Inadequate Surgical Technique Research Articles

Sistrunk technique as a surgical approach in thyroglossal duct cyst of His or Bockdalek

Thyroglossal duct cyst is one of the most common lesions in the midline of the neck and is found in around 7% of the population. It occurs equally in both genders and is detected in the first five years in 25 to 35%, between six to 10 years in 40 to 50% and in adolescence between 75 and 90% of cases and in some cases it preserves tissue. functional thyroid and in 0.17 to 1% it is the absolute ectopic thyroid. The diagnosis is fundamentally clinical, although an ultrasound may be useful. A thyroid scintigraphy is recommended not for a positive diagnosis of a thyroglossal duct cyst, but to demonstrate the existence of a normal thyroid gland and rule out the rare thyroid ectopias, whose inadvertent removal would cause permanent hypothyroidism. Diagnostic errors are the most frequent cause of inadequate surgical technique, which produces a high recurrence rate. Since its introduction in 1920, sistrunk surgery is the ideal treatment with the best results, with recurrence limits of 0.5 to 3%, this technique considerably reduces the risk of cyst recurrence to <3%, and one of the key points for the success of the surgery is the need to resect the medial third of the hyoid bone by approximately 1.5 cm. We present the case of a female patient who underwent resection of a thyroglossal cyst with the sistrunk technique to confirm the effectiveness of the technique in reducing the percentage of recurrences.

Use of Octopus™ Tissue Stabilizer for Minimal Manipulation Approach of Bronchial Anastomosis in Lung Transplant.

Bronchial anastomotic complications are a cause of grave concern for surgeons that perform lung transplantations. There are several risk factors that may lead to this complication, being inadequate surgical technique one of them, specifically regarding adequate exposure and manipulation of the bronchial stump and anastomosis. Here we report the use of Octopus™ Tissue Stabilizer as a mean to allow for a better exposure of the stump and facilitate a "no-touch" approach towards anastomosis. Systematic application of devices that facilitate the employment of the correct surgical techniques can have an effect in reducing the incidence of bronchial anastomotic complications.

217.8: How to Do It: Use of Octopus Tissue Stabilizer for Minimal Manipulation Approach of the Bronchial Anastomosis in Lung Transplant

Introduction: Bronchial anastomotic complications (BAC) are a cause of grave concern for surgeons that perform lung transplantation. There are several risk factors that may lead to this complication, being inadequate surgical technique one of them, specifically regarding the adequate exposure and manipulation of the bronchial stump and anastomosis. Method: We report the use of the Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) as a mean of allowing for a better exposure of the stump and facilitate a “no touch” approach towards the anastomosis. Results: The Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) is a validated device for cardiac surgery as a tissue stabilizer for off-pump coronary artery bypass. It utilizes vacuum at the extremity of its “U” shaped claw to soothe the beating of the heart on a designated spot and assist the cardiac surgeon. Our idea was to employ the distal claw of such device to stabilize the bronchial stump and perform the bronchial anastomosis with a “no touch” technique. As we did not have a need to smooth the beating of the heart, the suction mechanism was kept turned off (FIGURE 1). It is important to report that in this case, as in others, several other techniques were applied to reduce BAC (the use of end-to-end anastomosis and pericardial flap), therefore it is impossible to affirm that the application of the Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) is responsible for the favorable outcome of this patient. Conclusion: We believe that the systematic application of devices that facilitate the employment of the correct surgical techniques can have an effect in reducing the incidence of BAC, while providing no additional risk to the patient.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients.

Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

Arterio-biliary fistula caused by a hepatic artery pseudoaneurysm in a recently performed liver transplant: successful resolution and long-term liver implant preservation using a covered coronary stent

BackgroundThe formation of a hepatic artery pseudoaneurysm in a liver implant is a rare but potentially fatal complication. Fistulization of such pseudoaneurysms into the bile duct is sporadic. The most common causes of hepatic artery pseudoaneurysm are infection at the anastomosis site, inadequate surgical technique, and an iatrogenic origin due to minimally invasive procedures. Currently, there is no standardized treatment in neither of these complications, with surgery and various endovascular procedures among the alternatives available. None of these therapeutic approaches has demonstrated a significant increase in long-term liver implant preservation.Case presentationA 56-year-old man with a two-month liver transplant presented with massive upper gastrointestinal bleeding and hemobilia shortly after the performance of an endoscopic retrograde cholangiopancreatography due to the presence of a hepatic artery pseudoaneurysm with fistulization into the bile duct. This case report describes the successful treatment of both complications, the hepatic artery pseudoaneurysm and the arterio-biliary fistula, using a covered coronary stent placed in the hepatic artery. A year and a half after treatment, the patient maintains a preserved liver implant and a patent hepatic artery.ConclusionsTreatment of a hepatic artery pseudoaneurysm with fistulization into bile duct using a covered coronary stent allowed the correct repair of the defect, adequate hemorrhage control, and long-term liver implant preservation.

Bone sequestration after dental implant surgery

Background. Dental implants are used to rehabilitate missing teeth, and despite high success rates, failures are inevitable. Ostensibly avoidable human errors in planning or technique can contribute to implant failure. Case presentation. Herein, we report a case of an unsuccessful dental implant surgery due to an inadequate surgical technique and bone exposure in a 54-year-old healthy woman. Conclusions. This report underscores the relevance of reporting the consequences of these human factors, such as loss of the implant, alveolar bone segment, and three teeth.

IBS10.01 Surgerical Treatment of Tracheal Tumours

IBS10.01 Surgerical Treatment of Tracheal Tumours

Evaluation and Treatment of Nasal Obstruction Developed after Rhinoplasty

Nasal airway obstruction is one of the most frequent causes of revision rhinoplasty despite the golden rule that nasal function should not be sacrificed because of cosmetic reason. Nasal function is jeopardized due to diverse reasons including inaccurate diagnosis or inadequate surgical technique. Detailed and thorough evaluation of the nose with review of previous operative technique is necessary to find out exact causes of obstruction. Septum, middle vault, tip, nostril, and nasal mucosa are common anatomic areas of obstruction after rhinoplasty. They are often weakened, damaged, or even destroyed losing their original shape, strength, or position. Changes in these anatomic structures are strongly related to static and/or dynamic obstruction. In this article, authors reviewed the common locations, anatomic causes, and treatment strategies of nasal obstruction after rhinoplasty. Key words: Deformed nose ㆍ Nasal obstruction ㆍ Revision rhinoplasty ㆍ Revision septorhinoplasty

Compensation after treatment for anterior cruciate ligament injuries: a review of compensation claims in Norway from 2005 to 2015

PurposeTo assess the most common reasons for complaints following anterior cruciate ligament (ACL) injuries reported to the Norwegian System of Patient Injury Compensation (NPE), and to view these complaints in light of the ACL reconstructions (ACL-Rs) reported to the Norwegian Knee Ligament Registry (NKLR).MethodData from the NPE and the NKLR were collected for the study period (2005–2015). The age and gender and type of complaint and reason for granted compensation were collected from the NPE, while the graft choice and total number of ACL-R were collected from the NKLR. Risk for successful grant was estimated for graft type.Results18,810 primary ACL-Rs were reported to the NKLR during the study period. A hamstring graft was used in 12,437 (66.1%) but the bone-patellar tendon-bone (BPTB) became the graft of choice at the end of the study period. 240 patients filed a complaint to the NPE, of which 101 were granted compensation. The odds ratio for a claim being granted following a hamstring graft was 2.9 compared to that of a BPTB graft (p = 0.002) The most common reason for compensation was a hospital-acquired infection in 39 patients (38.6%) followed by inadequate surgical technique (27, 26.7%) and delayed diagnosis (13, 12.9%). Of the 39 patients with infection, 27 had received a hamstring graft and six a BPTB graft (two patients were not reconstructed, data missing for three patients). Of the 27 patients who were granted compensation due to inadequate surgical technique, 24 had received a hamstring graft and three a BPTB graft.ConclusionInfection and inadequate surgical technique are the most common causes for granted compensation from the NPE following ACL injury. Hamstring grafts have a threefold risk of complication that yields compensation from the NPE compared to BPTB grafts. This information is relevant for patients and surgeons when choosing graft type. The trend of increased use of BPTB grafts is warranted based on the results from this study.Level of evidenceLevel III.

