Inferior Edge Research Articles

Surgical outcome of graded Harada-Ito procedure in the treatment of torsional diplopia ‒ a retrospective case study with long-term results

ABSTRACT To review and evaluate the surgical outcomes of the Fells-modified Harada-Ito procedure using a dosage scale approach with long-term follow up in patients with torsional diplopia. The records of patients who underwent the modified Harada-Ito procedure by the same surgeon during 2012–2019 were retrospectively reviewed regarding pre- and post-operative data and individual dose-scale used for the surgery. The modified Harada-Ito procedure involved advancing the anterior half of the superior oblique tendon toward the inferior edge of the lateral rectus muscle by a distance determined using a five-graded scale. A total of 27 patients (mean age 57.6 years, range, 22–81 years; 10 female) were included. Evaluating surgical outcome showed a significant difference in pre- to post-operative cyclodeviation (p = <0.001). Pre-operative mean extorsion was −10.4° and mean torsional correction achieved was 7.7°. The dose-effect relationship showed a wide spread effect, yet yielded a high success rate. All but two patients were symptom free from their torsional diplopia at the last post-operative evaluation, on average 24 months after surgery. Post-operative results and the dose-effect of the modified Harada-Ito corresponded with the aimed-for correction of torsional diplopia.. Fusion evaluation and individually based pre-operative assessments proved essential in determining individual doses for successful surgical outcomes.

Evaluation of the position of lingula mandible, mental foramen and lingual foramen of individuals in the 7-17 age groups via Cone-Beam Computed Tomography

Objective: The identification of landmarks in mandible is an important stage before dental procedures ın pediatric patients. The purpose of this study was to determine the location of lingula mandible, mental foramen (MF) and lingual foramen (LF) in a paediatric population. &#x0D; Methods: The distance of lingula mandible to the anterior, posterior, superior, and inferior borders of mandible and to distal edge of the alveolar socket of the 1st molar tooth were measured. MF and LF distance to the top of the alveolar crest and the inferior edge of the basis mandibulae were determined. The horizontal location of MF was evaluated. &#x0D; Results: The distance between lingula mandible and the sigmoid notch, the inferior border of the ramus, the anterior border of the ramus and the posterior border of the ramus was 18.63±4.52 mm, 24.81 ± 5.19 mm 14.67±2.39 mm, and 15.14 ± 3.06 mm respectively. The MF was mostly located between long axes of first and second premolar teeth. LF is closer to the inferior edge of the basis mandibulae. &#x0D; Conclusion: It is necessary to determine anatomical landmarks in children prior to the surgical operations to prevent the possible neurovascular complications.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury.

The reconstruction of high‐level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp–Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic‐hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide‐hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien–Dindo grade III complications, including surgical site infection and intra‐abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp–Couinaud approach in cases of high‐level injury.

A Quantitative Analysis of Subchondral Bone Density Around Osteochondritis Dissecans Lesions of the Capitellum

In capitellar osteochondritis dissecans (OCD), unstable lesions generally demonstrate signs of subchondral sclerosis. We postulate that OCD lesions have abnormal subchondral bone density. We aimed to quantify the subchondral bone thickness around OCD lesions using conventional computed tomography (CT) imaging. This retrospective study included 15 patients with capitellar OCD (OCD group) and 12 patients with an unaffected radio-capitellar joint (control group). We constructed 3-dimensional humerus models using CT data and quantified the bone density with colored contour mapping to determine the subchondral bone thickness. We measured the thickness relative to the condylar height at the centroid and lateral, medial, superior, and inferior edge points of the OCD lesion, and compared the findings between the groups. We then correlated the CT measurements with the magnetic resonance imaging measurements. Subchondral bone thickness at the centroid and lateral, medial, superior, and inferior edges in the OCD group was significantly higher than that in the control group. Correlation analyses revealed that the magnetic resonance imaging measurements highly correlated with the CT subchondral bone measurements. We found that there is a zone of increased subchondral bone thickness around OCD lesions that should be considered during drilling, microfracture, or other reconstruction methods. We observed a high correlation with low errors between the measurements taken from conventional CT images and the measurements from magnetic resonance imaging, suggesting that both modalities are useful in clinical decision making. Diagnostic IV.

