Inferior Margin Research Articles

NIpple Position to Pinpoint Localization of Chest Drain Insertion in FEmale Trauma Patients: The NIPPLE-Trial-A Landmark Study.

Background: The insertion of chest drains (CD) in trauma patients is a lifesaving, albeit high-risk intervention. Safe insertion of CD in settings where aids like ultrasound are not available relies on a landmark technique defining the so-called triangle of safety. The inferior margin of this triangle is identified by nipple height, which is thought to correspond to the fifth intercostal space (ICS). Training manikins are modeled after a lean male body and oftentimes insinuating jokes fuel uncertainty about the height of the nipple as a reliable landmark in female trauma patients. This study aims to prove that the nipple can be considered a safe landmark for CD insertion in women: even if larger breasts follow the force of gravity, it should not act towards the direction of the feet, but to the sides of the thorax in a flat-lying trauma patient. Methods: An online questionnaire was designed and distributed amongst female surgeons. Epidemiological data (age, nr of pregnancies, history of breastfeeding) was collected. Height, weight, and body mass index (BMI) were reported. Chest circumference and underbust girth were self-measured. The nipple position in relation to the ICS was measured by the women while lying in a supine position. Results: 237 female surgeons completed the questionnaire. Nine questionnaires were excluded due to incomplete data sets. 20 women were excluded due to previous breast surgery. Thus, 208 participants (or 416 nipples) were included in analysis. In supine position, both nipples were located in the 5th (±0.8) intercostal space. Age, BMI, height, weight, and status post-pregnancy had no significant impact on nipple position. Interestingly, a history of breastfeeding correlated with lower nipple position. Conclusions: The nipple is a safe landmark for identifying the correct insertion position of chest drains in supine-lying female trauma patients.

Clinical value of transperineal ultrasound in evaluating the effects of different delivery methods on the primipara pelvic floor structure and function

To evaluate the effects of different delivery methods on the pelvic floor structure and function among primiparas by transperineal ultrasound, with a view to providing guidance for early postpartum intervention. Primiparas who underwent postpartum examination with transperineal ultrasound were recruited. Subjects were divided according to mode of delivery (vaginal and cesarean delivery). General information (including age, pre-pregnancy BMI and neonatal weight) were collected, and transperineal ultrasound was performed to measure such indicators as the levator hiatus areas in resting, constrictive anal and maximum Valsalva states, the posterior vesicourethral angles and distances between vesical neck and posterior inferior margin of pubic symphysis in resting and maximum Valsalva states, as well as the vesical neck mobility and urethral rotation angle in maximum Valsalva state. The inter-group differences in ultrasound indicators between the resting and Valsalva states were compared to analyze the postpartum incidences of pelvic floor dysfunctions like stress urinary incontinence, urethral funnel formation, bladder prolapse and uterine prolapse in primiparas. The levator hiatus areas in resting, constrictive anal and maximum Valsalva states were all larger in the vaginal delivery group than in the cesarean delivery group (P < 0.05). Compared to the cesarean delivery group, the vaginal delivery group exhibited larger posterior vesicourethral angles in resting and maximum Valsalva states (P < 0.05). The distances between vesical neck and posterior inferior margin of pubic symphysis were greater in the cesarean delivery group than in the vaginal delivery group at both resting and maximum Valsalva, with that at maximum Valsalva showing significant inter-group difference (P < 0.05). The vaginal delivery group exhibited greater vesical neck mobility and urethral rotation angle at maximum Valsalva compared to the cesarean delivery group (P < 0.05). The incidences of stress urinary incontinence, urethral funnel formation, bladder prolapse and uterine prolapse were all higher in the vaginal delivery group than in the cesarean delivery group, with the stress urinary incontinence and bladder prolapse incidences showing significant inter-group differences (P < 0.05). With transperineal ultrasound, various pelvic floor indicators of primiparas can be clearly measured and, through these ultrasound indicators, the effects of different delivery methods on the pelvic floor function can be evaluated, which is conducive to early clinical detection and intervention of postpartum pelvic floor dysfunctions, thus facilitating the early postpartum treatment.

