Extension Of Incision Research Articles

Retroauricular Hairline Incision and V-Shaped Incision for Parotidectomy

Background and Objectives There have not been any studies that compared retroauricular hairline (RAH) and V-shaped incisions for parotidectomy. In this regard, we aimed to evaluate the results of RAH and V-shaped incisions.Subjects and Method Between 2016 and 2019, 81 patients who underwent parotidectomy using RAH (n=46) and V-shaped (n=35) incisions were included in this study. Patient characteristics, tumor profiles, surgical parameters, postoperative complications, and cosmetic results were assessed. Mann-Whitney U test and the chi-squared test were used to inspect differences in continuous and categorical variables between the groups, respectively.Results In the RAH and V-shaped groups, the patient age was 52.7 and 42.1 years, respectively (p=0.002), and the tumour size was 2.7 and 1.8 cm, respectively (p<0.001). All parotidectomies were successfully completed with no incision extension or major complications. There were no significant differences in surgical parameters and postoperative complications between the two groups. The subjective scar satisfaction scores assessed at 3 months postoperatively were 9.0 and 9.3 in the RAH and V-shaped groups, respectively (p=0.191). The scores of male patients were 8.9 and 9.5 in the RAH and V-shaped groups, respectively, (p=0.026), while those of the female patients were 9.2 and 9.2, respectively (p=0.906).Conclusion The RAH and V-shaped incisions yields comparable surgical and cosmetic outcomes, with high patient satisfaction. For male patients, the use of V-shaped incision, if indicated, would provide higher scar satisfaction than the use of RAH incision.

In Vitro User Assessment of a Novel Wound Protection and Specimen Extraction System for Laparoscopic Procedures Involving Morcellation

Introduction: The risk of unknowingly disseminating leiomyosarcoma by morcellation in women undergoing laparoscopic hysterectomy has massively impacted gynaecological practice. Here, we present the results of an in vitro assessment of a novel protection system developed to mitigate this hazard. Methods: The Tissue Containment System for Manual Morcellation (Guardenia™, Advanced Surgical Concepts, Wicklow, Ireland) is an evolved wound protection/specimen extraction guarded bag system compatible with any 12mm trocar. Device use was assessed by device-naïve gynaecological and general surgeon volunteers (providing expert and inexpert morcellation cohorts, respectively) on a bench model consisting of biological tissue in a custom-built moulded rig with camera control after the operators were instructed in its use. Results: Twenty surgeons (10 gynaecologists/10 general surgeons, median duration of practice experience: 8 years, median annual number of laparoscopic operative procedures: 150 and 80, respectively) completed the user assessment. All subjects understood and correctly performed each step; i.e., (i) placement of the bag through the trocar, (ii) specimen bagging, (iii) incision extension (range 25-60 mm) after tethering the bag through the port, (iv) insertion of the device guard through the mouth of the bag after trocar removal, and (v) sufficient tissue morcellation within the bag to enable complete specimen removal (mean specimen weight 390g, range 201-1800g). There was 100% bag integrity by water-leak testing following use, despite scalpel contact with the guard in 14/20 cases (70%). Conclusion: Among first-time clinical users, this novel device enabled complete containment of morcellation debris and removal of a laparoscopic specimen, which would support further submission for regulatory approval.

Revision of failed resection arthroplasty of the CMC-1 joint using acostochondral graft

To correct and prevent the proximalisation of the 1st ray by safe stabilisation using an autologous costochondral graft. Reduction of pain and maintaining good pinch and grip strength while preserving the important opposition of the thumb. Painful proximalisation of the 1st ray after failed trapeziectomy with contact between the base of the 1st metacarpal and the trapezoid or scaphoid. Painful conditions following trapeziectomy for other causes. Perioperative antibiotic prophylaxis is required. Extension of the previous incision and exposure of the sensitive radial branches and the radial artery. Longitudinal incision of the capsule and excision of the scar from the trapezium cavity. Dissection of the scar tissue directly around the metacarpal1 base. After longitudinal resection of the oblique trapezoid surface, insertion of asuture anchor into the scaphoid joint surface close to the trapezoid. Removal of an approximately 2 cm long piece of rib cartilage from the middle costal arch. Insertion of the costochondral graft into the trapezium space and fixation with the suture anchor. Stable capsule closure. Suction drain. Skin suture. Thumb-forearm splint. Postoperative immobilisation of the carpometacarpal (CMC)-1 joint for 4weeks in medium abduction position. In case of uneventful wound healing also with awell-fitting orthosis. Afterwards independent movement exercises and exercises in warm water. Hand therapy only in case of difficult mobilisation at the earliest 2months after surgery. From 2015-2018, 18patients underwent surgery using this technique. The follow-up was at least 2years after surgery. Of the 15patients available for follow-up, 93% were classified as good and improved according to the Conolly-Rath score.