The effect of the magnetic fields from three different configurations of the MRIgRT systems on the dose deposition from lateral opposing photon beams in a laryngeal geometry – A Monte Carlo study

ObjectiveTo investigate the impact of different magnetic field strengths and orientations on the dose deposition from lateral opposing photon beams irradiating a laryngeal geometry, with particular attention focused on the dose homogeneity of the area around the air cavity inside the larynx. MethodsGeant4 simulation toolkit was used to perform Monte Carlo simulations on a phantom resembling the larynx. The energy spectrum of a 6 ​MV photon beam from a Varian Clinac iX machine was used to provide the source of radiation. Three configurations of the Magnetic Resonance Image-Guided Radiation Therapy (MRIgRT) system were simulated: the Fixed Cylindrical (FC) geometry, the Longitudinal Rotating Biplanar (LRBP) geometry, and the Transverse Rotating Biplanar (TRBP) geometry. Uniform magnetic fields of different field strengths were applied. The relative dose maps and the homogeneity index (HI) were obtained for evaluations. ResultsThe LRBP geometry together with a magnetic field strength of 0.5 ​T produced the most homogeneous dose distribution with a HI of 0.139 for the region of interest around the air cavity, compared with a HI of 0.180 when the magnetic field was absent. For TRBP geometry, the dose distribution shifted towards the cranial direction, leading to a region of hot spots at the superior edge and a region of cold spots at the inferior edge of the irradiated volume. The HI around the air cavity was therefore worse. In addition, strong electron streaming effect (ESE) was observed. For the FC geometry, hot and cold spots were formed around the air cavity which increased the HI. ConclusionsOut of the three configurations of the MRIgRT systems, the LRBP geometry produced the most clinically beneficial dose distribution in which it provided a higher dose to the treatment area and a boost in dose to the tissue immediately adjacent to the air cavity.

Does isolated arthroscopic anterior acromioplasty modify critical shoulder angle?

IntroductionCritical shoulder angle (CSA)>35° correlates significantly with primary rotator cuff tear and re-tear after repair. Acromial axial orientation varies between individuals. The present study aimed to assess the impact of strictly anterior acromioplasty on CSA. HypothesisCSA is reduced by arthroscopic anterior acromioplasty. Material and methodsA single-center retrospective study included patients receiving isolated arthroscopic acromioplasty between January 2016 and December 2017. Exclusion criteria comprised history of surgery and fracture or dislocation of the shoulder. Pre- and post-operative AP shoulder radiographs were taken. The angle subtended by a line between the inferior and superior edges of the glenoid and a line between the inferior edge of the glenoid and the most lateral point on the acromion was measured. ResultsOne hundred and two patients were included: mean age, 50.5±10.1 years (range, 23–82 years). Mean CSA was 34.7±4.4° (range, 26–48°) preoperatively and 31.7±3.7° (range, 23–40°) postoperatively (p<0.001). In the group with CSA >35°, the decrease was significant: 34.4±3.2° (range, 28–40°) versus 38.9±2.8° (range, 36–48°) (p<0.001), with 64% CSA <35° after isolated anterior acromioplasty. DiscussionCSA was decreased by arthroscopic acromioplasty. However, in 36% of cases with preoperative CSA >35°, CSA was not normalized. ConclusionAnterior arthroscopic acromioplasty significantly reduced CSA in the overall population, and especially in case of high CSA. Level of evidenceIV; retrospective study.

Intra Focal K-Wiring for Distal End Radius (Kapandji Technique): Surgical Technique

Many years distal end radius fractures (DRF) are the most encountered type of fracture. In standard form, extra-articular distal end radius fractures were fixed after manual reduction and then pinned extra-articular by drilling distal cortex and passing fracture site to fix proximal fragment (Figure 1). But after 2 to 3 weeks depending upon osteoporosis fracture collapse(cancellous bone heal by collapse) and flexibility of the K wire distal fragment moves back until the K wire abut the inferior edge of the proximal fragment and does not avoid secondary displacement (Figure 2) [1].

