Horizontal Mattress Research Articles

The Optimal Suture Technique for Mitral Valve Replacement in an <i>Ex Vivo</i> Animal Model

Objective: This study compared and evaluated three suture methods in order to find the method with the best durability for mitral valve replacement. The methods evaluated are horizontal mattress suture with subanular pledgets, horizontal mattress suture with supraanular pledgets and continuous running suture. Methods: Thirty hearts were explanted from newly terminated pigs. The hearts were randomized in the three groups. After an atriotomy, the mitral valve was cut out, and a patch was sutured into its place. An air pump model was connected to a balloon which was placed in the left ventricle through aorta and continuously filled with air to a maximum of 300 mmHg. The peak pressure at rupture was noted. If no rupture occurred before reaching 300 mmHg, the suture was found competent. Results: Two out of ten hearts in the continuous running suture-group had myocardial rupture within a pressure of 300 mmHg. In the remaining eight hearts there were no ruptures within 300 mmHg. In the two groups sutured with horizontal mattress with pledgets placed either subanular or supraanular, no rupture of myocardium occurred. When comparing continuous running suture with the horizontal mattress with subanular pledgets or the horizontal mattress with supraanular pledgets, the 1-sided Fishers’ exact was 0.237. At 5% significance level, there was no difference between the three suture methods. Conclusion: There was no statistically significant difference between the durability of the three suture methods, though rupture was only evident in the continuous running suture line. Since it is the surgeon’s choice to select the optimal suture technique, our study should be a reminder for the surgeon to reflect on the suturing factors that have an influence on successful mitral valve replacement.

Robotic reoperative pancreatectomy for recurrent disease after pancreaticoduodenectomy, with conversion of pancreaticojejunostomy to pancreaticogastrostomy: approach and outcomes

Presenter: Krishnaraj Mahendraraj MD | Cedars-Sinai Medical Center Background: We describe here the rare case of a reoperative pancreatectomy following pancreaticoduodenectomy with conversion of the pancreaticojejunostomy to a pancreaticogastrostomy. This is a 74yo woman who underwent a pancreaticoduodenectomy one year prior for pancreatic neuroendocrine tumor. On surveillance she was found to have a focal area of recurrence right at the pancreaticojejunostomy anastomosis, which progressed despite somatostatin analog therapy. Given that this was the sole site of recurrence and that she had 50-60% of native pancreas volume left, we opted for reoperative pancreatectomy. Methods: Case review Results: Four robotic ports were placed across the lower abdomen along with a suprapubic assist port. The pancreatic remnant was densely adherent to the underlying portal vein and superior mesenteric vein. Robotic exploration revealed a 3 cm mass of the proximal pancreatic remnant, right at the prior pancreaticojejunostomy. We traced the previous pancreaticobiliary limb to find a point between pancreas and the biliary anastomosis where this could be divided. We opened up the jejunum right at the pancreaticojejunostomy to allow full mobility. We used a linear stapler and divided the jejunum proximal to the biliary limb, preserving the hepaticojejunostomy. We were able to separate the pancreatic mass off the splenic artery as well as celiac artery and vein. Distally, fine branches were taken with clips and vessel sealer. We eventually got to the point where we were completely free of the underlying structures and the mass was completely mobilized. We used ultrasound to confirm our margin before dividing the pancreas down with cautery. The specimen was passed off the field in an Endobag and pathology confirmed negative margin at the point of transection. We now turned our attention to reconstruction. The stomach laid over the pancreatic remnant roughly at the body-tail junction of pancreas, which was well to the left of midline, placing it in an ideal location for tension-free anastomosis without the need for extensive mobilization. Her Whipple had been pylorus preserving, giving us a complete stomach to work with. We made a gastrotomy at the posterior gastric wall and the pancreatic anastomosis was performed by an invaginating technique. We used 4-0 Monocryl with interrupted horizontal mattress sutures to invaginate the gland into the back wall of the stomach. This anastomosis was tested with methylene blue into the stomach and we saw no leak. Her largest skin incision at the end of the operation was the 4 cm suprapubic assist post which was also used to deliver the specimen. The patient made an excellent recovery and was subsequently discharged on Postoperative Day 4 with normal vitals, ambulating, with good pain control, and tolerating food. She resumed somatostatin analog therapy and close surveillance is maintained due to her risk for recurrence. Pathology and subsequent imaging show her to be disease-free. Conclusion: The robotic approach allowed for precise navigation in narrow spaces, such as maneuvering the pancreatic remnant under the stomach. It allowed us to perform a complex oncologic resection through small incisions resulting in expedited recovery, as well as avoid her prior incision thereby reducing hernia risk.

