Operative Findings Research Articles

Pre-operative Difficulty Assessment of Elective Laparoscopic Cholecystectomy: Validation of a Scoring System

Laparoscopic cholecystectomy (LC) is performed all over the world, which is now considered as the gold standard procedure for management of cholelithiasis. Despite its safety standard, sometimes surgeons encounter various difficulties during this surgical procedure. A prospective, observational study was conducted in the Department of Surgery, Dhaka Medical College Hospital, Dhaka, Bangladesh, from December 2018 to June 2019, to identify various risk factors and their correlations with likely difficulty in patients admitted for elective laparoscopic cholecystectomy. All the patients were admitted before surgery and routine preoperative procedures were done. The difficulty was predicted by a scoring system that included clinical, biochemical and sonological indicators with a maximum score of 25 and those were compared with per operative findings. A total of 200 individuals were assessed and analyzed. Age>50, BMI >30, history of acute attack, prolonged symptom duration, and previous abdominal surgery showed a statistically significant predictive association. Biochemical predictors also showed a similar trend with elevated WBC, total bilirubin, ALT, AST, and ALP. Radiologically, gall bladder wall thickness, pericholecystic collection, impacted stone, and fibrosed gall bladder were observed as significant factors. A preoperative score £ 5 provided easy dissection, less operating time, and a good outcome while a score of 6 or more was indicative of difficult laparoscopic cholecystectomy. Preoperative scoring and risk stratification can be used to predict difficult laparoscopic cholecystectomy. High-risk patients may be informed beforehand regarding the possibility of conversion to open surgery. Surgeons and hospital administration also may have to schedule the operating time and team appropriately. It also helps surgeons to be aware of probable complications in high-risk patients based on preoperative scoring. Mugda Med Coll J. 2024; 7(2): 102-107

Does Arthrography Improve Accuracy of SPECT/CT for Diagnosis of Aseptic Loosening in Patients with Painful Knee Arthroplasty: A Systematic Review and Metaanalysis.

SPECT/CT combines scintigraphy with a CT scan forming a 3-dimensional reconstruction of bone-tracer uptake patterns. It has become a fundamental component of the work-up of a painful total knee arthroplasty (TKA). The addition of an arthrogram is purported to improve its diagnostic yield. The aim of this study was to assess whether the addition of a concurrent arthrogram to a SPECT/CT enhances its sensitivity and specificity for diagnosing aseptic loosening in a painful total knee replacement. Methods: PubMed, Embase, and Scopus were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies compared the results of SPECT/CT with or without an arthrogram against an appropriate reference standard for diagnosing TKA aseptic loosening. The quality of included studies was independently assessed using the QUADAS-2 tool. Results: In total, 160 abstracts were identified by our search strategy. Of these, 6 studies comprising 472 patients met our inclusion criteria. All included studies used operative findings or a period of clinical and radiologic observation as reference standards. The SPECT/CT arthrogram was more sensitive in identifying aseptic loosening of knee prostheses, and it also provided greater specificity for excluding its diagnosis. Conclusion: The amalgamated results of included studies of the use of SPECT/CT demonstrate it is the best test in helping determine aseptic loosening in patients with painful TKAs (specificity, 97% vs. 85%). It is also a more sensitive test (sensitivity, 78% vs. 75%). Considering the potential morbidity of injection of contrast into the prosthetic joint, addition of an arthrogram to SPECT/CT is not beneficial and is potentially harmful.

American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 Revision.

The American Association for the Surgery of Trauma Organ Injury Scale (OIS) Committee published the original pancreatic OIS in 1990 with the authors acknowledging at the time that the classification would need to undergo "continued refinement as clinical experience dictates." The current OIS overemphasizes injury location over ductal integrity; modifications are needed to improve concordance between OIS, therapy, and outcomes and promote accuracy in quality assessment and research. A subcommittee of the American Association for the Surgery of Trauma and invited experts in radiology and interventional gastroenterology were chosen. Contemporary literature was reviewed, and a standardized iterative and collegial process was used to arrive at consensus. The pancreatic OIS is anatomically based on operative, radiographic, or pathologic findings. Major changes to the grading system include moving lacerations of the pancreatic head without ductal injury from Grade IV to Grade II. Injuries to the duct in the neck, body, or tail remain Grade III but are further subclassified to distinguish between deep parenchymal injuries without ductal interrogation, partial ductal injuries, and complete ductal transection. Grade IV injuries follow the same nomenclature but for injuries to the right of the portal vein or superior mesenteric vein. Grade V injuries are destructive injuries of the pancreatic head with nonviable parenchyma. These injuries are further subgraded based on ductal injuries. The pancreatic OIS schema is revised based on contemporary experience informed by the current understanding of outcomes and treatment, including operative management and outcomes. Increasing grades now more closely reflect increasing severity. Expert Opinion; Level V.