Pain and adverse behavior in declawed cats.

Objectives The aim of this study was to assess the impact of onychectomy (declawing) upon subsequent development of back pain and unwanted behavior in cohorts of treated and control cats housed in two different locations. Methods This was a retrospective cohort study. In total, there was 137 declawed and 137 non-declawed cats, of which 176 were owned cats (88 declawed, 88 non-declawed) and 98 were shelter cats (49 declawed and 49 non-declawed). All cats were physically examined for signs of pain and barbering. The previous 2 years of medical history were reviewed for documented unwanted behavior such as inappropriate elimination and biting with minimal provocation and aggression. All declawed cats were radiographed for distal limb abnormalities, including P3 (third phalanx) bone fragments. The associations of declaw surgery with the outcomes of interest were examined using χ2 analysis, two sample t-tests and manual, backwards, stepwise logistic regression. Results Significant increases in the odds of back pain (odds ratio [OR] 2.9), periuria/perichezia (OR 7.2), biting (OR 4.5) and barbering (OR 3.06) occurred in declawed compared with control cats. Of the 137 declawed cats, 86 (63%) showed radiographic evidence of residual P3 fragments. The odds of back pain (OR 2.66), periuria/perichezia (OR 2.52) and aggression (OR 8.9) were significantly increased in declawed cats with retained P3 fragments compared with those declawed cats without. Optimal surgical technique, with removal of P3 in its entirety, was associated with fewer adverse outcomes and lower odds of these outcomes, but operated animals remained at increased odds of biting (OR 3.0) and undesirable habits of elimination (OR 4.0) compared with non-surgical controls. Conclusions and relevance Declawing cats increases the risk of unwanted behaviors and may increase risk for developing back pain. Evidence of inadequate surgical technique was common in the study population. Among declawed cats, retained P3 fragments further increased the risk of developing back pain and adverse behaviors. The use of optimal surgical technique does not eliminate the risk of adverse behavior subsequent to onychectomy.

Salvage of Lesser Toes Deformities: “Revision Forefoot”

Deformity of the digits and lesser metatarsals is a common surgical problem presenting to the foot and ankle surgeon. Although elective operative management is usually straightforward, even the most routine cases carry the risk of surgical complication, spanning from the simple to the devastating. Most often, it is difficult to determine the exact cause of failure in surgical treatment of lesser toe deformities. Some possibilities are: inadequate surgical procedure; choosing inadequate surgical technique; complications related to the surgical procedure; underestimation of the inherent risks and unrealistic expectations. This paper describes the authors’ approach to failed lesser toes surgical treatment. It presents a particular view of the problems resulting from lesser toes surgery, and an emphasis on revision operative procedures. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Complications associated with operative fixation of acute midshaft clavicle fractures

IntroductionThe aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated in a level I trauma centre. Patients and methodsWe identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients) and included 107 men (78%) and 31 women (22%); the median age of 35 years (interquartile range (IQR) 24–45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n=83) had an injury severity score of ≥15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1–6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 men and 25 women in the plate fixation group with median age of 35 years (IQR 25–45) There were 22 men and six women in the intramedullary fixation group with median age of 31 years (IQR 24–42 years). Statistical analysis was performed using independent sample t test, Mann Whitney test, and Chi square test. Significant P-value was <0.05. ResultsThe overall incidence of complication was 14.5% (n=20). The overall nonunion rate was 6%. Postoperative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (nine of 28 cases; P=0.003). Thirty-five percent of complications were related to inadequate surgical technique and were potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n=31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P=0.03). ConclusionsIntramedullary fixation of midshaft clavicle fracture is associated with a higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.