Arthroscopic Medial Meniscal Posterior Root Repair With Transtibial Luggage-Tag and Horizontal Mattress Sutures

Medial meniscal posterior root repair techniques have shown positive yet varied results in the literature. The decision to perform repair has improved clinical outcomes in many situations, although the healing rate is approximately 64% and the repair strength is roughly one-third of the native root strength, with meniscal extrusion being common. We present a technique based on biomechanical evidence to obtain a strong anatomic posterior root repair to restore nearly normal knee mechanics, combining an increased size of footprint under the lateral aspect of the medial meniscal horn for healing and a luggage-tag suture with a posteriorly placed horizontal mattress suture. The horizontal mattress suture is passed to capture the circumferential fibers of the meniscus and the luggage-tag suture is passed to capture the radial fibers of the meniscal body, through a single transtibial tunnel. The aim of this repair is to restore the normal meniscal function.

Isolated Meniscal Ramp Lesion Without Obvious Anterior Cruicate Ligament Rupture.

ObjectivesThe purpose of the present paper was to study isolated meniscal ramp lesions without obvious ACL rupture. Their biomechanical mechanisms were analyzed and their clinical characteristics were reviewed. The clinical effects of an all‐inside horizontal mattress suture for isolated ramp lesions were evaluated.Materials and MethodsTwenty isolated meniscal ramp lesion patients without obvious ACL rupture from 2015 to 2017 were retrospectively reviewed. Preoperative MRI showed intact ACL and signs of ramp lesions. These isolated ramp lesions were arthroscopically confirmed and repaired through an all‐inside horizontal mattress suturing method. MRI was performed 3 months postoperatively to assess isolated ramp lesion healing. The Tegner–Lysholm score and the visual analog scale score were recorded preoperatively and at 2 years postoperatively. The Wilcoxon rank sum test was performed to determine statistical significance.ResultsArthroscopic exploration confirmed isolated ramp lesions and longitudinal ACL splits or degeneration without obvious ACL rupture. MRI 3 months postoperatively showed healing of the isolated ramp lesions. At 2 years postoperatively, the VAS scores were significantly decreased and the Tegner–Lysholm scores were significantly increased. Knee function, without pain, was restored in all patients, including walking, climing and descending stairs, and squatting.ConclusionIsolated meniscal ramp lesions without obvious ACL rupture may exist because of ACL longitudinal splits or degeneration and can be repaired through anterolateral and anteromedial portals with an all‐inside horizontal‐mattress suturing method.

Updates and Advances in the Management of Lateral Meniscal Radial Tears: A Critical Analysis Review.

Because of their increased mobility, lack of resistance to hoop stresses, and decreased blood supply, radial tears of the lateral meniscus are more troublesome to heal than vertical longitudinal tears. Given the success of meniscal root repairs, radial tears of the lateral meniscal body should be given strong consideration for repair because of a more reproducible ability to heal such lesions in young, active patients. Technique options that should be considered for the less common anterior radial tears of the lateral meniscus include outside-in repair, self-capturing suture-passing devices, and orthobiologic treatments to stimulate healing. Although a variety of suture techniques, including the double horizontal mattress and horizontal butterfly patterns, have demonstrated improvements in patient outcomes, evidence is still limited with regard to the ideal suture pattern for radial tears.

The Pinch Stitch: A Pearl for Suturing Wounds Under Tension.

Closing defects under tension in areas such as the scalp and back may be challenging during dermatologic surgery. Different techniques have been advocated to ease the placement of the first deep suture under tension, including the slip-knot stitch, pully stitch, horizontal mattress suture, pulley set-back dermal suture, and tandem pulley stitch.