B-PO02-056 FACTORS RELATED TO SKIN THINNING OF THE CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE POCKET

The skin overlying cardiovascular implantable electronic devices (CIEDs) sometimes becomes very thin after implantation, which can cause not only pain or discomfort, but device erosion. However, the factors that are related to the thickness of the skin overlying the device have not yet been elucidated. Evaluate the thickness of the skin overlying the device with ultrasonography and search for factors associated with the skin thickness. A total of 70 patients with CIEDs were examined. Seventeen points of the skin thickness around the CIED pocket were measured in each patient through ultrasonography. The median distance from the skin surface to the device was defined as the skin thickness. The mean age of the participants was 76±10 years; 19 (27%) of them were females. The mean body weight was 58±11kg and the mean duration from the first implantation to the examination day was 109±69 months. The median skin thickness overlying the device was 4.5mm [ 3.6∼6.3mm]. The distance from the skin to the superior edge of the device was significantly thinner than that to the inferior edge (1.9mm vs 2.7mm, p<0.01). A significant correlation existed between skin thickness and body mass index (BMI), hemoglobin, and serum creatinine, respectively (BMI: p<0.01, r=0.40; hemoglobin: p<0.01, r=0.37; creatinine: p=0.02, r=-0.30). By contrast, age, gender, weight, albumin, device size, and the number of device exchanges did not show a significant correlation with skin thickness. Aside from low BMI, renal dysfunction and low hemoglobin impact the skin thickness overlying the device. Therefore, device erosion should be assessed in these patients during follow-up.

Clinical implementation of automated treatment planning for whole-brain radiotherapy.

The purpose of the study was to develop and clinically deploy an automated, deep learning‐based approach to treatment planning for whole‐brain radiotherapy (WBRT). We collected CT images and radiotherapy treatment plans to automate a beam aperture definition from 520 patients who received WBRT. These patients were split into training (n = 312), cross‐validation (n = 104), and test (n = 104) sets which were used to train and evaluate a deep learning model. The DeepLabV3+ architecture was trained to automatically define the beam apertures on lateral‐opposed fields using digitally reconstructed radiographs (DRRs).For the beam aperture evaluation, 1st quantitative analysis was completed using a test set before clinical deployment and 2nd quantitative analysis was conducted 90 days after clinical deployment. The mean surface distance and the Hausdorff distances were compared in the anterior‐inferior edge between the clinically used and the predicted fields. Clinically used plans and deep‐learning generated plans were evaluated by various dose–volume histogram metrics of brain, cribriform plate, and lens.The 1st quantitative analysis showed that the average mean surface distance and Hausdorff distance were 7.1 mm (±3.8 mm) and 11.2 mm (±5.2 mm), respectively, in the anterior–inferior edge of the field. The retrospective dosimetric comparison showed that brain dose coverage (D99%, D95%, D1%) of the automatically generated plans was 29.7, 30.3, and 32.5 Gy, respectively, and the average dose of both lenses was up to 19.0% lower when compared to the clinically used plans. Following the clinical deployment, the 2nd quantitative analysis showed that the average mean surface distance and Hausdorff distance between the predicted and clinically used fields were 2.6 mm (±3.2 mm) and 4.5 mm (±5.6 mm), respectively.In conclusion, the automated patient‐specific treatment planning solution for WBRT was implemented in our clinic. The predicted fields appeared consistent with clinically used fields and the predicted plans were dosimetrically comparable.

Recommendations and Clinical Validation of Inguinal Clinical Target Volume Delineation in Penile Cancer