Impact of Operating Table Height on the Difficulty of Mask Ventilation and Laryngoscopic View.

Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table's height was adjusted at four points: the operator's umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table's height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures.

Anatomical Study of the Superficial Musculoaponeurotic System in Relation to the Zygomaticus Major.

The superficial musculoaponeurotic system (SMAS) is crucial for the structural integrity and dynamics of facial expressions and is a particularly important consideration during facelift surgeries. This study investigated the anatomical structure and continuity of the SMAS at the site where the zygomaticus major (Zmj) originates, which is where the SMAS extends from the lateral to the anterior aspects of the face. Knowledge of these aspects is crucial for understanding the mechanics of facial movements and also the aging process. Dissections of 66 specimens and histological analyses were used to explore the intricate relationships and attachments between the SMAS and facial muscles. The findings indicated that at the Zmj origin site, the SMAS-connected to the inferior margin of the orbicularis oculi-covered the superficial surface of the Zmj fibers. As it tracked downward, the SMAS was observed to split into two layers lateral to the Zmj fibers, enveloping them both superficially and deeply. Additionally, as the SMAS continued forward, it ceased to be distinctly visible in the buccal area. These results provide a deeper understanding of the complex layering and interconnectivity of the SMAS, which supports facial dynamics and structural integrity. This information could be particularly useful in surgical and aesthetic procedures in the midfacial area.

A new approach: Cervical approach for marginal resection of the posterior mandible

Gingival squamous cell carcinoma (SCC) of the posterior mandible often requires marginal resection of the mandible in conventional surgery. However, the posterior location of the lesion can limit surgical visibility, which is critical for complete tumor removal and minimizing recurrence. Typically, marginal resection of the posterior mandible is achieved through a midline lower lip incision and mental nerve transection, providing adequate exposure but resulting in nerve damage, lip numbness, and facial scarring. In this paper, we describe a case using a submandibular incision for neck dissection, extending from the mandibular angle to the mental foramen, to fully expose the posterior mandible. The intraoral incision, extending 1 cm beyond the tumor margin, connected with the submandibular incision. Under direct vision, we performed a marginal resection of the mandible, preserving the inferior alveolar neurovascular bundle and the mental nerve, and maintaining at least 1 cm of the inferior mandibular margin. This technique achieved complete tumor removal while preserving mental nerve function and lower lip integrity, reducing surgical difficulty and patient trauma. This approach maintains nerve function and aesthetics as much as possible, with a faster postoperative recovery. In treating gingival SCC of the posterior mandible, it is essential to preserve surrounding healthy tissue and critical anatomical structures, minimizing postoperative complications while ensuring complete tumor resection.

Biomechanical Study of Symmetric Bending and Lifting Behavior in Weightlifter with Lumbar L4-L5 Disc Herniation and Physiological Straightening Using Finite Element Simulation.