Estudo da qualidade de pinos de titânio para implantes odontológicos utilizando a fluorescência de raios x por dispersão de energia

The use of biomaterials is very common for dental implant surgery in arder to recover the a esthetics and function of the affected area. For the success of the implant using a biomaterial, it must have good resistance to wear and corrosion in the body environment and does not present toxicity. ln the human body the bone degeneration, as well as the wear or corrosion ofthe implants, often leads to clinicai complications. The aim of this study is to use the Energy Dispersive X-ray Fluorescence (ED-XRF) technique to analyse the purity of the titanium pins used in dental implants that did not undergo osseointegration, establishing a relationship between the composition of the impurities found in implants and adverse biological response. This system consists of an X-ray tube of Moxtek brand and a semiconductor detector SR-lOOCR of Amptek brand. The results of the analyzes of the pins, from various manufacturers, collected in different courses and dental clinics, showed that the pins have high purity Ti (99%) and the elements considered as impurities (Ca, Cr, Fe, Ni and W) were evidenced in trace levei ( &lt;1%) and the major technological developments in nationalcompanies in the manufacture of pins allows the production of high quality and purity pins. The resultsa l s o&nbsp; s u p p o r t e d&nbsp; t h e&nbsp; c o n c l u s i o n&nbsp; t h a t&nbsp; n o osseointegration of the implants, cannot be attributed to impurity of titanium pins, but other factors, such as:inadequate hygiene of the surgical site, overloading, infection around the implant, instability at installation time, inadequate surgical technique.&nbsp

Stenosis and ulceration after bariatric surgery

The increasing number of morbidly obese patients leads to a rising number of bariatric procedures in Germany. The operative techniques are highly standardized but such a standardization is lacking for the management of postoperative complications such as stenosis and ulceration after Roux-en-Y gastric bypass (RYGB) surgery and sleeve gastrectomy (SG). The current literature is reviewed and a complication management is developed and presented in this article. Postoperative stenoses occure with a frequency of 0.1-3.9% after SG and 3-27% after RYGB. Stenosis is secondary to inadequate surgical technique or microinsufficiency. Ulcers can be due to reaction to foreign body, local ischemia, peptic lesion, fistula and microinsufficiency. Endoscopic interventions are successful in most cases for stenosis after RYGB and for short stenoses after SG. After SG long stenoses require redo surgery and conversion to RYGB. Ulcers can be managed by medication with the exception of perforation and hemorrhage, which require emergency laparoscopy.

Reoperative Retroperitoneal Lymph Node Dissection for Metastatic Germ Cell Tumors: Analysis of Local Recurrence and Predictors of Survival

While reoperative retroperitoneal lymph node dissection results in durable long-term survival, outcomes are comparatively worse than in patients who undergo initial adequate resection. We identified predictors of cancer specific survival and correlated technical aspects of initial resection to local recurrence in patients treated with repeat retroperitoneal lymph node dissection. We reviewed subsequent data on 203 patients treated with reoperation for recurrent retroperitoneal germ cell tumor after initial retroperitoneal lymph node dissection with local relapse. We used multivariate Cox proportion hazard models for cancer specific survival and multivariate logistic regression for local recurrence. The only 2 factors associated with local recurrence at lymph node dissection were incomplete lumbar vessel division at initial resection (p<0.01) and teratoma histology in the reoperative pathology specimen (p=0.01). Median followup was 73 months. Initial survival analysis including preoperative variables indicated that active cancer at initial operation (p=0.04), increased serum tumor markers (p=0.02), M1b stage (p<0.01) and salvage chemotherapy (p=0.01) were independent predictors of worse cancer specific survival. After introducing the final pathological data from reoperation into the final multivariate model only active cancer at reoperation (p<0.01), M1b stage (p=0.01) and salvage chemotherapy before reoperation (p=0.02) retained the association with worse oncologic outcomes. Tumor biology and inadequate surgical technique (incomplete lumbar ligation) are associated with local recurrence after initial retroperitoneal lymph node dissection. Decreased cancer specific survival is expected in this population, mostly driven by active cancer in the final pathology specimen.

