated with prolonged aortic cross-clamp time, cardiopulmonary bypass time, and operation time. The amount of postoperative chest tube drainage and blood transfusion was higher in the sternotomy group. No difference was found between the groups in terms of postoperative morbidity and mortality rates. Despite a higher level of pain in the thoracotomy group on the first 3 postoperative days, patient satisfaction was higher in this group. In a resource-limited setting, minimally invasive cardiac surgery with direct vision using central aortic-venous cannulation through a right vertical infra-axillary thoracotomy may help to establish minimally invasive cardiac surgery with better cosmetic results, and higher patient satisfaction compared to the median sternotomy approach. Outcomes during the learning curve were similar.

Role of ultrasound-guided trucut muscle biopsy using biopsy gun in inflammatory myopathies: A comparative analysis with open biopsy

BackgroundOpen muscle biopsy (OMB) is traditionally considered the “gold standard” method for muscle biopsy since a large specimen can be obtained under direct vision. However, there are issues related to logistics, duration of procedure, post operative pain and associated complications. This led us to explore minimally invasive percutaneous biopsy procedures in IM to overcome these shortcomings. MethodsForty two consecutive patients with suspected IM who underwent a diagnostic muscle biopsy at a tertiary care institute in North India between July 2017 to Jun 2019 were included. All such patients who reported to Neurology clinic underwent OMB, whereas those attending Rheumatology clinic were subjected to US guided TMB using a 14 gauge trucut BARD® biopsy gun. Results and conclusionUSG guided TMB using a bard biopsy gun is a relatively safe, convenient and less traumatic alternative to OMB with significantly less procedural and post-procedural morbidity. It may be considered as a fist line method for obtaining muscle specimen.

Efficacy of Angioscopy for the Detection of Mobile Carotid Artery Lesions

Case presentation A 78‐year‐old man with a mobile lesion was diagnosed with thrombus using carotid ultrasonography, but the lesion was not completely resolved with dual antiplatelet and anticoagulation therapy. Direct visualization by angioscopy showed a white mobile plaque. The carotid artery was stented with a double‐layered stent, as the plaque persisted despite continuing the medical treatment and was linked to an increased risk of cerebral embolism. The plaque was attached to the arterial wall, and it subsequently disappeared. The patient recovered well and no further emboli were observed. Conclusions Angioscopy is effective for identifying lesions under direct vision. The characteristics and dynamics of plaques may be viewed via angioscopy, which aids in making treatment‐related decisions, particularly in the case of carotid artery plaques.

Diagnosis and Treatment of Adenomyosis with Office Hysteroscopy-A Narrative Review of Literature.

Adenomyosis is a common chronic disease in women of reproductive age, characterised by the presence of ectopic endometrial tissue within myometrium. Even though adenomyosis presents with chronic pelvic pain, menorrhagia or abnormal uterine bleeding, dysmenorrhoea, and dyspareunia and is often recognised after hysterectomies. However, the development of ultrasonography and magnetic resonance imaging has improved the pre-operative diagnosis of the disease. Hysteroscopy provides information in real time from the uterine cavity and the offers the possibility of obtaining direct biopsies. The literature was searched via Pubmed and Embase with the following headings: diagnosis of adenomyosis or adenomyoma and office hysteroscopy, hysteroscopy findings of adenomyosis or adenomyoma, treatment of adenomyosis or adenomyoma with office hysteroscopy. The literature showed that hysteroscopy can identify superficial adenomyosis. There are a variety of hysteroscopic images that can be connected with the disease. New equipment like the spirotome has been used to access deeper layers of myometrium and obtain biopsies under direct vision from the adenomyotic areas. Different methods of treatment have been also described, like enucleation of focal superficial adenomyoma, coagulation, evacuation of cystic adenomyosis when the lesion is smaller than 1.5 cm, and resection of adenomyotic nodules in case of bigger lesions (>1.5 cm). Diffuse superficial adenomyosis is also managed by resection. Hysteroscopy has revolutionised the approach to adenomyosis. It is a useful tool in assessing mainly superficial adenomyosis. The role of hysteroscopy in surgical management of adenomyosis need to be confirmed with further studies.

Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis.

Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of unrecognised oesophageal intubation. We conducted a systematic review and meta-analysis of the diagnostic accuracy of five clinical examination tests and the oesophageal detector device when used to confirm tracheal intubation. We searched four databases for studies reporting index clinical tests against a reference standard, from inception to 28 February 2023. We included 49 studies involving 10,654 participants. Methodological quality was overall moderate to high. We looked at misting (three studies, 115 participants); lung auscultation (three studies, 217 participants); combined lung and epigastric auscultation (four studies, 506 participants); the oesophageal detector device (25 studies, 3024 participants); 'hang-up' (two non-human studies); and chest rise (one non-human study). The reference standards used were capnography (22 studies); direct vision (10 studies); and bronchoscopy (three studies). When used to confirm tracheal intubation, misting has a false positive rate (95%CI) of 0.69 (0.43-0.87); lung auscultation 0.14 (0.08-0.23); five-point auscultation 0.18 (0.08-0.36); and the oesophageal detector device 0.05 (0.02-0.09). Tests to exclude events that invariably lead to severe damage or death must have a negligible false positive rate. Misting or auscultation have too high a false positive rate to reliably exclude oesophageal intubation and there is insufficient evidence to support the use of 'hang-up' or chest rise. The oesophageal detector device may be considered where other more reliable means are not available, though waveform capnography remains the reference standard for confirmation of tracheal intubation.

Urethral Sheath to Evacuate Blood Clots through Mitrofanoff Appendicovesicostomy

Background: the Mitrofanoff appendicovesicostomy provides a catheterizable submucosal tunnel between umbilicus and bladder (or neobladder). In patients with a closed bladder neck, the Mitrofanoff channel is the only way to access the bladder. We describe our case of a 17 year-old girl with a Mitrofanoff appendicovesicostomy and a previous surgical closure of the bladder neck and who developed a large bladder clot due to hematuria after a surgical cystolithotomy in an augmented bladder; Methods: after an unsuccessful trans-appendicovesicostomy bladder washing, the endoscopic evaluation was performed using a 14 Ch rigid cystoscope and surrounded by its own urethral sheath. The clot was progressively fragmented through the cystoscope under direct vision. Clot fragments were aspirated to obtain a complete evacuation; Results: the urethral sheath prevented damages to the appendicovesicostomy, allowing at the same time repeated accesses of the cystoscope into the neobladder and ensuring the procedural success. The postoperative period was uneventful, and the neobladder catheter was removed after two days. Neither channel stenosis nor anastomosis dehiscence nor incontinence were reported after five months; Conclusions: the use of urethral sheath 14 Ch through an appendicovesicostomy preserves both the stoma and the channel, making possible endoscopic procedures such as blood clot evacuation into the neobladder.

The "Bubble Test" in the Arthroscopic Diagnosis of Triangular Fibrocartilage Central Lesion: Description and Relevance to Treatment.

Background Ulnarly sided wrist pain is a common and challenging symptom. Arthroscopy has become a safe and effective tool for the correct diagnosis and treatment, proving to be better than all other clinical and imaging diagnostic methods. Some tests have been described for the diagnosis of triangular fibrocartilage (TFC) lesions, such as the trampoline test for peripheral lesions and the hook, ghost, and suction tests for foveal detachments. In tears at the disc level, when they affect all layers of the TFC (complete lesion) at the same point, testing with the probe will usually suffice for the diagnosis. However, in some apparently partial lesions, the probe cannot pass through all layers because the proximal and distal sites of the lesion are not aligned. There has been no arthroscopic test described for such cases. Case Description We describe a simple and practical test that we have called the "bubble test" in a typical case to diagnose TFC central injuries, aiming to discriminate partial from complete lesions, which are eventually hard to differentiate through direct vision and arthroscopic probing, leading to a direct influence onto the treatment. The bubble test is performed with external compression of the distal radioulnar joint (DRUJ) aspect, with the thumb on the back of the DRUJ and the index and middle fingers onto the volar aspect. The abrupt compression of this region causes the passage of air mixed with synovial fluid from the DRUJ to the radiocarpal joint, generating bubble formation. Clinical Relevance The bubble test should correlate to physical examination and imaging (magnetic resonance imaging [MRI]) findings and is particularly useful in central and degenerative (Type II) TFC lesions in patients complaining of chronic pain on the ulnar region of the wrist, with no history of trauma and with inconclusive MRI findings. Once the diagnosis is confirmed, arthroscopic treatment consists of wide debridement of the lesion with resection of the injured tissue and the local inflammatory reaction. Thus, it is essential for the correct treatment to define the exact location of the lesion and to know whether the disc injury is complete.