This study determined the patterns of distribution of inguinal nodes and the optimal margin needed around the femoral vessels to propose guidelines for inguinal clinical target volume (CTV) delineation in penile cancer. Patients with biopsy-proven penile squamous cell carcinoma with inguinal node metastases were identified on a computed tomography scan. Distribution of nodes and distance of nodes to the nearest femoral vessel and inferior edge of pubic symphysis (IPS) were obtained. A 3-dimensional CTV margin to cover 95% of the nodes was estimated to evolve contouring guidelines. A comprehensive contouring guide with a visual atlas for inguinal CTV delineation was created. The proposed CTV was prospectively validated in 14 consecutive patients with penile squamous cell carcinoma treated with post-operative radiation therapy to the inguino-femoral region. Of the 222 inguinal lymph nodes analyzed in 33 patients, 99% were located anterior (81% antero-medial, 18% antero-lateral) to femoral vessels. A majority (95%) of the antero-laterally located nodes were superior to IPS. Margin around the femoral vessels to cover 95% of the nodes for supra-IPS region in anterior, medial, and lateral directions was 29, 23, and 21 mm, respectively, and for infra-IPS region in anterior and medial directions was 21 and 23 mm, respectively. Cranial and caudal extent of CTV delineation with respect to IPS was at 48 and 50 mm, respectively for 95% nodal coverage. On prospective validation, after a median follow-up of 24 months (range, 5-31), none of the patients developed marginal recurrences. Grade 1 and grade 2 lymphedema was seen in 6 (42.8%) and 4 (28.5%) patients, respectively. This study analyzed pattern of distribution of inguinal nodes and proposes guidelines for inguinal CTV delineation in penile cancer. The proposed guidelines were validated prospectively in a small cohort of patients and found to be implementable and safe.

Cadaveric Study of Crista Fenestra: Revisited.

Objectives: Since there is great confusion in the literature about the anatomy and terms of the crista fenestra (CF) and the crista semilunaris, this paper is confined to the anatomy of the inferior margin of the round window (RW).Methods: This study was carried out on 20 cadaveric temporal bones. We measured the maximal height of the RW and the maximum height of the inferior bony edge of the RW, (termed CF type A), in this study. The ratio of the maximum height of CF type A to the maximum height of the RW was calculated. After drilling the CF type A, the scala tympani was visualized using a sialendoscope, and any bony projection in the inferior wall of the scala tympani just behind the round window membrane (RWM) was assessed and reported (termed CF B in this study).Results: We identified CF type A in 19/20 of cases (95%), and it was absent in only 1 case (5%). Its height ranged from 0.228 to 1.329 mm with an average of 0.604±0.347 mm. The percentage of CF type A to RW ranged from 19 to 75%, with an average of 42%. CF type B was present in only 2 specimens (10%).Conclusion: CF type A occupied a significant part of the RW in most specimens, and therefore its drilling was essential in a large percentage of cases. CF type B (inside the scala tympani) was present in 10% of the temporal bone samples, and curettage had to be done in these cases.

Evaluation of Difficult Airway in Trauma Patients from Lateral Cervical Radiographs

Background: Many tests have been developed that are used either singly or in combination to identify a difficult airway. However, airway patency may not be adequately evaluated in some patients despite these tests. Lateral cervical radiography can be an auxiliary technique to evaluate difficult airway in patients of trauma due to its bedside applicability, cost-efficiency and rapidity. The aim of this study was to investigate the usefulness of lateral cervical radiographic measurements in predicting difficult laryngoscopy in trauma patients. Patients and Methods: The study consisted of patients of trauma who were admitted to the emergency department between July 2017 and March 2018. All patients underwent bedside cervical radiography and seven measurements were obtained. The anterior and posterior mandibular depths, effective mandibular length, atlanto-occipital distance, mandibulohyoid distance, thyromental distance and distance between the superior temporomandibular joint and the inferior edge of the fourth cervical vertebra (C4) were measured on the radiographs. Patients were divided into two groups as difficult and easy laryngoscopy groups, and the parameters were compared between the groups. Results: A total of 97 patients were included in our study. Of these patients, 54 (55.6%) were in the difficult laryngoscopy group, while 43 (44.4%) were in the easy laryngoscopy group. The interincisor, hyomental and thyrohyoid distances were significantly lower in the difficult laryngoscopy group compared to the easy laryngoscopy group. Conclusion: Bedside lateral cervical radiography is not a useful imaging method to demonstrate difficulty in laryngoscopy in patients of trauma.

Imaging the pediatric retina: An overview.