Blunt incision vs. sharp incision of uterus in cesarean section in post-operative morbidity

Background: Several surgical procedures to minimise intraoperative blood loss in caesarean section births have been developed. One of these still disputed approaches is the extension of uterine incision using sharp or stubborn ways. Different surgeons have endorsed each strategy based on their personal experiences. The purpose of this research was to examine the effects of acute vs. blunt uterine expansion. Method: This is a randomised, controlled trial of 400 C-sector patients split into two groups at Benha University Hospitals and Benha Insurance Hospital. (Group 1); 200 of them have had blunt uterus incisions (Group 2); 200 of them have been sharply uterine incised; The results: average age in Group A was 28.91 (± 3.95 SD) with a range (23-35); 41% were nulliparous; 19% had parity; 19.5% had two parities; 6% had three parities; 7.0% had four; 7.5% had five; and average BMI was 29,72 (± 2,86 SD). As regards unintentional extensions <2cm, there was substantial difference between the two groups. There was no significant difference in postoperative discomfort between both groups. The risk of intraoperative or postpartial haemorrhage did not change. Sharp uterine expansion technique may be healed quicker than the blunt uterine expansion technique and with a sharp uterine expansion technique, the demand for blood transfusion is lower. Conclusion: Based on this finding, future investigations with bigger patients and a longer follow-up time are required in order to highlight this conclusion.

Curative claw trimming for mechanical relief of sole ulcers - an ex-vivo study

Overloading or excessive mechanical stress to the claws may damage the sensitive claw tissues and subsequently lead to sole ulcers. Corrective treatment can prevent complications of these sole ulcers. The aim of this study was to investigate the effects of a wedge-shaped relief incision from the bulb to the tip of the outer claw of the pelvic limb on the pressure distribution beneath the pertaining claw. Furthermore, it aimed to clarify whether a change in the pressure distribution would lead to dermal pressure relief in the area of a horn defect. Nineteen isolated bovine limbs from an abattoir were gradually trimmed resulting in following stages. A: initial condition; B: functional claw trimming, steps 1-3; C: extension of the model and drill of a circular lesion at the Rusterholz site (outer claw ulcer simulation); D: wedge shaped, weight-relieving incision from the bulb halfway towards the sole tip; E: further extension of the wedge-shaped incision towards the sole tip. The limbs were loaded with 200 kg following each of the procedures. A pressure sensor system was used in order to analyze the pressure distribution beneath the claws. Furthermore, positioning of the claws on a glass plate allowed for an evaluation of corium resp. fat cushion protrusion through the artificial lesion. In the untrimmed claws, an average of 63 % of the total force applied rested on the outer claw area. This value decreased to 30 % following step E. Maximum pressure values shifted from the bulb area towards the sole tip with increasing degree of claw trimming. The relative loading area of the inner claw increased to up to 18.4 % following the procedures. The described incision technique (step E) resulted in a significant reduction of corium protrusion through the artificial horn defect in comparison to the claw situation in step C. The wedge-shaped, weight-relieving incision (step E) led to pressure reduction in the area of the outer claw and the bulb region in this ex-vivo-study. Therefore, this trimming method may serve to relieve pressure from the vulnerable Rusterholz site as well as providing means for reducing corium compression. The described trimming method facilitates pressure relief on the outer claw area in live animals. In this, it may exert a positive effect on disease progression in Rusterholz sole ulcers.

Patient-Controlled Epidural Analgesia/Continuous Epidural Catheters

Although useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated. Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block. Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug. This review contains 2 figures, 4 tables and 30 references.

Patient-Controlled Epidural Analgesia/Continuous Epidural Catheters

Although useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated. Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block. Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug. This review contains 2 figures, 4 tables and 30 references.

