Invasive Surgery Techniques Research Articles

Comparison of strategies based on DTI visualisation for stereotactic minimally invasive surgery in the treatment of moderate-volume thalamo-basal ganglia cerebral haemorrhage: a protocol for a multicenter prospective study

IntroductionHypertensive intracerebral hemorrhage (HICH) is a condition associated with significant morbidity, mortality, and disability, particularly among the elderly population. The management of moderate thalamic-basal ganglia cerebral hemorrhage primarily relies on conservative approaches. Nevertheless, the rate of long-term disability remains high. In recent years, there has been significant advancement in minimally invasive surgery and diffusion tensor imaging techniques. Consequently, the utilization of Diffusion Tensor Imaging (DTI) technology in patients with cerebral haemorrhage allows for the identification of the haematoma’s location in relation to the Corticospinal Tract (CST). This enables the development of precise puncture pathways that can be visualized, thereby avoiding any potential damage to the CST.Methods and analysisDiffusion Tensor Imaging (DTI) is a method used to assess the structural and physiological characteristics of biological tissue by examining the diffusion behavior of water molecules.In the central nervous system, limb paralysis will be inevitable if the corticospinal tract is damaged. By employing DTI imaging techniques on individuals, it becomes possible to visualize the spatial relationship between the hematoma and the CST. This approach allows avoidance of the CST during preoperative planning of the puncture path, thus reducing secondary injuries caused by the procedure. The primary objective of this study was to assess the ability of patients in the minimally invasive surgery group and the conservative group to perform activities of daily living after 6 months of treatment. In addition, secondary outcomes included assessment of hematoma resorption/clearance ratios, cytokine levels, complication rates, and therapeutic indexes at different treatment durations, as well as long-term safety and efficacy at 2–3 years of follow-up. Furthermore, subgroup analysis, and sensitivity analysis were conducted to further analyze the data. Logistic single-variate and multivariate regression analyses were applied to understand the adverse factors affecting prognosis.Ethics and disseminationThe clinical study was reviewed and approved by the Ethics Committee of the First People’s Hospital of Yibin. The ethical number is: 2023 Review (64).Registration numberThis protocol is registered in the Prospective Registry of Chinese Clinical Trial Registries (PROCCTR). The full date of first registration is 28/12/2023. The registration number for PROCCTR is ChiCTR2300079252.

Proximal lumbar anterior column realignment for iatrogenic sagittal plane adult spinal deformity correction: a retrospective case series

Anterior column realignment (ACR) is a powerful minimally invasive surgery (MIS) technique to restore sagittal alignment in adult spinal deformity (ASD). This can accomplish similar segmental lordosis restoration as 3-column osteotomy with less blood loss and comparable complication rates. ACR can be performed at adjacent disease segments in the proximal lumbar spine in revision cases. However, two-thirds of physiologic lordosis occurs between L4-S1, and concerns remain about altered lumbar morphology. We evaluated patients who underwent proximal lumbar ACR for iatrogenic flatback deformity. A total of 19 consecutive patients who underwent L1-2 or L2-3 ACR were retrospectively analyzed. All patients were treated with lateral MIS interbody technique, followed by posterior reconstruction with Smith-Peterson osteotomy (SPO). Pre- and post-operative radiographic and clinical outcomes were obtained. Mean follow-up was 19-months. All but one patient had a history of prior lumbar or lumbo-sacral fusion. SVA and PI-LL decreased from 11.9 cm to 6.1 cm (p<0.0001) and 34.2° to 12.8° (p<0.0001). Segmental lordosis increased from -2.7° to 21.9° (p<0.0001). Proximal lumbar lordosis (PLL) increased from -0.4° to 22.6° (p<0.0001), and lordosis distribution index (LDI) decreased from 79.5% to 48.9% (p<0.0001). Mean ODI and NPRS back pain decreased from 58.0 to 36.2 (p=0.0041) and 7.9 to 3.4 (p<0.0001). PROMIS-10 Physical and Mental Health T-scores increased from 34.1 to 43.3 (p=0.0049) and 40.4 to 45.0 (p=0.0993). Major complication rate was 15.8%. One patient required revision for mechanical failure. There were no permanent neurological or vascular injuries. Proximal lumbar ACR plus SPO can achieve sagittal correction with low major complication rates in patients with ASD and prior distal fusion. Differentially increasing PLL and lowering LDI did not have deleterious effects on radiographic or clinical outcomes. Further work is needed to understand the effect of proximal ACR in the surgical management of ASD.

Age-Related Association Between Unilateral Single-Channel and Double-Channel Surgery and Postoperative Multifidus Muscle Atrophy and Fat Infiltration.