The Congenitally Malformed Aortic Valve in Type A Aortic Dissection: Its Frequency and Consequences

A congenitally malformed aortic valve, unicuspid (UAV) or bicuspid (BAV), occurs in about 1% of the population and is known to be more frequent in patients with aortic dissection. The clinical and operative findings in a series of 134 patients with spontaneous, acute Type A aortic dissection (TAAD) were studied, comparing patients with normal and abnormal aortic valve morphology. The aortic valve was normal in 123/134 (92%) patients and abnormal in 11/134 (8%) patients: BAV in 10/134 (7.5%) and UAV in 1/134 (0.7%). Demographics were similar between groups except for a lower frequency of systemic hypertension in the UAV/BAV group (46 vs. 82%, p<0.01). Penn class stratification was also similar in the 2 groups. The UAV/BAV group had a greater frequency of aortic root enlargement (64 vs. 18%, p<0.01) and a larger median root diameter (5.7 vs. 4.6cm, p=0.02). In the UAV/BAV group, the entry tear was more frequently in proximal (intrapericardial) zone 0 (91 vs. 62%, p=0.049). The frequency of abnormal aortic media histology was similar. The rate of root replacement was higher in the UAV/BAV group and early mortality was similar. The frequency of congenitally malformed aortic valve in this series was 8x the normal population. The one UAV in the series was the only severely stenotic valve. In TAAD patients with a congenitally malformed valve, aortic root aneurysm was more common and the entry tear was nearly always proximal.

An Application of Combined Transpetrosal Approach with Micro-neurovascular Transposition in Recurrent Trigeminal Neuralgia caused by Dolichoectatic Vertebral Artery

PurposeIn general, the superior cerebellar artery (SCA) is the most prevalent vessel that compresses the trigeminal nerve root exit zone (TGNREZ) and is responsible for trigeminal neuralgia (TGN). Nevertheless, the surgical outcome is less efficacious when the offending vessel is a dolichoectatic vertebrobasilar vessel (DVB). In addition, the potential for post-procedural adhesion and fibrosis renders recurrent TGN after prior surgery an extremely challenging operation. MethodsWe describe our surgical strategy and procedure that effectively resolved recurrent TGN in a patient whose offending vessel was a large DVB following standard microvascular decompression surgery. The size and nature of the offending DVB indicated that there was limited space for mobilization away from the TGNREZ, as evidenced by previous operative findings. Consequently, the patient's TGN may not be effectively treated by re-operating with the same standard lateral suboccipital approach. ResultsOur surgical approach comprised the creation of an expanded area to facilitate the mobilization of the DVB from the TGNREZ, as well as the untethering of the trigeminal nerve and its subsequent mobilization from the DVB using the transposition technique. ConclusionA combined transpetrosal approach with micro-neurovascular transposition technique was selected to achieve all objectives. A case illustration with a surgical video is demonstrated.

Diagnostic Accuracy of Magnetic Resonance Imaging(Mri) For Perianal Fistula Tract Taking Operative Findings as Gold Standard

Diagnostic Accuracy of Magnetic Resonance Imaging(Mri) For Perianal Fistula Tract Taking Operative Findings as Gold Standard

Emergency primary anastomosis with or without intraoperative colonic lavage following sigmoidectomy in sigmoid volvulus: 175-patient experience in a tertiary referral hospital