Squamous cell carcinoma of an eyelid in a horse: A case report

The aim of this report is to describe a clinical case of squamous cell carcinoma in an 18-year-old horse. This tumor is one of the most common superficial oncological problems in these animals. A lesion in the lateral corner of the eye was already observed about 10 years earlier, but due to the lack of significant growth or alarming symptoms, no diagnostics or treatment was implemented. A year before surgery, an episode of acute inflammation in the eye and a slight enlargement of the nodule occurred. Initially, an autoimmune origin of the lesion was assumed, but anti-inflammatory and bactericidal treatment did not lead to a significant improvement. As a result of sampling for histopathological examination, the tumor doubled its volume, so, given the inefficacy of the subsequent anti-inflammatory and antibiotic therapy, the horse was sent to the clinic. A convex, painful lesion partially covering the cornea was found on arrival. In view of the rapid growth of the tumor and its infiltration of surrounding tissues, a decision was made to carry out transpalpebral enucleation. The procedure was performed under general anesthesia and with an additional retrobulbar block. Because of significant tissue tensions and the risk of hematoma, an intermittent horizontal mattress suture was used. The area was secured with a compression dressing. The horse returned to sport, and no recurrence of the tumor was observed up to 7 months after surgery. Histopathological examination confirmed squamous cell metaplasia forming keratin pearls, characteristic of squamous cell carcinoma.

Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients With Ankle Fractures.

To assess which skin suture pattern-simple, vertical mattress, horizontal mattress, Allgöwer-Donati (AD), or running subcuticular-enables the greatest degree of perfusion as measured by indocyanine green laser angiography after ankle fracture surgery. Prospective, randomized. Level 1 Academic Trauma Center. Seventy-five patients undergoing ankle fracture surgery were prospectively randomized to 1 of 5 skin suture patterns (n = 15 per cohort). Patient demographics and operative parameters were similar between groups. Skin perfusion was assessed intraoperatively after skin closure using indocyanine green laser angiography and quantified in fluorescence units. Two perfusion values were collected: (1) mean incision perfusion was the mean of 10 points along the incision and (2) mean perfusion impairment was the perfusion difference between the incision and the skin adjacent to it. We also collected a postoperative patient scar assessment score. Running subcuticular closure had significantly better mean incision perfusion than all other closure patterns. Mean perfusion impairment also favored running subcuticular closure, which was significantly lower than all other suture patterns except AD. We found no patient perceived cosmetic differences between the 5 suture pattern types. Running subcuticular suture pattern resulted in the greatest incision perfusion than simple, horizontal mattress, vertical mattress, and AD techniques after ankle fracture fixation. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Low-Profile Knotless Repair of SLAP Tears With Suture Tape

SLAP tears have been a controversial topic in shoulder surgery for decades. The indications for repair of SLAP tears, as well as the methods of repair, have undergone a recent evolution. The use of intra-articular knots for SLAP repair has fallen out of favor because of potential abrasive damage to the rotator cuff and glenohumeral articular cartilage due to knot migration and prominence. In response to this potential iatrogenic injury, arthroscopic techniques have undergone an evolution using advanced techniques with low-profile knotless repairs. We describe our preferred low-profile knotless technique for SLAP repair using LabralTape (Arthrex) in a horizontal mattress configuration.

Arthroscopic Bankart repair: A matched cohort comparison of the modified Mason Allen method and the simple stitch method

IntroductionArthroscopic Bankart repair (ABR) has become a standard treatment for recurrent anterior shoulder dislocation in cases with minimal bone loss. Using the standard Bankart repair technique, the failure rate has been reported to be approximately between 4 and 35%. In addition to the original injury, multiple pathologies can occur after a dislocation including a Bankart lesion, capsular redundancy and bone defects. In cases with no significant bone loss, soft tissue plays a major role in stabilizing the shoulder joint. We hypothesized that effective repair of soft tissue with good inferior capsular shifting and proper capsulolabral restoration can create a proper level of soft tissue tension so the horizontal mattress suture method should improve outcomes. Materials and methodsA retrospective cohort study was conducted by reviewing the records of patients with recurrent anterior instability who underwent ABR at a single institution between January 2009 and December 2017. Demographic information, preoperative radiographic data including glenoid bone loss, Hill-Sachs width, glenoid track and other surgical details were retrieved from the medical records. The patients identified were divided into 2 groups. Group 1 had one modified Mason Allen stitch plus simple stitches, while Group 2 had only simple stitches. Data obtained from the patient included failure rate, patient satisfaction, the ROWE score and Walch-Duplay score at a minimum of 2 years after surgery. Risk factors for failure were also identified. ResultsGroup 1 included 50 patients (mean age 27.2 ± 9.4 years) who underwent modified Mason Allen stitch ABR (median follow-up, 59.2 months; range, 26.2–128.6 months). Group 2 included 30 patients (mean age 26.9 ± 8.5 years) who underwent simple stitch repair ABR (median follow-up, 68.0 months; range, 24.0–127.9 months). All patients met the inclusion criteria. Evaluation at the final follow-up compared Group 1 and Group 2: ROWE score (86.8 vs 76.3, P = 0.001), Walch-Duplay score (87.2 vs 82.0, P = 0.035), respectively. Failure rates were 6% in group 1 compared to 10% in group 2 (P = 0.511). ConclusionsThe modified Mason Allen stitch technique and the simple stitches technique ABR both result in excellent patient satisfaction at a minimum 2-year follow-up. Both techniques successfully restore shoulder stability, but the modified Mason Allen stitch technique results in better functional outcomes. Study designCohort study; level of evidence, 3.