Recent decade has seen a shift in the causes of childhood blinding diseases from anterior segment to retinal disease in both developed and developing countries. The common retinal disorders are retinopathy of prematurity and vitreoretinal infections in neonates, congenital anomalies in infants, and vascular retinopathies including type 1 diabetes, tumors, and inherited retinal diseases in children (up to 12 years). Retinal imaging helps in diagnosis, management, follow up and prognostication in all these disorders. These imaging modalities include fundus photography, fluorescein angiography, ultrasonography, retinal vascular and structural studies, and electrodiagnosis. Over the decades there has been tremendous advances both in design (compact, multifunctional, tele-consult capable) and technology (wide- and ultra-wide field and noninvasive retinal angiography). These new advances have application in most of the pediatric retinal diseases though at most times the designs of new devices have remained confined to use in adults. Poor patient cooperation and insufficient attention span in children demand careful crafting of the devices. The newer attempts of hand-held retinal diagnostic devices are welcome additions in this direction. While much has been done, there is still much to do in the coming years. One of the compelling and immediate needs is the pediatric version of optical coherence tomography angiography. These needs and demands would increase many folds in future. A sound policy could be the simultaneous development of adult and pediatric version of all ophthalmic diagnostic devices, coupled with capacity building of trained medical personnel.

The Glossopharyngo-Cochlear Triangle-Part I: Quantitative Anatomic Analysis of High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach.

An extended retrosigmoid approach can offer sufficient space for clip reconstruction of some high-riding posterior inferior cerebellar artery (PICA) aneurysms. To quantitatively investigate the glossopharyngo-cochlear triangle (GCT) and anatomic structures within it. Extended retrosigmoid craniotomies were performed on 10 sides of cadaveric heads, and the GCT was identified in each specimen. The length of the base and the area of the GCT were measured. The depth of the vertebrobasilar system and the abducens nerve to the GCT were measured. The proximal and distal exposable and controllable points on the vertebrobasilar system were identified. Two imaging-based patient selection algorithms are provided using the lengths from those points to the vertebral artery dural entry point and the superoinferior distances from those points to the inferior edge of the foramen magnum. Other factors related to accessibility via the GCT were investigated. The mean (standard deviation [SD]) area of the GCT was 45.7 (12.55) mm2. The mean (SD) depth of the abducens nerve was 14.3 (1.42) mm. The mean (SD) superoinferior distances from the foramen magnum to those points were 23.1 (7.39), 24.7 (8.25), 30.0 (9.56), and 32.6 (7.79) mm, respectively. The lower segment of the vertebrobasilar system was more superficial in the setting of a high-lying vertebrobasilar junction (VBJ) than a low-lying VBJ. We describe the GCT in an extended retrosigmoid approach for high-riding PICA aneurysms and evaluate the spatial relationship of the neurovascular structures within it. Two potential algorithms are offered for preoperative patient selection.

Evaluation of margins in pelvic lymph nodes and prostate radiotherapy and the impact of bladder and rectum on prostate position