Physiological curvature changes of the lumbar spine and disc herniation can cause abnormal biomechanical responses of the lumbar spine. Finite element (FE) studies on special weightlifter models are limited, yet understanding stress in damaged lumbar spines is crucial for preventing and rehabilitating lumbar diseases. This study analyzes the biomechanical responses of a weightlifter with lumbar straightening and L4-L5 disc herniation during symmetric bending and lifting to optimize training and rehabilitation. Based on the weightlifter's computed tomography (CT) data, an FE lumbar spine model (L1-L5) was established. The model included normal intervertebral discs (IVDs), vertebral endplates, ligaments, and a degenerated L4-L5 disc. The bending angle was set to 45°, and weights of 15 kg, 20 kg, and 25 kg were used. The flexion moment for lifting these weights was theoretically calculated. The model was tilted at 45° in Abaqus 2021 (Dassault Systèmes Simulia Corp., Johnston, RI, USA), with L5 constrained in all six degrees of freedom. A vertical load equivalent to the weightlifter's body mass and the calculated flexion moments were applied to L1 to simulate the weightlifter's bending and lifting behavior. Biomechanical responses within the lumbar spine were then analyzed. The displacement and range of motion (ROM) of the lumbar spine were similar under all three loading conditions. The flexion degree increased with the load, while extension remained unchanged. Right-side movement and bending showed minimal change, with slightly more right rotation. Stress distribution trends were similar across loads, primarily concentrated in the vertebral body, increasing with load. Maximum stress occurred at the anterior inferior margin of L5, with significant stress at the posterior joints, ligaments, and spinous processes. The posterior L5 and margins of L1 and L5 experienced high stress. The degenerated L4-L5 IVD showed stress concentration on its edges, with significant stress also on L3-L4 IVD. Stress distribution in the lumbar spine was uneven. Our findings highlight the impact on spinal biomechanics and suggest reducing anisotropic loading and being cautious of loaded flexion positions affecting posterior joints, IVDs, and vertebrae. This study offers valuable insights for the rehabilitation and treatment of similar patients.

Practical Reconstructive Techniques Using the Transoral Approach to Segmental Mandibulectomy With Cosmofix: Technical Report.

This paper introduces a new, less invasive, aesthetic, and functional reconstructive method using a transorally inserted, custom-made Cosmofix fixation plate. Two medication-related cases with stage 3 osteonecrosis of the jaw (MRONJ) are presented. Both procedures required a segmental mandibulectomy as the osteonecrosis had progressed to the mandibular inferior margin and was reconstructed by a transoral approach with a good prognosis. The reconstructed sites were satisfactorily restored with good occlusal conditions and with dentures. No esthetic or functional problems were evident >1 year after surgery. Compared to traditional reconstructive surgery involving facial skin incisions, this technique takes less time, is minimally invasive, is not associated with aesthetic complications, and does not cause facial nerve palsy. Therefore, this procedure may be safely performed in patients with advanced MRONJ who are in poor general condition or older patients.

Quantitative orbital tightening for pain assessment using machine learning with DeepLabCut

Pain assessment in animal models is essential for understanding mechanisms underlying pathological pain and developing effective pain medicine. The grimace scale (GS), facial expression features in pain such as orbital tightening (OT), is a valuable measure for assessing pain in animal models. However, the classical grimace scale for pain assessment is labor-intensive, subject to subjectivity and inconsistency, and is not a quantitative measure. In the present study, we utilized machine learning with DeepLabCut to annotate the superior and inferior eyelid margins and the medial and lateral canthus of the eyes in animals’ video images. Based on the annotation, we quantified the eyelid distance and palpebral fissure width of the animals’ eyes so that the degree of OT in animals with pain could be measured and described quantitatively. We established criteria for the inclusion and exclusion of the annotated images for quantifying OT, and validated our quantitative grimace scale (qGS) in the mice with pain caused by capsaicin injections in the orofacial or hindpaw regions, the Nav1.8-ChR2 mice following orofacial noxious stimulation with laser light, and the oxaliplatin-treated mice following tactile stimulation with a von Frey filament. We showed that both the eyelid distance and the palpebral fissure width were shortened significantly in the animals in pain compared to the control animals without nociceptive stimulation. Collectively, the present study has established a quantitative orbital tightening for pain assessment in mice using DeepLabCut, providing a new tool for pain assessment in preclinical studies with mice.

Cranial-first approach for laparoscopic extended right hemicolectomy.

Complete mesocolic excision and central vascular ligation with D3 lymphadenectomy are important surgical principles for improving oncological outcomes in colon cancer. The cranial-first approach is a colonic mobilization-first approach to radical right hemicolectomy, which has several advantages, including early feasibility assessment, safe dissection from surrounding organs, preestablished inferior margin of lymph node dissection, and revelation of the tangible anatomy of the tributaries of the gastrocolic trunk. This video demonstrates the cranial-first approach to radical right hemicolectomy in a 66-year-old man with locally advanced cecal cancer.