Differences in Failure Mode Between Simple and Mattress Suture Configuration in Arthroscopic Bankart Repairs: A Cadaveric Study.

Background:Traumatic anterior shoulder dislocations disrupt the anteroinferior labrum (Bankart lesion), leading to high rates of instability and functional disability, necessitating stabilization.Purpose:To investigate modes and locations of repair failure between simple and horizontal mattress suture configurations after arthroscopic Bankart repair using suture anchors in a cadaveric model.Study Design:Controlled laboratory study.Methods:A total of 48 fresh-frozen human cadaveric shoulders from 48 specimens underwent creation of Bankart lesions from either the 3:00 to 6:00 o’clock position on the right glenoid or the 6:00 to 9:00 o’clock position on the left glenoid. Shoulder laterality between specimens was alternated and randomized to either simple or mattress suture repair configurations. In each shoulder, anchors were placed on the glenoid at the 3:00, 4:30, and 6:00 o’clock positions on the right or 6:00, 7:30, and 9:00 o’clock positions on the left and were secured via standard arthroscopic knot-tying techniques. Specimens were tested in the supine anterior apprehension position using a servohydraulic testing machine that was loaded to failure, simulating a traumatic anterior dislocation. After dislocation, open inspection of specimens was performed, and failure mode and location were documented. Differences in failure mode and location were compared using nominal multivariate generalized estimating equations.Results:Simple suture repairs most frequently failed at the labrum, while mattress suture repair failed at the capsule. Regardless of configuration, repairs failed most commonly at the 3:00 o’clock position on the right shoulder and 9:00 o’clock position on the left shoulder. Compared with mattress suture repairs, simple suture repairs failed at a significantly higher rate at the 6:00 o’clock position.Conclusion:Traumatic anterior shoulder dislocation after arthroscopic Bankart repair in a cadaveric model resulted in simple suture configuration repairs failing most commonly via labral tearing compared with capsular tearing in mattress repairs. Both repair configurations failed predominately at the anterior anchor position, with simple suture repairs failing more commonly at the inferior anchor position.Clinical Relevance:Horizontal mattress suture configurations create a larger area of repair, decreasing the risk of repair failure at the labrum. The extra time required for mattress suture placement at the inferior anchor position is used effectively, resulting in lower biomechanical failure rates.

Subbrow Lift Using Frontalis Sling to Correct Lateral Orbital Laxity

BackgroundIn order to correct upper lid laxity, upper blepharoplasty, subbrow excision, and forehead lift have been utilized. Our newly developed subbrow excision attaches the orbicularis oculi muscle to the frontalis muscle. This improves the longevity of the result without inhibiting the gliding plane of the periorbita.MethodFrom January 2016 to July 2018, 564 patients were operated on using this technique. Among them, 41 were male and 523 were female with the average age of 59.5 years. The average size of the subbrow excision was 55 mm × 8 mm. From the upper skin incision site, the upper dissection proceeded cephalad in the subcutaneous plane just above the orbicularis oculi muscle to the point where the frontalis muscle was seen. The lower flap was created by incising the orbicularis oculi muscle 5 mm cephalad to the distal skin incision. From this 5-mm orbicularis muscle stump, the dissection proceeded caudally in a plane between the orbicularis muscle and the orbital septum. Once this flap was created, the 5-mm muscle stump was attached to the exposed frontalis muscle in a horizontal mattress fashion in three areas. The skin incision was then closed. Three months after the operation, a satisfaction survey was conducted using the Likert scale.ResultsThe patients were followed postoperatively for at least 6 months. In all but two cases, the orbital laxity improved. However, in the brow’s lateral third where the frontalis muscle does not exist, a slight lowering of the brow had occurred. The incision healed well without any keloid or hypertrophic scars. There were no significant complications such as superior orbital nerve entrapment-related sensory problems.ConclusionsSubbrow lift utilizing the frontalis muscle attachment to the lower flap orbicularis muscle is a novel method of correcting upper eyelid skin hooding. The technique does not rely on periosteal fixation. Therefore, the eyebrow gliding plane is not violated. Thus, the natural eyebrow movement is maintained. There were no cases of injury to the deep branch of the supraorbital nerve, poor wound healing, or other significant complications.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Effects of type II SLAP lesion repair techniques on the vascular supply of the long head of the biceps tendon: a cadaveric injection study