Unilateral biportal endoscopic laminotomy (UBE) and percutaneous endoscopic laminotomy (PEL) are minimally invasive spinal surgery (MISS) techniques used for unilateral and dual-channel endoscopic laminectomy. However, limited research has been conducted on lumbosacral multifidus muscle injuries in elderly individuals undergoing MISS for lumbar spinal canal stenosis. The objective of this study was to investigate the impact of single-channel and double-channel MISS on the multifidus muscle in elderly patients. A total of 107 patients who underwent MISS were stratified into two cohorts: group A (<65 years) and group B (≥65 years). Preoperative imaging data, including magnetic resonance imaging, were gathered to classify the degree of stenosis based on the nerve root compression. The extent of multifidus muscle atrophy and fat infiltration was assessed by calculating the fat-free cross-sectional area (FCSA)/cross-sectional area (CSA) ratio before and after surgery through measurements of CSA and FCSA. Total cross-sectional area/FCSA were calculated using MRI cross-sectional T2WI. The degree of atrophy and fat infiltration did not change between procedures in group A (P>.05), but changed significantly in group B (P<.05). Unilateral single-channel and double-channel surgery had no significant effect on the degree of multifidus muscle atrophy and fat infiltration in patients younger than 65 years. However, in patients 65 years and older, the degree of multifidus muscle atrophy and fat infiltration significantly increased with the increasing incidence of lateral recess stenosis, which was positively correlated with the duration of surgery. [Orthopedics. 202x;4x(x):xx-xx.].

Complications after Gonioscopy-Assisted Transluminal Trabeculotomy in glaucoma treatment - literature review.

Glaucoma is a disease that leads to optic nerve damage and irreversible loss of the visual field. Gonioscopy-assisted transluminal trabeculotomy (GATT) is a minimally invasive glaucoma surgery technique, where the surgeon opens the trabecular network and Schlemm's canal to improve the outflow of the aqueous humor. This method has shown efficacy in reducing intraocular pressure in patients with primary and secondary glaucoma. GATT has gained popularity due to its minimally invasive nature, compatibility with cataract surgery and relatively low cost. Despite its advantages, the procedure can be associated with many complications such as hyphema, intraocular pressure spikes and corneal edema. In rare cases, it can lead to Descemet's membrane detachment or cystoid macular edema. The success of GATT procedure mostly depends on the surgeon's skill and experience, but also on the patient's risk factors, including age and preoperative intraocular pressure levels. Further studies are required to understand long outcomes and identify the patients, who may be at higher risk of complications.

Laparoscopic transductal common bile duct exploration after previous laparoscopic cholecystectomy and failed endoscopic retrograde cholangiopancreatography: minimally invasive surgery technique.

Laparoscopic transductal common bile duct exploration after previous laparoscopic cholecystectomy and failed endoscopic retrograde cholangiopancreatography: minimally invasive surgery technique.

Single-Level Unilateral Biportal Endoscopic versus Tubular Microdiscectomy: Comparing Surgical Outcomes and Opioid Consumption

Unilateral biportal endoscopic (UBE) microdiscectomy is an emerging minimally invasive surgery technique for treating symptomatic lumbar disc herniation. There is limited literature regarding outcomes. Here, we assess surgical outcomes and pain medication consumption for UBE vs. tubular lumbar microdiscectomy. This was a retrospective cohort study of adult patients undergoing primary, single-level UBE or tubular lumbar microdiscectomy surgery at a high-volume institution between 2018 and 2023. Variables of interest included operative time, complications and reoperations, as well as postoperative opioid and nonopioid pain medication consumption from discharge to 6 months. Opioid consumption was converted to morphine milligram equivalents. Standard statistical analyses were performed for comparative analyses. One hundred two patients-48 UBE and 54 tubular-were included. Average operative time (minutes) was higher for UBE patients (133.1 UBE vs. 86.6 tubular, P<0.001), which trended downward over time but did not reach statistical significance (P=0.07). There were no differences in complication or reoperation rates. Average daily MME was lower from discharge to 2-week follow-up in the UBE group (11.1 v. 14.1, P=0.02), but were comparative thereafter. Nonopioid medication prescription was lower in the UBE cohort from discharge to 2 weeks (70.8% vs. 92.6%, P=0.01) and 2 to 6 weeks (52.1% vs. 85.2%, P<0.001), with no significant differences thereafter. UBE microdiscectomy is associated with longer operating times. Both opioid and nonopioid pain medication consumption were lower for UBE patients during the initial postoperative period, perhaps owing to the less-invasive nature of the surgery.