Identificação de fatores de risco pré-operatórios para disfagia pós-operatória persistente após cirurgia laparoscópica para doença do refluxo gastroesofágico

Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result. This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery. Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia. A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry. Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Iatrogenic giant cell tumor at bone graft harvesting site

30 year old female patient with giant cell tumor of the distal tibia initially treated at a peripheral nononcological center by curettage and autologous bone grafting from the ipsilateral iliac crest reported to us with local recurrence and an implantation giant cell tumor at the graft harvesting site which required extensive surgeries at both sites. The risk of iatrogenic direct implantation of tumor, often attributable to inadequate surgical planning or poor surgical techniques, and the steps to prevent such complication is reported here.

Risk factors for postoperative complications of displaced clavicular midshaft fractures

This study evaluated the risk factors of the complications following operative treatment of an acute displaced clavicular midshaft fracture using a reconstruction plate. One hundred twenty-five patients with an acute displaced clavicular midshaft fracture underwent open reduction and plate fixation using a reconstruction plate. Cerclage wires or interfragmentary screws were used for additional comminuted fragment fixation. Clinical outcomes and radiologic evaluation were assessed. Risk factors for postoperative complications requiring reoperation were analyzed by univariate analysis. Bony union was achieved in 110 patients without any complications within 10.6 weeks postoperatively. Fifteen patients (12%) had a complication requiring reoperation. Implant-related complications occurred in 10 patients (plate breakage in 6 and plate loosening in 4). Deep infection and intractable adhesive capsulitis occurred in one and two patients, respectively. Refracture of the same clavicle after plate removal occurred in two patients. All patients with plate breakage demonstrated nonunion at the time of second operation. Unlike plate breakage, plate loosening was found to be associated with technical errors. Preoperative fracture pattern (p = 0.012) and usage of cerclage wires for additional fragment fixation were found to be significantly related to implant failure (p = 0.009). Open reduction and internal fixation using a reconstruction plate for acute displaced clavicular midshaft fractures demonstrated satisfactory clinical outcomes and favorable bony union rates. However, hardware-related complications because of fracture pattern, nonunion, and inadequate surgical techniques require detailed consideration. Furthermore, when additional fixation is needed for comminuted fracture fragments, interfragmentary screw fixation is recommended before cerclage wiring.

Wiederherstellung der sagittalen Balance bei der Versorgung thorakaler und lumbaler Wirbelkörperfrakturen

Posttraumatic kyphosis (PTK) is a possible consequence of a missed fracture, a wrong indication for conservative therapy or an inadequate surgical technique but PTK can also be a complication after adequate surgery. Avoidance of PTK is of importance because subsequent surgical therapy can be extensive. A thorough planning as well as surgical experience with anterior and posterior revision cases is necessary. The various types of osteotomy which allow correction of local as well as global deformities should also be mastered. Knowledge of the principles of sagittal balance and spinopelvic parameters are indispensable in the treatment of PTK. Our experience and results from the literature show that a good long-term outcome with limited complications can only be achieved when considering the biomechanical principles as well as restoration of sagittal balance.

Pleomorphic adenoma of palate

58-year old man presented with slow growingpainless lump in the centre of hard palate threemonths duration. He had tenderness, bleeding frommouth or nose, difficulty in swallowing or breathing.Examination revealed a non tender spherical lumpin the centre of inferior surface of the posterior hardpalate (Figure 1). Fine needle aspiration cytologyrevealed it to be pleomorphic adenoma. Uppergastro intestinal endoscopy was normal.Examination under anaesthesia showed no otherlesion. Wide local excision was performed.Histology was compatible with benign pleomorphicadenoma of palate.Pleomorphic adenoma contains elements of bothepithelial and mesenchymal origin (1). Rarely, it mayarise from the minor salivary glands localized in thehard palate and other parts of oral mucosa (2).These tumours usually do not recur after adequatesurgical excision. Most recurrences can beattributable to inadequate surgical techniques suchas simple enucleation leaving behind microscopicpseudopod-like extensions (2).This has not been reported in Sri Lanka previously.