The safety and efficacy of the trans-umbilical approach for pyloroplasty in the management of post-acid corrosive gastric outlet obstruction in children

BackgroundGastric outlet obstruction (GOO) may follow acid corrosive ingestion. Several surgical techniques have been reported after the failure of endoscopic dilatation. The aim of this study was to evaluate the feasibility and safety of Heinecke-Mikulicz pyloroplasty (HMP) through a circum-umbilical skin incision in children with pyloric stricture after accidental acid corrosive ingestion.ResultsSeven patients were males and 4 were females, their ages ranged from 17 months to 6 years at the time of definitive treatment. The surgery was completed successfully in all patients through the circum-umbilical incision. Vertical extension of skin incision was needed in one patient. The pylorus was grossly affected in 9 patients. Both pylorus and gastric antrum were involved in 2 patients. Nine patients had an excellent postoperative course with the cessation of vomiting and progressive weight gain. One patient developed postoperative recurrent stricture treated by gastrojejunostomy. Another patient with associated esophageal stricture responded to repeated endoscopic dilatation for the esophageal stricture and pyloroplasty for the pyloric stricture. No surgical site infection or wound dehiscence occurred in any patient.ConclusionHeinecke-Mikulicz pyloroplasty through a circum-umbilical approach is both feasible and safe in the majority of children with post-acid corrosive GOO. It is associated with satisfactory wound healing and excellent cosmetic outcome. Different techniques are recommended in cases of severe pyloric stricture associated with significant proximal gastric antral scarring.

Transurethral endoscopic extensive incision of complex urethral diverticula in symptomatic women: case series in a single center experience with long-term follow-up.

Urethral diverticula (UD) affect 1-6% of adult women. Complex UD are rare, but can be challenging to manage. To evaluate the efficacy and safety of transurethral endoscopic extensive incision of complex UD in symptomatic women. We retrospectively evaluated 22 female patients with complex UD who underwent transurethral endoscopic extensive incision management in our hospital. This technique was completed by one experienced surgeon over a 7-year period between August 2012 and July 2019. The surgical technique involved placing the patient in a lithotomy position, inserting the needle electrode endoscopically, and incising the tented roof of the UD from its orifice until the entire roof had been opened widely. Outcome data included complete symptom resolution rate, imaging data, de novo stress urinary incontinence (SUI), recurrence, short-term and long-term complications. Cure was defined as decreased UD volume on postoperative magnetic resonance imaging and no post-voiding urinary retention in the diverticular cavity, with symptom resolution. The initial symptom-resolution rate after 37.0 (27.0, 50.0) months' follow-up was 81.80% (18/22) and the de novo SUI rate was 13.60% (3/22). No patients required additional operations after conservative therapy. There was no symptomatic or imaging recurrence, and no short-term complications. Transurethral endoscopic extensive incision was an effective and safe treatment for symptomatic female complex UD. Its symptom-resolution rate and de novo SUI rate might be superior to the conventional transvaginal approach. Moreover, it was less invasive and easier to conduct, with fewer complications.

Supra-Temporalis Approach for Treating Zygomaticomaxillary Complex Fracture.

There are multiple approaches described to access the zygomaticomaxillary complex (ZMC) fractures: lateral eyebrow, upper blepharoplasty, coronal, subciliary, subtarsal, infraorbital, transconjunctival, and transoral. All these approaches have their advantages, disadvantages, and indications according to location of fracture, degree of displacement, and surgeon's experience with a specific technique. However, there is not a good approach for treating the zygomatic arch or body fracture. In this paper, the authors described a supra-temporalis approach to treat the zygomatic arch or body fracture. Eight patients with traumatically ZMC fractures who received open reduction and internal stable fixation with supra-temporalis approach were retrospectively reviewed. A minimized supra-temporalis incision and trans-temporalis fascia access was used. Blunt dissection was performed perpendicularly to the fractured zygomatic arch and body. The open reduction and internal fixation of ZMC fractures were performed. After confirming that the fracture was fixed rigidly, the incision was closed layer by layer. Using this approach, the zygomatic arch, body, frontozygomatic suture, and fracture stumps were exposed perpendicularly. No extensive incision was needed and minimal invasion was realized. Postoperative CT scan showed that the fractures been repositioned and fixed in the normal position. Facial asymmetry was reconstructed and keep in the follow-up. Supra-temporalis approach gave an optimal view of the bony field, which allowed surgeons to work perpendicularly to the fracture, and facilitated the reduction of the displaced fractured stumps. It was regarded as an ideal and valuable alternative in this potentially complicated procedure.

Urinary bladder injury during cesarean delivery: risk factors and the role of retrograde bladder filling.

Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity. A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well. During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident. Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.