Objectives: Emergency primary anastomosis following sigmoidectomy is one of the main treatment options in sigmoid volvulus (SV). However, during this procedure, the role of intraoperative colonic lavage (ICL) is controversial. Our aim was to evaluate the role of ICL in 175-patient SV series. Methods: In Ataturk University Faculty of Medicine Department of General Surgery, ICL was applied in 76 cases (43.4%), while it was not used in the remained 99 patients (56.6%) in 58.5-year period. In a partial retrospective (first 20 years, from June 1966 to June 1986) and prospective (later 38.5 years, from June 1986 to December 2024) evaluation, some preoperative, operative, and postoperative findings were utilized. Results: As preoperative data, mean age (56.4 years vs. 57.1 years, P&gt;0.05), male/female ratio (4.8 vs. 4.2, P&gt;0.05), and rate of shock (5.3% vs. 6.1%, P&gt;0.05) were statistically similar in both groups, while mean ASA score (3.1 vs. 2.9, P&lt;0.05) was significantly lower in ICL group. Among operative findings, rates of bowel gangrene (67.1% vs. 63.6%, P&gt;0.05) and perforation (1.3% vs. 1.0%, P&gt;0.05) were statistically similar in both groups, while mean operation time (205.4 minutes vs. 176.8 minutes, P&lt;0.005) was significantly longer in ICL group. As surgical outcomes, rates of mortality (13.2% vs 12.1%, P&gt;0.05) and morbidity (39.5% vs. 28.3%, P&gt;0.05) were statistically similar in both groups, while mean hospitalization time (14.7 days vs. 9.4 days, P&lt;0.001) was significantly longer and mean cost (3,455.4 USD vs. 2,752.1 USD, P&lt;0.001) was significantly higher in ICL group. Conclusion: When compared with that of primary anastomosis with ICL, primary anastomosis without ICL provided shorter operation and hospitalization times, and less cost in addition to similar mortality and morbidity rates in the emergency treatment of SV. doi: https://doi.org/10.12669/pjms.41.2.11399 How to cite this: Altundas N, Peksoz R, Disci E, Atamanalp SS. Emergency primary anastomosis with or without intraoperative colonic lavage following sigmoidectomy in sigmoid volvulus: 175-patient experience in a tertiary referral hospital. Pak J Med Sci. 2025;41(2):603-607. doi: https://doi.org/10.12669/pjms.41.2.11399 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Aggressive Super-Giant Prolactinoma in a Male Adolescent: A Case Report

Giant prolactinoma (GP) in childhood and adolescence is a rare entity with scarce litterature. We report a case of A 17-year-old adolescent Moroccan boy presented with a Rapidly progressive vision loss complicated with an incomplete Intracranial hypertension syndrome. Magnetic resonance imaging (MRI) showed a very large intrasellar mass with suprasellar extension and evidence of recent necrotic and hemorrhagic remodeling. Patient underwent an urgent transsphenoidal surgery for tumor resection. Post operative labroratory findings were in favor of a hyperprolactinemia a panhypopituitarism and transient Diabetes insipidus. Histological assessment confirmed diagnosis of prolactinoma. Pituitary MRI control revealed an intrasellar residue. Patient was then started on cabergoline.This case highlights the importance of early identification and the need for a multidisciplinary approach in managing Giant aggressive prolactinomas in young patients.

Atypical lacrimal sac mucoceles

ABSTRACT Purpose To report the clinical features and operative findings of a series of patients with lacrimal sac mucoceles extending above the anatomic level of the medial canthal tendon (MCT). Methods A retrospective chart review of all patients presenting with lacrimal sac mucocele extending above the anatomic level of the MCT over a period of five years from 2019 and 2023. All patients underwent surgical management. Diagnosis of lacrimal sac mucocele was based on clinical examination, imaging where indicated and intraoperative confirmation. Data obtained include demographics, clinical presentations, duration, imaging features, type of surgical intervention, intraoperative findings, and outcomes. Results A total of 62 patients were analyzed, of whom 67.7% were female. The mean age at presentation was 49.11 years. The mean duration of the lacrimal sac swelling was 18.15 months (SD = 21.94). Epiphora, discharge, and dacryocystitis were frequent associations. Regurgitation on Pressure over the lacrimal sac area (ROPLAS) decompressed the swelling in 35 (56.5%) patients. In 61.3% of patients, the medial canthus remained in its normal position, while the medial canthal tendon (MCT) exerted pressure on the overextending mucocele to varying degrees, resulting in a dumbbell-shaped appearance in certain cases. In 38.7% of patients, the mucocele caused superior displacement of the medial canthus compared to the contralateral side. The surgical interventions were successful in resolving the mucocele. Conclusions Lacrimal sac mucoceles can extend above the level of the MCT. While a lacrimal sac swelling above the MCT should raise suspicion for a mass lesion of neoplastic etiology, it is not a tell-tale sign.