PurposeThe aims of this study were: determination of the CTV to PTV margins for prostate and pelvic lymph nodes. Investigation of the impact of registration modality (pelvic bones or prostate) on the CTV to PTV margins of pelvic lymph nodes. Investigation of the variations of bladder and rectum over the treatment course. Investigation of the impact of bladder and rectum variations on prostate position. Patients and methodsThis study included 15 patients treated for prostate adenocarcinoma. Daily kilo voltage images and weekly CBCT scans were performed to assess prostate displacements and common and external iliac vessels motion. These data was used to calculate the CTV to PTV margins using Van Herk equation in the setting of a daily bone registration. We also compared the CTV to PTV margins of pelvic lymph nodes according to registration method; based on pelvic bone or prostate. We delineated bladder and rectum on all CBCT scans to assess their variations over treatment course at 4 anatomic levels [1.5cm above pubic bone (PB), superior edge, mid- and inferior edge of PB]. ResultsUsing Van Herk equation, the prostate CTV to PTV margins (bone registration) were 8.03mm, 5.42mm and 8.73mm in AP, ML and SI direction with more than 97% of prostate displacements were less than 5mm. The CTV to PTV margins ranged from 3.12mm to 3.25mm for external iliac vessels and from 3.12mm to 4.18mm for common iliac vessels. Compared to registration based on prostate alignment, bone registration resulted in an important reduction of the CTV to PTV margins up to 54.3% for external iliac vessels and up to 39.6% for common iliac vessels. There was no significant variation of the mean bladder volume over the treatment course. There was a significant variation of the mean rectal volume before and after the third week of treatment. After the third week, the mean rectal volume seemed to be stable. The uni- and multivariate analysis identified the anterior wall of rectum as independent factor acting on prostate motion in AP direction at 2 levels (superior edge of, mid PB). The right rectal wall influenced the prostate motion in ML direction at inferior edge of PB. The bladder volume tends toward significance as factor acting on prostate motion in AP direction. ConclusionsWe recommend CTV to PTV margins of 8mm, 6mm and 9mm in AP, ML and SI directions for prostate. And, we suggest 4mm and 5mm for external and common iliac vessels respectively. We also prefer registration based on bony landmarks to minimize bowel irradiation. More CBCT scans should be performed during the first 3weeks and especially the first week to check rectum volume.

Harvesting Split Costal Cartilage Graft in Revision Rhinoplasty Without Disturbing the Costal Integrity.

Graft use is inevitable in some primary and secondary rhinoplasty cases with cartilage or bone deficiency. Although rib graft is one of the best graft sources, it has several disadvantages. The purpose of this study is to minimize the risks of using rib grafts. Between 2018 and 2020, a total of 21 patients aged between 25 and 55 have undergone revision rhinoplasty under general anesthesia with a split cartilage graft of central origin. A 3-4-mm-thick bridge was left at the superior and inferior edges of the donor area, and the graft was harvested from the central region without disrupting the costal integrity. A special retractor was placed between the perichondrium and the rib at the posterior of the costa to prevent damage to the pleura while cutting the rib. The previously marked grafts were cut in the donor area and harvested ready for use. The harvested grafts were used as spreader, strut, alar rim and nasal valve grafts. None of the patients had complications due to rib graft harvesting. After the operation, pain in the donor region and analgesic requirement of these patients were less compared to the patients with full-layer grafts. The grafts taken from the center of the costa without breaking its integrity seem quite suitable for revision rhinoplasty surgeries. This technique prevents various morbidities and enables patients to have a more comfortable postoperative period. This 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Successful closure of a large abdominal wall defect using endoscopic component separation technique in an infant with a giant ventral hernia after staged surgery for omphalocele

BackgroundThe management of large abdominal wall defects, such as omphalocele or gastroschisis, remains a challenge for pediatric surgeons. Though several techniques have been described to repair those conditions, there is no procedure considered to be the standard worldwide. We report an infant girl with a giant ventral hernia after staged surgery for omphalocele in whom delayed closure of a large abdominal wall defect was performed successfully using “endoscopic component separation technique (ECST)” without serious complications.Case presentationA baby girl was admitted to our hospital because of a giant omphalocele, which had been prenatally diagnosed. The omphalocele was supraumbilical and included the entire liver. After staged surgery, a large abdominal wall defect was closed by skin, creating a giant ventral hernia. We performed endoscopic separation component technique (ECST) for the closure of her abdominal wall defect when she was 11 months of age. ECST was initiated with placement of a 5.0-mm port just above the inguinal ligament and under the external oblique muscle. The space between the external and internal oblique muscles was created by the insufflation pressure, and a second 5.0-mm port was placed at 1.0 cm below the inferior edge of the rib into the space. As the further dissection was carried, the aponeurosis of the external oblique muscle was identified as a white line, running vertically from the epigastrium to inguinal ligament. It was transected longitudinally using electrocautery over its full length. The same procedure was performed on the contralateral side and the abdominal wall was successfully closed. Postoperative course was uneventful.ConclusionsThe technique of ECST, described here, is simple and safe for infants, and the cosmetic result is satisfactory.