Urinary tract injuries during cesarean delivery: long-term outcome and management

Objective Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. Methods We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. Results In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. Conclusion Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Individualized Use of Facelift, Retroauricular Hairline, and V-Shaped Incisions for Parotidectomy

Despite the increased need for better cosmetic outcomes following parotidectomy, there is no study on the individualized use of esthetic approaches for parotidectomy. We aimed to evaluate the feasibility of individualzsed esthetic approaches for parotidectomy using facelift (FL), retroauricular hairline (RAH), and V-shaped incisions, and compare their surgical and cosmetic outcomes. This was a retrospective cohort study. Between 2015 and 2019, we included patients who underwent parotidectomy using FL, RAH, and V-shaped incisions for the treatment of benign parotid tumors. The surgical approach for parotidectomy was determined based on tumor location and each patient's cosmetic demand, following a comprehensive discussion of available esthetic approaches. Surgical and cosmetic outcomes were assessed as primary outcome variables, which were compared among the 3 incision groups. One-way analysis of variance/Kruskal-Wallis test and the chi-squared test were used to inspect differences in continuous and categorical variables, respectively, among the groups. A total of 213 patients, consisting of 122, 50, and 41 patients in the FL, RAH, and V-shaped groups, respectively, were included in the present study. In the FL, RAH, and V-shaped groups, the patient age was 53.5, 51.8, and 42.1years, respectively (P<.001), and the tumor size was 2.8, 2.7, and 1.9cm, respectively (P<.001). All parotidectomies were successfully completed with no incision extension or major complications. The subjective scar satisfaction scores assessed at 3months postoperatively were 8.5, 9.1, 9.2 in the FL, RAH, and V-shaped groups, respectively (P<.001). However, the Vancouver scar scale was consistent across all groups. Individualized use of esthetic approaches for parotidectomy is feasible and yields improved cosmetic results, leading to high patient satisfaction. Although FL incision is still the standard approach for esthetic parotidectomy, both RAH and the V-shaped incisions could further enhance the cosmetic outcomes of parotidectomy.

Anatomic Variations From 120 Mental Nerve Dissections: Lessons for Transoral Thyroidectomy

BackgroundTransoral endoscopic thyroidectomy vestibular approach (TOETVA) is a promising technique for eliminating a neck incision. A new risk of TOETVA is the potential for injury to the mental nerves during placement of three oral endoscopic ports. A better understanding of the variations in mental nerve anatomy is needed to inform safer TOETVA technique. Materials and methodsWe performed 120 dissections of mental nerve branches exiting the mental foramen in 60 human cadavers. Anatomic distances and relationships of the foramen to the midline were evaluated. Mental nerve branching patterns were studied and compared with previously reported classification systems to determine surgical safe zones free of nerve branches. ResultsThe mean midline-to-mental foramen distance was 29.2 ± 3.3 mm, with high variability across individuals (18.8-36.8 mm). There were differences in this distance between the left and right foramina (29.8 ± 3.2 versus 28.8 ± 3.3 mm, P = 0.03). All mental nerve branches exiting the mental foramen distributed medially. The branching patterns were classified into eight distinct categories, three of which are previously undescribed. One of these novel patterns, occurring in 9.2% of cases, had a dense and wide clustering of branches traveling toward the midline. ConclusionsThe location of the mental foramen and mental nerve branching patterns demonstrate high variability. To avoid mental nerve injury in TOETVA, we identify a safe zone for lateral port placement lateral to the plane of the mental foramen. Placement and extension of the middle port incision should proceed with caution, as clustering of mental nerve branches in this area can frequently be present.

Open transumbilical intussusception reduction in children: A prospective study

PurposeManual intussusception reduction can sometimes be accomplished through the existing umbilical incision after a laparoscopic attempt has failed. We compared the safety and efficacy of open transumbilical intussusception reduction (OTIR) and laparoscopic reduction (LAP). MethodsWe prospectively enrolled children diagnosed with intussusception at our hospital from June 2014 to December 2018. Clinically stable patients who failed pneumatic intussusception reduction were randomly assigned to the OTIR or LAP group. We compared reduction rates, complications, operative times, and surgery costs between the two groups. ResultsFifty-one of 451 patients with an intussusception met the study criteria. In the OTIR group (n = 27), 22 intussusceptions were successfully reduced, and 5 required incision extension. The mean operative time was 47.7 ± 10.5 min, and mean surgery cost was 1259.74 ± 46.24 US dollars. In the LAP group (n = 24), 5 patients required conversion to open surgery. Three of the 5 cases were resolved by OTIR, while the other 2 needed incision extension. The mean operative time was 68.63 ± 17.13 min, and mean surgery cost was 1750.63 ± 106.98 US dollars. Severe complications did not occur in either group. ConclusionsOTIR was as safe and effective as LAP and had a shorter operative time and lower surgery cost. OTIR is a good option for intussusception reduction in children. Type of studyTreatment study. Levels of evidenceLevel I.