A Study of Symptomatic Umbilical Remnants in Children with Evaluation of the Role of Ultrasound as a Diagnostic Modality

ABSTRACT Aims: The aim of this study was to study the presentation and management of children with symptomatic “umbilical remnants” (SUmR) and the efficacy of ultrasound (US) in diagnosis and predicting a need for surgery. Materials and Methods: This study included 65 children aged 2 months–12 years with clinical findings suggestive of umbilical remnants (UmR): umbilical granuloma (UG); umbilical polyp or prolapsing mucosa, periumbilical inflammation/mass, or persistent umbilical discharge. Investigations included US and bacteriological culture-sensitivity tests of umbilical discharge. UG and umbilical polyps were excised. Minilaparotomy was performed for other SUmR and UG/umbilical polyps where US suggested intra-abdominal pathology. The excised UmR tissue underwent histopathologic examination (HPE) for final diagnosis. Results: There were 40 males and 25 females, with a median age of 6 months. The three groups after final diagnosis were (i) UG (n = 38), (ii) vitellointestinal (VI) remnants (n = 21), umbilical polyp (n = 17), patent VI duct (PVID) (n = 3), and umbilical cyst (n = 1), and (iii) urachal remnants (UR) (n = 6), urachal cysts (n = 3) and patent urachus (n = 3). Forty-nine UG/umbilical polyps underwent simple excision. Sixteen (24.6%) patients underwent minilaparotomy, and in seven, US findings correlated with operative findings. US was false positive for intra-abdominal pathology in six cases (UG = 3; umbilical polyp = 3) and false negative in PVID (n = 3). UG and umbilical polyps were differentiated only by HPE. There were no complications or recurrence. On grouping by presentation, US as a diagnostic modality in UG/umbilical polyp had a specificity of 85% with a diagnostic accuracy of 89.09%. In UR, the figures were sensitivity 100%, specificity 0%, positive predictive value (PPV) 100%, negative predictive value (NPV) 0%, and diagnostic accuracy 100%. For VID remnants excluding umbilical polyps, the sensitivity was 25%, specificity 0%, PPV 100%, NPV 0%, and diagnostic accuracy 25%. Overall, the sensitivity of abdominopelvic US as a diagnostic modality in SUmR was 70%, specificity 89%, PPV 53%, and NPV 94% with overall diagnostic accuracy of 84%. Conclusions: SUmR is most commonly UG or umbilical polyp and could not be differentiated on clinical grounds alone. In suspected urachal anomalies/UR, US is an effective diagnostic modality. Overall, however, US has relatively low sensitivity and a low PPV and should be regarded as an accessory rather than a very effective diagnostic modality in SUmR. One-stage excision of SUmR is safe and effective. HPE of the excised SUmR is essential for the final diagnosis.

The incidence, technical management and outcomes of impacted stones encountered during 1447 laparoscopic bile duct explorations.

Stone impaction is an obstacle to successful laparoscopic common bile duct exploration (LCBDE). This study aims to identify the incidence, operative difficulties and techniques used to disimpact and remove impacted stones during LCBDE. Prospectively collected data from a large series of LCBDE. Preoperative and operative findings in patients with impacted stones including the difficulty grading, impaction site, disimpaction methods, operative complications and postoperative outcomes were analysed. 136 of 1447 (9.4%) LCBDEs had impacted stones; 63.2% females, median age 54years. 88.2% were emergencies including 94 Jaundice (69.1%), 19 acute pains, 6 acute cholecystitis and 5 pancreatitis. 16.9% had previous ERCP, all at other units pre-referral. LCBDE was transcystic in 52 (38.2%) and via choledochotomy in 84 (61.8%), all requiring choledochoscopy. LCBDE was difficulty grade IV in 60 (44.1%) and grade V in 76 (55.9%).The number of stones ranged from 1 to 70 (median 2) and stone size 4-30mm (median 11). Impaction was at lower CBD in 83 (61%), Mid-CBD 29 (21.3%), Intra-hepatic 15 (11%), intra and extra hepatic in 6 (4.4%) and intramural in 3. Disimpaction was by biopsy forceps fragmentation in 37 patients (27.2%), basket dislodgment in 35 (25.7%), biopsy forceps plus basket/hook retractor or cholecochoscope push in 20 (14.7%), Fogarty/Foley balloon with or without basket in 15 (11%), laser in 12 (8.8%), grasper fragmentation in 9 patients (6.6%), and open conversion in 7 (5.1%); 3 stone removal, 2 choledochoduodenostomy and 2 hepaticojejunostomy. Stones left for postoperative ERCP in four patients (2.8%). The median operative time was 160min. Impacted stones increase the difficulty of LCBDE. The evolution of techniques and instruments over the course of this study increased the success of transcystic exploration and reduced reliance on choledochotomy. The prediction of impaction, availability of lithotripsy and increasing experience should improve postoperative outcomes.