Ankle Fractures Treated with Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique

OBJECTIVES: To describe and report outcomes of a minimally invasive open intramedullary (IM) fibular nailing technique for fixation of ankle fractures. METHODS: Design: Case Series Setting: Urban Level 1 trauma center Patient Selection Criteria: Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing via a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Outcome Measures and Comparisons: Quality of reduction, complications, and patient-reported outcomes (PRO). RESULTS: A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean BMI was 30.6 ± 7.4 kg/m2. 93(62%) patients were female, and 78 (52%) patients were Caucasian. 72 (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients were diabetic, and 23 (15.3%) patients had open fractures. 37 (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65(43.3%) had trimalleolar fractures. 123 (82%) patients had 2 syndesmotic screws placed, 26 (17.3%) had 1 screw, and 1 (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan’s criteria. 113 patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months). 110 patients (97.3%) went on to successful clinical and radiographic union following the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. 3 patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). 9 (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9° (0-40) of dorsiflexion, 39.6° (10-70) of plantarflexion, 23.5° (5-40) of inversion, and 18.2° (5-50) of eversion. Mean PROs at final follow-up visit were: Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72) and Mobility: 36.9 (16-65.3). CONCLUSIONS: Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Recent patterns in minimally invasive colectomies: Where are we now?

ObjectiveMinimally invasive surgery (MIS) techniques such as laparoscopy and robotic surgery for colorectal resection have been cited as superior to traditional open surgery because of their associations with decreased operating room time, hospital stay length, and postoperative morbidity. Despite these benefits, the open approach remains a common surgical method for colorectal resection procedures. We aim to evaluate the most recent yearly trends in open, laparoscopic, and robotic approaches to provide insight into uptake and present the status of MIS in the field of colorectal surgery. MethodsData were collected from the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database for the years 2014–2020. The surgical approach was classified as either open, laparoscopic, or robotic. Analysis was performed to identify trends in colorectal surgery categorized by year, patient age, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and emergency status. ResultsThere was an overall decline in both open and laparoscopic surgery cases (from 38.4% to 34.4% and from 57.4% to 50.8%, respectively) and an overall increase in robotic surgery cases (from 4.2% to 14.8%) from 2014 through 2020. Open surgery was the most common approach for the lowest BMI category (<18.5), highest risk ASA classes (4–5) and most emergent surgeries, whereas robotic surgery rates were negligible for these groups. Laparoscopy was the most prevalent approach for all other categories. ConclusionLaparoscopy was the most prevalent approach in colorectal surgery, although the total case proportions generally tended to decrease. While open surgery remains the approach of choice for emergent procedures, laparoscopic case proportions increased marginally in this category, likely owing to increases in surgeon comfort and continued expansion of laparoscopic training efforts. Importantly, the total prevalence of robotic surgery increased significantly between 2014 and 2020, which may be attributable to advancements in the robotic platform and increases in familiarity and competence with the technology. We anticipate a continuation of these trends in the future and recommend the creation of a national robotic surgery training standard.

Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access.

Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

Minimally Invasive Surgery for Hirschsprung Disease: Current Practices and Future Directions.

Hirschsprung disease (HD) is a congenital disorder characterized by the absence of ganglion cells in the distal colon and rectum, leading to functional obstruction and severe constipation. Over the past decades, the surgical management of HD has significantly evolved, with minimally invasive surgery (MIS) techniques revolutionizing treatment approaches. This review explores recent innovations in MIS for HD, focusing on laparoscopic, transanal endorectal pull-through (TERPT), and robotic-assisted techniques. These approaches offer numerous advantages over traditional open procedures, including reduced surgical trauma, improved cosmesis, faster recovery times, and potentially lower complication rates. Laparoscopic surgery has become widely adopted, providing excellent visualization and precise dissection. TERPT has gained popularity for short-segment disease, offering a completely transanal approach with minimal scarring. Robotic-assisted surgery represents the cutting edge, enhancing surgical precision and dexterity. The review also examines emerging technologies and future directions, such as advanced imaging techniques, artificial intelligence applications, and potential developments in tissue engineering. While MIS techniques have shown promising outcomes, challenges remain in standardizing approaches, addressing long-segment disease, and optimizing long-term functional results. The future of HD surgery lies in personalized approaches that integrate genetic and molecular profiling with advanced surgical technologies. As the field continues to evolve, comprehensive long-term studies and efforts to improve access to specialized care will be crucial to further enhancing outcomes for patients with HD.

New Perspectives on Risk Assessment and Anticoagulation in Elective Spine Surgery Patients: The Impact of Ultra-Minimally Invasive Endoscopic Surgery Techniques on Patients with Cardiac Disease.