Bilastine 0.6% Preservative-free Eye Drops: A Once-daily Treatment for Allergic Conjunctivitis.

Bilastine is a second-generation antihistamine approved for the symptomatic treatment of allergic rhinoconjunctivitis and urticaria. The present trial evaluated the efficacy and safety of a new bilastine 0.6% preservative-free eye drop formulation for the symptomatic treatment of allergic conjunctivitis. This phase 3, multicenter, double-masked, randomized study compared the efficacy, safety, and tolerability profile of bilastine 0.6% ophthalmic solution with that of ketotifen 0.025% and vehicle. The primary efficacy endpoint was reduction in ocular itching. The Ora-CAC® Allergen Challenge Model was used to assess ocular and nasal symptoms at 15 minutes (onset of action) and 16 hours after treatment. Patients (N=228) were 59.6% male, and the mean (SD) age was 44.1 (13.4) years. Bilastine demonstrated efficacy in reducing ocular itching compared to vehicle at both onset of action and 16 hours after treatment (P<.001). Symptoms improved with ketotifen compared to vehicle 15 minutes after treatment (P<.001). Bilastine demonstrated statistical noninferiority to ketotifen for all 3 post-CAC timepoints at 15 minutes after instillation, based on an inferiority margin of 0.4. Compared with vehicle, bilastine improved in conjunctival redness, ciliary redness, episcleral redness, chemosis, eyelid swelling, tearing, rhinorrhea, ear and palate pruritus, and nasal congestion at 15 minutes after treatment (P<.05). Ophthalmic bilastine was safe and well tolerated. Mean drop comfort scores were significantly better for bilastine than for ketotifen immediately upon instillation (P<.05) and similar to those of vehicle. Ophthalmic bilastine effectively reduced ocular itching for 16 hours after administration, suggesting that it could be used as a once-daily treatment for the signs and symptoms of allergic conjunctivitis. ClinicalTrials.gov identifier: NCT03479307.

Endoscopic Cartilage Modified Inlay Technique With Preserving External Auditory Canal Skin for Repairing Posterior Marginal Perforation.

Objective: To evaluate the graft success rate and hearing gain of endoscopic cartilage myringoplasty with preserving external auditory canal (EAC) skin for posterior marginal perforation. Materials and Methods: We performed a prospective study in 36 patients with posterior marginal perforation who underwent endoscopic cartilage modified inlay technique with preserving EAC skin. Patients were followed up for 12 months. Results: All the 36 patients with unilateral posterior marginal perforation were included in this study. Clinical inosculation of the perichondrium graft and remnant tympanic membrane (TM) occurred at 2 to 3 weeks postoperatively. Simultaneously, neovascularization was initiated at the perichondrium graft. The perichondrium graft had been clinically incorporated to the EAC skin at 2 to 3 weeks postoperatively, which could not be distinguished. At 12 months, residual perforation was seen in inferior margin in one but reperforation was not. The graft success rate was 97.2% (35/36). The mean preoperative air bone gap (ABG) was 29.7 ± 3.8 dB, and the mean postoperative ABG at 12 months was 15.2 ± 3.1 dB; the difference between these values was significant (P < .05; paired-samples t test). The successful surgery rate (postoperative ABG ≤ 20 dB) was 91.7% (33/36). No any intratympanic or EAC cholesteatoma was noted during the follow-up period. Conclusions: Endoscopic cartilage modified inlay technique with preserving EAC skin for repairing posterior marginal perforation is simple and minimally invasive technique, which had shorter operative time, similar graft success rate compared with raising a tympanomeatal flap techniques.

Imaging anatomy study related to unilateral biportal endoscopic lumbar spine surgery.