Preoperative Medication for Ovarian Endometrioma Reduces Cyst Size and PainBut Not rASRM score.

To investigate the impact of preoperative hormonal medication, including combined oral contraceptives (COCs) or dienogest, on operative findings in ovarian endometrioma surgery. A single-center, retrospective study. Department of Gynecology, Samsung Medical Center, Republic of Korea. Among patients who underwent ovarian endometrioma surgery for the first time at Samsung Medical Center between January 2020 and July 2023, those who started hormonal medication at another institution before their initial visit to our center, those with a waiting period of less than three months until the surgery date, and those with an endometrioma size of less than 4cm at the initial visit were excluded. A total 140 remaining patients were included in the study. The patients were divided into two groups: the group that received preoperative hormonal medication (COCs or dienogest) and the group that did not receive medication. To evaluate the impacts of preoperative hormonal medication on ovarian endometrioma patients, the operative findings were compared between the groups. Of the140 patients, 65 were in the no-medication group and 75 were in the medication group. Except for the median duration of follow-up and age, there were no differences in the baseline characteristics between the two groups. Operative findings were quantified using the revised American Society for Reproductive Medicine (rASRM) score. Although medication significantly reduced the size of the ovarian endometrioma, there were no significant differences in rASRM score between the two groups. However, the medication group experienced significant preoperative pain relief. Preoperative hormonal medication can reduce the size of ovarian endometriomas but does not significantly affect the overall operative findings. Nevertheless, preoperative medication is helpful in reducing pain in patients before surgery.

Early recognition and management of gangrenous cholecystitis: a single-center experience and a comprehensive review of risk factors and imaging findings

Background: Annually, approximately 200,000 acute cholecystitis (AC) cases are diagnosed in the U.S., with gangrenous cholecystitis (GC) occurring in 2-20% of AC cases. GC, characterized by ischemic necrosis of the gallbladder, is often associated with delayed diagnosis, leading to increased complications, longer hospital stays, and mortality rates ranging from 15-50%. This study presents a series of GC cases treated at our institution. Methods: A retrospective review was conducted at a community hospital on patients from October 2012 to December 2022 with GC confirmed by pathology. Data collected included demographics, clinical parameters, lab values, imaging, operative findings, management, and outcomes, aiming to identify risk factors, treatment approaches, and associated outcomes. Results: Out of 5,746 cholecystectomy patients, 67 (1.16%) had GC. The average age was 56, with a male predominance (64%). Incidence was highest among Hispanic (37%) and Asian (28%) populations. Common comorbidities included hypertension (48%), obesity (36%), and diabetes (33%). Clinical presentations included right upper quadrant pain (64%) and epigastric pain (46%). Computed tomography (CT) findings showed gallbladder distention (43%), fat stranding (22%), and perforation (3%). Surgical approaches were laparoscopic cholecystectomy (75%), converted-to-open cholecystectomy (19%), and open cholecystectomy (3%). Complications included bile leak (7%), wound infection (4%), hematoma (3%), and wound dehiscence (1%), with a 1.4% mortality rate. Conclusions: GC is a severe AC complication linked to delayed presentation, with higher complication and mortality rates. Recognizing risk factors such as age, gender, and imaging/laboratory findings can facilitate early diagnosis and timely surgical intervention, improving patient outcomes.

Prognostic Value of Immune Scoring System for Colorectal Cancer Patients with Peritoneal Metastasis.