One option for the treatment of type 2 superior labral anterior to posterior (SLAP) lesions is arthroscopic repair. However, the fact that the vascular supply of the proximal long head of the biceps tendon (LHBT) arises from the soft tissue near the SLAP repair site must also be considered. The aims of this study were to evaluate the vascular channel of the proximal long head biceps tendon and to compare potential damage to the vascular supply with alternative SLAP techniques. Forty-five fresh cadaveric shoulders were divided into 3 groups: 9 shoulders each for the normal group and the created SLAP group, and 27 shoulders for the repaired SLAP group. SLAP group shoulders were repaired using one of 3 techniques: 2 anchors with simple sutures, 1 anchor with double sutures, or 1 anchor with a horizontal mattress suture. India ink was then injected into the acromial branch of the thoracoacromial artery. The proximal LHBT was resected for a histologiccross-sectional study. The intratendinous vascular distance was measured and compared among the groups. The vascular supply of the proximal LHBT arises from soft tissue lying anterior and dorsal to the tendon origin. In the normal shoulders, the average intratendinous vascular distance was 16.9 ± 1.5 mm(95% confidence interval: 15.8-18.1). A comparison of nonrepaired SLAPs with each of the repair techniques found that using 2 anchors with simple sutures showed no significant difference in vascular distance (P = .716), whereas the other techniques showed a significant disruption of the blood supply. The differences in vascular distance among the 3 repair techniques were statistically significant (P = .0001). The main vascular supply of the proximal LHBT comes from the anterior-dorsal direction. Some SLAP repair techniques can disrupt vascularization; however, the technique using 2 anchors with simple sutures, 1 anchor 3 mm anterior to the anterior border and 1 at the posterior border of the tendon, can preserve the vascularization of the LHBT.

Techniques for successful vaginal anastomosis in the uterine transplantation patient

To demonstrate techniques for successful donor-to-recipient vaginal anastomosis in uterine transplantation including illustration of a tension-free technique. This video uses live-action footage from surgery, detailed animations, and illustrations to review the step-by-step technique we use for vaginal anastomosis in uterine transplantation. Institutional Review Board approval was obtained for this experimental surgery. Academic medical center. Patients undergoing uterine transplantation. Preparation of recipient vagina with illustration of challenges and risk secondary to dense adhesions between bladder and neo-vagina. Use of surgical techniques. Key steps include appropriate preparation of both donor and recipient vaginal tissues and a tension-free closure with horizontal mattress stitches. Intraoperative techniques in the clinical research trial of uterine transplantation. Successful vaginal anastomosis in the uterine transplantation patient. This video provides a step-by-step guide to vaginal anastomosis in uterine transplantation patients. Our team has applied techniques from vaginal reconstructive surgery in an attempt to reduce the occurrence of postoperative vaginal strictures, with attention to planned donor and recipient anastomosis site tissue preparation and closure of the anastomosis using a tension-free suturing technique.

Rebar Repair of Radial Meniscus Tears: A Reinforced Suture Technique

The purpose of this paper is to describe the rebar repair as a technique for repair of radial meniscus tears and compare the rebar technique with current techniques used for meniscus repairs. This technique consists of 4 sutures placed with the inside-out technique. First, the vertical mattress reinforcement sutures are placed anteriorly and posteriorly to the tear. Then, 2 parallel horizontal sutures are placed directly in juxtaposition to the vertical sutures, ensuring the needles pass on the side of the reinforcing stitch away from the tear. This technique is less technically challenging than other meniscus repair techniques that require drilling of a transtibial tunnel. Overall, the rebar technique offers a more optimal way for stabilizing the meniscus by using 2 reinforcement sutures that run with the circumferential fibers to help restore the natural hoop stress of the meniscus. Also, the placement of the vertical mattress sutures in the rebar technique offers more direct reinforcement to the horizontal mattress sutures as compared with other techniques, which reduces the risk of pull-out tears.