Outcomes of Mini-Appendectomy: an Experience of 150 Cases at a Tertiary Care Hospital of Nepal

A new era of minimally invasive surgery has led to the advancement of new approaches for the existing operations. Mini-appendectomy is a randomly practiced preexisting underestimated form of open surgery, which serves the purpose of minimally invasive surgery, i.e., 1.5–2.5 cm incision to cure appendicitis. This study aims to describe the perioperative outcome of mini-appendectomy to combat appendicitis. A descriptive cross-sectional study was conducted at Nobel Medical College and Teaching Hospital, Biratnagar, Nepal. All cases undergoing mini-appendectomy from August 2016 to August 2017 were included in the study. Convenience sampling was done. A proforma was used to collect data on patient’s detailed clinical history, physical examination, operative details, operative time, postoperative complications, postoperative analgesic requirements, ambulation, length of hospital stay, return to routine, and patient satisfaction. Among 150 patients who underwent mini-incision appendectomy, 3 (2%) patients required extension of incision up to 4 cm. The average (SD) operating time was 16.67 (3.10) minutes. The average (SD) time in which patients could ambulate was 6.08 (0.4) hours. Only 6 (4%) patients required postoperative additional analgesic. The mean (SD) hospital stay was 28.80 (16.91) hours. Wound infection occurred in 2 (1.3%) patients. A majority of 148 (98.7%) patients reported satisfaction with the minimal scar. Mini-appendectomy is a safe, feasible, and promising procedure to cure appendicitis and gives high satisfaction to the patient.

Examining the Association of Obesity With Postpartum Tubal Ligation.

To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication. We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P<0.05 considered significant. During the study period, 3,670 women were studied: 263 were underweight or normal weight (BMI 24.9 or lower), 1,044 were overweight (25-29.9), 1,371 had class I obesity (30-34.9), 689 had class II obesity (35-39.9), and 303 had class III obesity (40 or higher) at the time of admission. Composite morbidity occurred in 49 cases (1.3%) and was not significantly different across the BMI categories (P=.07). Twelve cases of incomplete transection were noted on pathology reports; however, none of these accounted for the six subsequent pregnancies that were identified. There were no deaths or events leading to death noted in the study population. The length of time to complete the procedure increased across BMI categories (23 minutes in women with normal weight, and 31 in women with class III obesity) (P<.001). There was no association between increased BMI and morbidity with women undergoing postpartum tubal ligation. Postpartum tubal ligation should be considered a safe and reasonable option for women, regardless of BMI.

Reduced port laparoscopic radical nephrectomy using an umbilical zigzag skin incision for renal cell carcinoma

Reduced port laparoscopic radical nephrectomy (RPLRN) is an equivalent approach to conventional laparoscopic radical nephrectomy (LRN). In LRN, one wound generally needs to be extended for specimen extraction; therefore, some ingenuity is needed to achieve a good cosmetic outcome. We herein describe our initial experience of RPLRN using an umbilical zigzag skin incision for renal cell carcinoma (RCC). A 64-year-old female [body mass index (BMI): 20.0kg/m2] was diagnosed with right RCC, which was 35mm in diameter (clinical T1aN0M0). Case 2: a 68-year-old male (BMI: 23.2kg/m2) was diagnosed with right RCC, which was 58mm in diameter (clinical T1bN0M1), and perinephric fat was relatively thick. The procedure was safely completed in both cases. Total operative times, pneumoperitoneal times, and estimated blood loss in Case 1 and 2 were 90 and 145min, 49 and 90min, and 5 and 80ml, respectively, and the times required to construct umbilical ports and close umbilical wounds were 8 and 9min and 33 and 46min, respectively. In Case 1, the specimen was easily extracted without the extension of the umbilical skin incision, whereas it was extended by an additional 2cm in Case 2. The umbilical wound was inconspicuous in both cases. RPLRN using an umbilical zigzag skin incision for RCC was safely performed without complications, and clashing between instruments was minimized. The high level of cosmesis is advantageous and an umbilical zigzag skin incision may contribute to more widespread use of RPLRN for RCC; however, further studies on long-term oncological outcomes are needed.

Risk factors for uterine incision extension during cesarean delivery

Background Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4–8% of cesarean deliveries. The aim of this study was to examine risk factors associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition. Study design We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor Results During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm. Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant – past cesarean delivery and failed vacuum attempt. Conclusions Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral.

Fetal extraction maneuvers during cesarean delivery in the second stage of labor

Objective To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method. Methods A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012–2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events. Results Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p = .013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69–46.40% in others, p < .001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12–15% in others, p < .001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44–6.56, p = .0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081–7.448, p = .0342). Conclusion Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods. Abbreviations NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.