Background and Objectives: There is no reliable immune scoring system that can help us predict the postoperative outcomes of colorectal cancer patients with peritoneal metastases after cytoreductive surgery. In this cohort, the aims were (1) to evaluate the postoperative morbidity, mortality and surgical oncological outcomes in colorectal cancer patients with peritoneal metastasis; (2) to compare oncological and postoperative outcomes of colon cancer patients with peritoneal metastasis and rectal cancer patients with peritoneal metastasis; and (3) to assess the prognostic value of the modified Glasgow Prognostic Score (mGPS) and the CRP-albumin ratio (CAR). Materials and Methods: A prospectively maintained database of 258 patients who underwent cytoreductive surgery for peritoneal metastases of colorectal origin between 2007 and 2024 was analyzed. According to the anatomical location of the primary tumor, two different groups were created: rectum cancer patients with peritoneal metastasis (Group A) and colon cancer patients with peritoneal metastasis (Group B). All standard clinico-pathological characteristics, operative findings, morbi-mortality results, and final oncologic outcomes were compared between Groups A and B. We evaluated whether CAR and mGPS could predict postoperative morbi-mortality and overall survival in the two groups or not. Results: No significant difference was detected between Groups A and B in terms of clinical-demographic characteristics. In both groups, the preoperative mGPS and CAR values were statistically significantly higher in those who developed postoperative high-grade complications (C-D grade III/IV) (p < 0.001) and those who died perioperatively (p = 0.001 and p = 0.002). Conclusions: In multivariate Cox analysis, the CAR was found to be an independent prognostic factor for overall survival in this cohort. CAR and mGPS predicted high-grade complications and postoperative mortality in both groups.

Evaluating and Improving the Quality of Surgical Operative Notes at the Port Sudan Teaching Hospital.

Background Thorough and standardized documentation of operative notes is essential for effective communication, patient safety, legal protection, and the continuity of care. However, in many hospitals in Sudan, surgeons often use non-standardized methods, resulting in inconsistent and incomplete records. This study evaluates the quality of operative notes at the Port Sudan Teaching Hospital using the Royal College of Surgeons of England (RCSEng) guidelines, aiming to improve compliance and documentation practices. Methods A clinical audit was conducted in two cycles at the General Surgery Department. The first cycle, a retrospective review of 50 surgical notes, was carried out over one week in July 2024. The second cycle conducted prospectively on another 50 notes throughout September 2024, involved the implementation of an improved proforma and staff training. Data were collected using a standardized checklist aligned with Royal College of Surgeons in Ireland (RCSI) guidelines, covering 18 documentation criteria. Results were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States) to assess improvements in compliance. Results The compliance with documentation standards increased significantly from 51.9% in the first cycle to 82.1% in the second cycle. Notable improvements were observed in recording operative findings (17, 34%), complications (34, 68%), and deep vein thrombosis (DVT) prophylaxis (47, 94%). Despite the overall progress, modest improvements were noted in documenting the anesthetist's name (2.5, 5%) and the surgeon's signature (3, 6%). These findings underscore the positive impact of structured proformas and targeted staff training. Conclusion The implementation of standardized documentation tools and staff training significantly improved the quality of surgical operative notes at the Port Sudan Teaching Hospital. While notable progress was achieved, continued efforts, including digital solutions and regular audits, are needed to sustain these improvements and promote patient safety.

Pre-operative imaging for inguinal hernia: routine or waste? A single institution perspective.

Inguinal hernia is a very common surgical problem in Australia. This study aims to assess at a single institution the perioperative use of imaging for these patients, and the accuracy of that imaging. Data were collected retrospectively for 215 adult patients who underwent inguinal hernia repair at a single public hospital. Clinical, operative, and imaging findings were collected and recorded. The study included 215 patients who had surgery on 240 groins. 90% of patients had preoperative imaging, with 70% undergoing ultrasound, and 28% undergoing CT scan. 82% of patients who had imaging had a clinically palpable hernia. Ultrasound and CT had high sensitivity for the presence of hernia, 97.5% and 90.6%, respectively. Ultrasound was inaccurate at assessing for direct versus indirect hernia, correlating with operative findings only 62% of the time. Data suggest that imaging is being overused for investigation of groin hernias, and imaging findings do not appear to alter operative management.

Changes in Cerebral Hemodynamics During Pediatric Cardiac Surgery with Cardiopulmonary Bypass for Congenital Heart Disease.