Measuring Forces in Suture Techniques for Wound Closure

BackgroundThe use of sutures remains the first choice for wound closure. However, incorrect use of a suture technique can lead to impaired healing. Many techniques are described for high-tension wounds, but not much is known about their mechanical properties. Complications of excessive tension include dehiscence, infection, and ischemic necrosis and could be prevented. This study aimed to compare forces in five techniques (single, horizontal mattress, vertical mattress, pulley, and modified pulley suture) in a standardized wound tension model. Materials and methodsA standardized neoprene wound model was developed on the ForceTRAP system (MediShield B.V., Delft, The Netherlands) to mimic a 5 Newton (N) wound. Five different suture techniques were each repeated 10 times by a student, resident dermatology, and dermsurgeon. The pulling force of the suture's first throw was measured with the Hook-in-Force sensor (Technical University Delft, The Netherlands). Changes in wound tension were measured by the ForceTRAP system. The ForceTRAP is a platform measuring forces from 0 to 20 N in three dimensions with an accuracy of 0.1 N. The Hook-in-Force is a force sensor measuring 0-15 N with an accuracy of 0.5 N. Maximum and mean forces were calculated for each suture technique and operator. ResultsMean maximum pulling force: 5.69 N (standard deviation [SD], 0.88) single, 7.25 N (SD, 1.33) vertical mattress, 8.11 N (SD, 1.00) horizontal mattress, 3.46 N (SD, 0.61) pulley, and 4.52 N (SD, 0.67) modified pulley suture. The mean force increase on the skin (substitute) ranged between 0.80 N (pulley) and 0.96 N (vertical mattress). ConclusionsThe pulley suture requires less pulling force compared with other techniques. The mechanical properties of sutures should be taken in consideration when choosing a technique to close wounds.

Treatment of Entropion – A modified Technique

Purpose: To study the results of a modified technique of Entropion correction at a Tertiary care hospital.Study Design: Quasi experimental study.Place and Duration of Study: Layton Rahmatullah Benevolent Trust (LRBT), a tertiary care teaching Eyehospital, Korangi, Karachi, for a duration of six months, from January 2018 to June 2018.Material and Methods: Patients with senile entropion were included in the study. Patients with recurrententropion, cicatricial entropion, chronic/acute ocular and adnexal infection were excluded. Three equally spaceddouble-armed 6–0 vicryl horizontal mattress sutures were used to close the skin and orbicularis muscle of thewound with a bite of the retractors in the center and a 5 mm silicone tube bolster place in the superior loop. Postoperativetreatment of antibiotics, anti-inflammatory drugs and topical lubricant eye gel were given. Patients wereexamined on 11stpost operative day and then weekly interval for up to one month and thereafter every month forup to six months.Results: There were 40 eyes of 30 patients with ages ranging from 50 to 65 years. Twenty (66%) patients hadunilateral repair and 10 (33%) had bilateral repair done. No recurrence was seen in 39 (97.5%) eyes at the endsix months after surgery. Out of the 40 patients, only 2 (5%) patients complained of heaviness which went awayeventually with the disintegration of the external tamponade.Conclusion: This modified technique of entropion repair using skin excision with retractor plication in the woundhas a favorable outcome with minimum recurrences and complications.