Robotic extended distal pancreatectomy with splenectomy for pancreatic adenocarcinoma

Presenter: Sharona Ross MD | AdventHealth Tampa Background: This video describes our technique of an extended distal pancreatectomy for locally advanced post neoadjuvant chemoradiation. Methods: This video is of a 72-year-old woman who presented with epigastric pain and was found to have a pancreatic body mass. Preoperative workup included triple phase CT scan and EUS/FNA showing abutment < 180 degrees of SMV/SMA and encasement of the splenic artery and vein. Patient progressed after 6 months of neoadjuvant chemotherapy and 30 sessions of radiation therapy. Results: The operation began by taking down the gastrohepatic ligament followed by the gastrocolic omentum. The short gastric vessels were taken down and the stomach retracted. An intraoperative ultrasound was utilized to identify the location of the tumor mass and the pancreas was dissected along its inferior edge. The colonic mesentery area along the inferior edge of the pancreas and the common hepatic artery was excised and sent to pathology which returned negative for malignancy. The neck of the pancreas was dissected, and the pancreas was divided with a robotic hook cautery. The left side of the SMV and portal vein was dissected. All the tissue surrounding the celiac trunk, the splenic artery and common hepatic artery were dissected. Next, we arrived at the splenic artery and vein which was divided with two clips on either side. The specimen was removed off the SMV, SMA, portal vein and the celiac trunk. Lastly the pancreas was dissected, medial to lateral, and all the attachments to the spleen were taken down. Conclusion: Operative duration was 3.5 hours with 50 ml of estimated blood loss. Final pathology showed microscopic focus of viable ductal carcinoma of the pancreas in the pancreatic body, associated with extensive fibrosis with zero nodes positive for malignancy. Patient had an uneventful postoperative stay and was discharged on postoperative day 4. This video shows that the robotic approach is safe and efficacious for resection of locally advanced pancreatic carcinoma following neoadjuvant therapy.

The New Concept of making the Excellent Result in Mastopexy

Background: Breast ptosis is one of the more common issues seen in cosmetic surgeons’ offices, particularly those performing a significant amount of aesthetic breast surgery. Patients with ptosis generally desire the same result – youthful and “perky” breasts. However, due to wide variations in breast volume and tissue quality, ultimate results vary with each patient, and as a result, preoperative management of expectations is critical. There are many surgical options that can be customized to patients’ needs, but these generally address repositioning of the glandular tissue and nipple areolar complex and management of skin excess. Scar patterns include circumareolar, circumvertical (including J or L scar variations), and inverted-T patterns. If author’s new concept can eliminate the remaining skin excess that occur from approximately preoperative markings of traditional mastopexy and can decrease the scar pattern (J or L scar variations and inverted-T patterns), they are interesting to bring an alternative to reduce complications and more satisfactory results. Objective: Author study the new concept of surgical techniques of mastopexy in severe ptotic breasts. The new concept is the changing steps of procedure that performs repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex before, follow by design and excise the excess skin flaps. Surgical result, main complications and patient satisfaction are evaluated. Methods: The study has performed in 11 patients who have severe ptotic breasts with author’s techniques of mastopexy since July 2017 to march 2018. The techniques including repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex, skin flaps are designed and excised accurately. Postoperative care makes as standard protocols. Results: Of 11 patients who underwent mastopexy with author’s techniques, all patients have symmetric, only short vertical scar and beautifully shaped breasts and 2 patients have superficial necrosis of skin which at junction of inferior edge of areola and vertical incision, both sides and right side respectively. Three breasts which have superficial skin necrosis, manage include death tissue was removed, dress wet wound every day and make delay primary wound closure in some areas. Nipple sensation is usually normal. Some patients have decrease sensation and fully recover within three months. Conclusion: Author’s surgical techniques change steps of standard mastopexy, as new concept for severe ptotic breast. Repositioning and reshaping of glandular tissue and repositioning of nipple areolar complex firstly, these will help surgeon design and excise the excess skin flaps more accurately. But surgeons do not over excise skin flap to prevent skin necrosis especially junction area. Accordingly, author’s technique can decrease frequent complications of mastopexy including asymmetry, improper of flap excision and undesired J or L, inverted T scar.