During pediatric cardiac surgery with cardiopulmonary bypass (CPB) for congenital heart disease, systemic hemodynamics dramatically change, which also causes changes in the cerebral hemodynamics. One of the representative methods in bedside monitoring for the estimation of cerebral hemodynamics during pediatric cardiac surgery is transcranial Doppler ultrasonography (TCD). However, there seem to be few reports on the changes in TCD findings in such operations, especially in cyanotic children. Accordingly, we examined the changes in TCD indices during these procedures in cyanotic children as well as non-cyanotic children. In the post hoc analysis of a previous prospective observational study, TCD indices of the middle cerebral artery at the start and end of surgery in patients aged 6years or less were compared. The cerebral oxygenation (rSO2) values were also compared. For this study, 47 cyanotic children and 49 non-cyanotic children were evaluated. At the end of surgery, cerebral blood flow velocities decreased and cerebrovascular resistance increased significantly compared to the start of surgery in both the cyanotic and non-cyanotic patients. This finding was almost constant regardless of age differences, although cerebral blood flow velocities and the rSO2 increased until around 20months after birth. The rSO2 values did not change between the start and end of surgery. Thus, the changes in cerebral hemodynamics during pediatric surgery with CPB in cyanotic children were not so different from those in non-cyanotic children. The significance of monitoring of cerebral hemodynamics by TCD and rSO2 should be evaluated further.

Risk factors for complications following titanium mesh cranioplasty.

Studies on complications following titanium mesh cranioplasty have predominantly focused on patients with cranial defects after decompressive craniectomy. This study investigates possible risk factors for complications using titanium mesh for smaller cranial defects. All patients treated with titanium mesh cranioplasty over a 5-year period at Copenhagen University Hospital were identified. Demographics, comorbidities, and active smoking and drinking status were recorded in addition to indication for cranioplasty and operative findings. Severe complications recorded included superficial and deep infection, delayed wound defects, postoperative hematomas, and death within 30 days postoperatively. Minor complications recorded included skin atrophy, cosmetic complaints, pain, and loosening of the mesh. The management of complications was also documented. A total of 247 patients with primary titanium mesh cranioplasty were included in the study. The overall complication rate was 17.4%. 15.0% suffered from severe complications and 2.4% developed minor complications. Elderly smokers, patients previously treated with radiation, and patients operated via a posterolateral approach to the skull base had the strongest association with complications. The complication rate was not higher in patients with cranioplasty after postoperative infections or in those with a frontobasal approach to the skull base compared with patient operated on for smaller cranial tumors. The risk of complications following titanium mesh for smaller cranial defects is higher in elderly smokers, patients with a history of radiation, and those undergoing a posterolateral approach to the skull base.

Isolated Cardiac Echinococcosis of Interventricular Septum.

Cardiac cystic echinococcosis is a rare form of cystic hydatid disease. Hydatid cysts are multilocular and are picked up incidentally. We here describe a case of an isolated unilocular cardiac hydatid cyst of the interventricular septum withmultimodality imaging, treatment approach, and operative findings.

Patient-Reported Outcomes Following Periacetabular Osteotomy versus Hip Arthroscopy for Borderline Acetabular Dysplasia Are Comparable: A Systematic Review.

The purpose of this systematic review was to compare patient populations and outcomes in studies treating borderline hip dysplasia (BHD) with either hip arthroscopy or periacetabular osteotomy (PAO). We hypothesized that studies would show significant postoperative improvement following both PAO and arthroscopy for BHD, and that subjects undergoing arthroscopy would have a higher rate of Cam morphology. A literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies published after 2014 that reported patient-reported outcome measures (PROMs) following hip arthroscopy or PAO for BHD. Preoperative demographics, radiographic variables, operative findings, procedures, postoperative outcomes, and complications were recorded. Forest plots were constructed of disaggregated data to identify study heterogeneity using the I2 statistic. 26 studies (8 PAO; 18 Arthroscopy) were included. Acetabular morphology was comparable between the PAO and arthroscopy studies while the arthroscopy studies reported higher alpha angles (range 48.3-75.3°) compared to the PAO studies (range 47.6-55°). No PAO studies reported an average alpha angle greater than 60° while this was reported in 71% of arthroscopy studies. The most common PROMs were the modified Harris Hip Score (mHHS), with average improvement ranging from 20-29 for PAO and 17.9-34.4 for arthroscopy, and the International Hip Outcome Tool-12 (iHOT-12), with mean postoperative scores ranging from 73.3-74.3 for PAO and 67.5-85.4 for arthroscopy. Postoperative PROM improvement was significant for all studies with significant heterogeneity for the mHHS (I2=0.90) and iHOT-12 (I2=0.98). There was significant postoperative improvement following both PAO and modern hip arthroscopy for the surgical management of BHD with high levels of heterogeneity limiting comparability between study groups. Hip arthroscopy studies recorded higher alpha angles suggesting that cam deformities in the setting of BHD can be managed arthroscopically, however further study on optimizing indications between procedures is required.