Technical Refinements of Vulvar Reconstruction in Gender-Affirming Surgery

Penile inversion vaginoplasty involves creation of vulva and a vaginal canal. Few studies describe techniques for creating aesthetic vulvar components, particularly the clitoral hood and labia minora. The authors present their approach to primary vulvoplasty, aiming to achieve the following: (1) labia minora that are well-defined and three-dimensional; (2) labia minora that frame the introitus; (3) sufficient clitoral hooding; (4) a patent introitus that appears closed at rest; and (5) prominent labia majora. In this technique, the labia majora are created by first pulling the superolateral scrotal skin inferiorly and medially toward the perineum. The labia majora incisions may be made laterally, medially, or both laterally and medially, dependent on the amount of penile and scrotal skin available. Initial approximating sutures are placed to anchor the labia inferiorly, and then excess skin is removed medially. The surgeon should avoid excess defatting of the labia majora, which are subject to initial edema and often atrophy with time. The preputial or distal penile shaft skin is used for the clitoral hood and medial aspect of the labia minora, with proximal penile shaft skin used for the lateral surface. The penile skin used for the lateral aspect of the labia minora must be pulled inferomedially toward the perineum, to create a narrow, tapered appearance and avoid effacement of the labia minora. Interrupted horizontal mattress quilting sutures are used to define the labia minora as distinct subunits. By considering homologous structures and anatomical subunits, we are able to create well-defined, aesthetic vulva in trans women and nonbinary individuals.

Thoracoscopic plication of the membranous portion of crescent-type tracheobronchomalacia in an elderly patient: a case report

BackgroundIt is presumed that tracheobronchomalacia in adults is caused by airway pressure-induced injury due to chronic cough related to pulmonary emphysema or chronic bronchitis. Commonly, a posterolateral approach using stabilizing materials is the surgical technique of choice for treating tracheobronchomalacia. We report a case in which thoracoscopic plication of the membranous portion was performed instead of airway stent placement for tracheobronchomalacia in an elderly individual.Case presentationAn 87-year-old man who had been treated for bronchial asthma, pulmonary emphysema, and tracheobronchomalacia was admitted to our hospital with acute exacerbation of dyspnea. The patient underwent tracheal intubation, which was followed by tracheostomy 16 days later. Insertion of the tip of the adjustable-length tracheostomy tube to the end of the stenotic lesion enabled him to breathe spontaneously. However, conservative management failed due to recurrent pneumonia caused by the tracheobronchomalacia. Crescent-type tracheobronchomalacia (Johnson’s classification grade III) was diagnosed, and the main narrowed area of the trachea was assumed to be approximately 3–10 cm from the tracheal bifurcation. A thoracoscopic approach was selected because a posterolateral approach was considered too invasive considering the patient’s age and general condition. We placed eight stitches on the tracheal membranous portion and four stitches on the membranous portion of the right main bronchus, using the horizontal mattress suture technique. The use of foreign materials was avoided because meropenem-resistant Pseudomonas aeruginosa was cultured in a tracheal specimen. Immediately after the operation, the expiratory airway stenosis improved, and subsequently, spontaneous ventilation was possible using a normal type of tracheostomy tube instead of an adjustable-length tracheostomy tube.ConclusionsTracheobronchomalacia is not a rare condition in patients with chronic obstructive pulmonary disease. The thoracoscopic approach is less invasive than the posterolateral approach and is suitable in cases that are otherwise refractory to medical treatment. We believe that thoracoscopy may be a useful treatment option in cases where conservative treatment is not appropriate.

Influence of Interlocking Horizontal Mattress Epitendinous Suture Placement on Tendinous Biomechanical Properties in a Canine Common Calcaneal Laceration Model.

This article evaluates the effect of an interlocking horizontal mattress epitendinous suture (IHMES) in addition to a three-loop pulley (3LP) core suture for canine tendon repair. Twenty-eight cadaveric common calcaneal tendons were randomized, sharply transected and repaired with either a 3LP or 3LP + IHMES. Tensile loads required to create a 1- and 3-mm gap, yield, peak and failure loads, and mode of failure were analysed. Significance was set at p < 0.05. Mean ± standard deviation yield and failure force for 3LP + IHMES was 178.0 ± 45.3 N and 242.1 ± 47.8 N, respectively, which was significantly greater compared with 3LP alone, 97.9 ± 36.2 N and 119.3 ± 35.6 N (p < 0.0001). Occurrence of 3-mm gap formation was significantly less in the 3LP + IHMES group (p < 0.013). Mode of failure was significantly different between the groups (p < 0.001) with 3LP + IMHES patterns failing by suture breakage (13/14) compared with suture pull-through in the 3LP (11/14). Addition of an epitendinous suture pattern significantly reduced gap formation between tendon ends and significantly increased loads at yield (1.8 × ), peak (2.0 × ) and failure (2.0 × ) force of repairs. Use of an epitendinous suture should be considered to significantly increase biomechanical strength of repairs; however, further in vivo testing is necessary to evaluate its effect on tendinous blood supply.