To provide lumbar spine anatomical parameters relevant to the UBE technique and explore their intraoperative application. CT imaging data processed by Mimics for parametric measurements, including laminar abduction angle (LAA), laminar slope angle (LSA), minimum laminar height (MLH), distance between the inferior margin of the lamina and attachment of the ligamentum flavum onto the cephalad lamina (DLL), distance between the initial point and the middle of the articular process (DIA), and distance from the inferior margin of the lamina to the inferior border of the vertebral body (DLV), and were manually measured. LAA and DIA gradually increase from L1 to L5. At L1, the DIA is approximately the length of 2 drill bits with a diameter of 3mm (male: 7.77 ± 1.39mm, female: 7.22 ± 1.09mm), while at L5, it can reach the length of 4-5 drill bits (male: 14.96 ± 2.24mm, female: 13.67 ± 2.33mm). MLH, DLL, and DLV reach their maximum values at the L3 and decrease toward the cranial and caudal ends. The DLL is smallest at L5 (male: 9.58 ± 1.90mm, female: 9.38 ± 2.14mm), equivalent to the length of 3 drill bits, while the DLL at L3 is the length of 4-5 drill bits (male: 14.17 ± 2.13mm, female: 14.01 ± 2.07mm). Referring to the drill diameter during surgery can mark the extent of laminotomy. The characteristics of vertebral plate angles at different lumbar levels can provide references for preoperative incision design.

Exploring cranial macromorphoscopic variation and classification accuracy in a South African sample

To date South African forensic anthropologists are only able to successfully apply a metric approach to estimate population affinity when constructing a biological profile from skeletal remains. While a non-metric, or macromorphoscopic approach exists, limited research has been conducted to explore its use in a South African population. This study aimed to explore 17 cranial macromorphoscopic traits to develop improved methodology for the estimation of population affinity among black, white and coloured South Africans and for the method to be compliant with standards of best practice. The trait frequency distributions revealed substantial group variation and overlap, and not a single trait can be considered characteristic of any one population group. Kruskal-Wallis and Dunn’s tests demonstrated significant population differences for 13 of the 17 traits. Random forest modelling was used to develop classification models to assess the reliability and accuracy of the traits in identifying population affinity. Overall, the model including all traits obtained a classification accuracy of 79% when assessing population affinity, which is comparable to current craniometric methods. The variable importance indicates that all the traits contributed some information to the model, with the inferior nasal margin, nasal bone contour, and nasal aperture shape ranked the most useful for classification. Thus, this study validates the use of macromorphoscopic traits in a South African sample, and the population-specific data from this study can potentially be incorporated into forensic casework and skeletal analyses in South Africa to improve population affinity estimates.

Dual-plane lift-and-hold technique for brow ptosis in young patients with facial paralysis

Direct browlift is useful but leaves a scar above the brow. We proposed a dual-plane browlift to avoid facial scarring while effectively resolving brow ptosis in young and young adult patients. Seven patients with facial palsy underwent dual-plane browlift between July 2018 and June 2022. The mean postoperative follow-up period was 31.9months. Skin resection at the hairline was combined with subcutaneous dissection down to the inferior margin of the brow to "lift" the brow. Fascia lata strips were fixed to the dermis just inferior to the eyebrow to "hold" the brow, and the strips were suspended upward through the subperiosteal tunnel and fixed to the periosteum. Brow height was compared before and after the procedure and with the contralateral side. The reported complications included slight hematoma at the recipient site, temporary difficulty in closing the eye, and seroma at the fascia donor site. The paralyzed side showed significant differences between the preoperative period and postoperative months (POM) 3, 6, and 12, but differences were not shown in the intervals between POM 3 and 6, 6 and 12, or 3 and 12. The difference in eyebrow height between the paralyzed and nonparalyzed sides was significant preoperatively but not at POM 3, 6, or 12. All scars matured well, and the fascia silhouette was not visible in the forehead region. Dual-plane browlift enables rigid suspension using the fascia lata and excises flaccid skin without leaving facial scars, yielding excellent cosmetic quality and stable long-term outcomes.

Radiographical Assessment of the Subpubic Angle among Adult Bini Tribe in Nigeria and Overview of its Significance

Abstract Background: Pelvimetry is an important component of anthropometry which entails the assessment of pelvis morphometry. This includes subpubic angle (SPA) which is an important parameter with diverse applications. Objective: This study was conducted to determine the standard SPA values among the Bini tribe in Nigeria and elucidate their significance. Materials and Methods: This study employed anteroposterior pelvic radiographs of 85 male and 95 female adult Binis between 25 and 55 years. The SPA was measured as the angle formed by the intersection of inferior margins of the pubic rami. Data obtained were analyzed and presented as mean and standard deviation with comparison undertaken using a t-test (where P &lt; 0.05 was regarded as statistically significant). Results: The male SPA (85.67 ± 8.04) was significantly lower (P = 0.035) than the female SPA (114.38 ± 9.70). Regarding the age groups, the male SPA (85.94 ± 6.08) was significantly lower than the female SPA (112.88 ± 9.59) among &lt; 30 years; the male SPA (85.76 ± 8.78) was significantly lower than the female SPA (116.40 ± 7.41) among 31 to 40 years; the male SPA (84.75 ± 8.02) was significantly lower than the female SPA (113.59 ± 10.03) among 41 to 50 years, and the male SPA (86.13 ± 7.53) was significantly lower than the female SPA (113.96 ± 8.63) among over 50 years. Conclusion: The SPA has great significance as an estimator of sex and race during forensic procedures. Clinically, it is a vital parameter that plays a significant role in the determination of the mode of parturition in pregnant females at term.

Supernumerary Puncta: An Uncommon Underdiagnosed Cause of Unilateral Epiphora

Introduction The presence of multiple eyelid puncta is known as supernumerary puncta. The presence of supernumerary puncta is caused by lacrimal outflow dysgenesis and can result in unilateral epiphora. Although an infrequent diagnosis, supernumerary puncta should be considered in the differential diagnosis of unilateral epiphora to allow for the correct management of patient’s symptoms. Case Report A 74-year-old white male presented with a chief complaint of unilateral epiphora of his right eye. The presence of two puncta on the inferior lid margin of one eye was noted. Further evaluation with anterior segment optical coherence tomography (OCT) revealed that both puncta were functional. Occlusion of the accessory punctum and use of artificial tears four times a day was the treatment which led to the resolution of his symptoms. Conclusion Through a careful examination and assessment, the root cause of epiphora can be determined, and the appropriate management can be pursued. Although not exceptionally rare, supernumerary puncta may be present and cause epiphora through lacrimal outflow dysgenesis. Supernumerary puncta can be identified easily with careful slit lamp examination. Probing of the punctum and anterior segment OCT can be used to identify the accessory punctum and determine its functionality.

New neovagina-creating technique on the basis of a fasciocutaneous flap for Müllerian agenesis

To present a new surgical technique on the basis of an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of the external genitalia. Video demonstration of the surgical steps. An 18-year-old woman with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counseling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve the external genitalia with the chance to have a sensitive vagina guided the choice. The cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm-long canal bounded anteriorly by the bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying the vascular-from the pudendal artery-and nervous pedicles. A tunnel between the flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching the vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. The inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. During the postoperative period, no special positioning or ambulation restrictions were used. Compliance and sensitivity of the neovagina, esthetic result, and perioperative and long-term complications. The postoperative course was uneventful, with early mobilization. The length of hospital stay was 16 days to allow proper vaginal dilator use; initial daily followed by intermittent use was planned. At a 2-year follow-up, the neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and esthetic result. The new surgical technique was feasible and effective, preserving the external genitalia and avoiding graft healing and bowel secretion drawbacks without an intra-abdominal surgical step and related risks. However, more cases-2 cases performed to date with similar results-and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and the connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.

Right upper lobectomy with mediastinal dissection under uniportal video-assisted thoracoscopic surgery for lung cancer in a patient with a right-sided aortic arch: a case report

BackgroundA right-sided aortic arch is a rare congenital vascular structure variation. Right lobectomy is not commonly performed on patients with such a condition. Further, there are no reports on lobectomy under uniportal video-assisted thoracoscopic surgery (VATS) in this patient group.Case presentationA 67-year-old man with a right-sided aortic arch and Kommerell diverticulum underwent right upper lobectomy with mediastinal lymph node dissection under uniportal VATS for primary lung cancer. Due to the right descending aorta, which narrows the space of the dorsal hilum, handling of the stapler for stapling the right upper lobe bronchus from the uniport in the 6th intercostal space at the medial axillary line can be challenging. This issue was resolved by manipulating the staple over the azygos vein toward the inferior margin of the aortic arch. Via mediastinal lymphadenectomy, we found that the right recurrent laryngeal nerve branched from the right vagus nerve and hooked around the right-sided aortic arch.ConclusionsRight lobectomy with mediastinal lymph node dissection under uniportal VATS can be performed for lung cancer in patients with a right-sided aortic arch.

Raktamokshana by Jalauka in the management of Shophayukta Charmakeela Arsha w.s.r. to inflamed sentinel tag: A case study

Chronic fissure in a no is characterized by a sentinel tag externally between which lies the slightly indurated anal ulcer overlying the fibers of the internal sphincter. Chronic fissure is an inflamed &amp; indurated margin and a sentinel tag at its inferior margin, which is edematous &amp; acts like a guard. It causes repeated infections, discomfort, burning sensation. Charmakeela arshas is an immovable growth in exterior skin, correlated with sentinel pile. Here the shophayukta charmakeela arshas (inflamed sentinel piles) are treated with jalauka. Jalauka has sheetha and madhuraguna because it helps to remove excess doshas from inflamed sentinel piles and helps to reduce pain and swelling. Jalaukavacharana done on inflamed pile mass for 3 days of interval of 1 day, other oral medications, avagaha sweda (sitzbath) and local application. This paper elaborates upon the effect of jalaukavacharana in the management of inflamed sentinel pile.

Inverted Internal Limiting Membrane Flap Coverage With Autologous Blood Technique After Air-Fluid Exchange and Silicone Oil Tamponade for Extensive Macular Hole Retinal Detachment in Highly Myopic Eyes.

To report a technique consisting of inverted internal limiting membrane (ILM) flap coverage with autologous blood after air-fluid exchange and silicone oil tamponade in treating extensive retinal detachment secondary to a myopic macular hole (MH). This was a retrospective case series. 18 eyes with MHRD extending beyond the equator were included in this study with a minimum follow-up of 6 months. The procedures for pars plan vitrectomy (PPV) included the following: 1) The ILM was peeled to the superior and inferior arcade margins and, except for the ILM in the temporal region, was hinged toward the edge of the MH. 2) Air-fluid exchange was then performed to drain the subretinal fluid through the MH with a flute needle, ensuring that a small amount of subretinal fluid remained to facilitate ILM flap inversion. 3) The ILM flap was used to cover the MH with the assistance of autologous blood. Six months after surgery, the MH was successfully anatomically closed, and retinal reattachment was observed in all 18 eyes of 18 patients. The mean best-corrected visual acuity logarithm of the minimum angle of resolution (logMAR) improved from 2.03 ± 0.61 (ranging from hand motion [2.6] to finger counting [2.3]) to 1.23 ± 0.63 (ranging from hand motion [2.6] to 20/28 [0.15]) ( P < 0.01) at 6 months. This surgical technique using an inverted ILM flap combined with autologous blood provides an option for the treatment of extensive MHRD.