The advent of ultra-minimally invasive endoscopic spine surgery, characterized by significantly reduced surgery times, minimal blood loss, and minimal tissue trauma, has precipitated a paradigm shift in the preoperative management of patients with cardiac disease undergoing elective spine procedures. This perspective article explores how these advancements have influenced the requirements for preoperative cardiac workups and the protocols surrounding the cessation of anticoagulation and antiplatelet therapies. Traditionally, extensive cardiac evaluations and the need to stop anticoagulation and antiplatelet agents have posed challenges, increasing the risk of cardiac events and delaying surgical interventions. However, the reduced invasiveness of endoscopic spine surgery presents a safer profile for patients with cardiac comorbidities, potentially minimizing the necessity for rigorous cardiac clearance and allowing for more flexible anticoagulation management. This perspective article synthesizes current research and clinical practices to provide a comprehensive overview of these evolving protocols. It also discusses the implications of these changes for patient safety, surgical outcomes, and overall healthcare efficiency. Finally, the article suggests directions for future research, emphasizing the need for updated guidelines that reflect the reduced perioperative risk associated with these innovative surgical techniques. This discussion is pivotal for primary care physicians, surgeons, cardiologists, and the broader medical community in optimizing care for this high-risk patient population.

Prospective comparison of minimally invasive glaucoma surgery techniques for goniotomy in primary congenital glaucoma: Optimizing intraocular pressure control

BackgroundA family of less invasive glaucoma procedures has been developed to provide moderate reductions in intraocular pressure and medication burden in eyes with therapeutic needs that may not warrant the risks associated with trabeculectomy and tube shunt implantation. This study aims to compare the effectiveness and clinical outcomes of pediatric goniotomy using minimally invasive glaucoma surgery techniques to manage primary congenital glaucoma. Materials and methodsUsing a computer-generated set of random numbers, the patients were randomized into three groups: Kahook blade group, microvitreoretinal blade group, and 23G needle group. Each group contained 22 eyes. All patients underwent anesthesia for intraocular pressure measurement, corneal diameter evaluation, and fundoscopy. Preoperative intraocular pressure at presentation and postoperative intraocular pressure were recorded during a one-year follow-up period. Outcome measures included decreases in corneal diameter from preoperative size, mean postoperative reduction in intraocular pressure for each minimally invasive glaucoma surgery technique and absence of intraoperative or postoperative complications. Surgical success was defined as a postoperative intraocular pressure of ≤20 mmHg without antiglaucoma medications or reoperation, based on the last recorded intraocular pressure during postoperative follow-up. ResultsA total of 66 eyes were diagnosed with primary congenital glaucoma and underwent goniotomy surgeries during the study period in 2022. The majority (89%) were bilateral cases. Among the patients, there were 26 males and 9 females, which makes up an 8: 2 male-to-female ratio, with an average age range of 2 months to 2 years. After a one-year postoperative follow-up, a significant reduction in intraocular pressure was achieved of ≤18 mmHg. In terms of surgical success with minimally invasive glaucoma surgery techniques, goniotomy with a 23-gauge needle had the most postoperative intraocular pressure, followed by the microvitreoretinal blade and the Kahook blade. On average, the 23-gauge needle had a corneal diameter of 13.8 mm, while the microvitreoretinal blade was 13.9 mm and the Kahook blade recorded 14 mm. ConclusionsGoniotomy using minimally invasive glaucoma surgery techniques has been proven to be an effective surgical technique for the management of childhood glaucoma among Nigerian patients. A reduction in postoperative intraocular pressure, corneal diameter, and absence of complications provide clinical evidence of successful glaucoma management and preservation of outcomes of visual function in patients. Level of evidenceLevel 1 (Prospective study)

Frequency and management of rod fractures following minimally invasive bipolar fusionless surgery in neuromuscular scoliosis patients

IntroductionNeuromuscular scoliosis (NMS) is associated with an abnormal muscle tone. Traditional conservative treatments, with the historical practice of early posterior fusion, have proven ineffective. Recently, growth-sparing techniques have gained traction owing to their ability to maximize trunk height. However, these techniques have a substantial risk of complications, particularly rod breakage, with reported incidence rates ranging from 15 % to 42 %. The objective of this study was to conduct a descriptive analysis of NMS patients who experienced rod breakage following the minimally invasive fusionless surgery (MIFS) technique. MethodsThis was a single-center, retrospective study that included all NMS patients who underwent surgery between January 2015 and January 2021 and subsequently presented with rod breakage after MIFS. The MIFS technique is based on proximal fixation with double hook claws made of pedicular and -sus laminar hooks and pelvic fixation with iliosacral screws. ResultsThe mean follow-up was 5.2 ± 2.2 years. The mean dominant etiology of NMS was cerebral palsy (67 %). Of the 217 patients who underwent surgery, 15 (6.9 %) developed rod breakage. Rod breakage occurred 2.7 ± 1.3 years after the initial surgery. Four cases of rod fracture recurrence were reported in ambulatory patients with dystonia or hyperactivity. ConclusionCompared with other fusionless techniques, the minimally invasive bipolar technique appears promising for patients with NMS, with a lower rate of rod breakage. We recommend the use of a four-rod construct for ambulatory patients or for those with dystonia or hyperactivity.

The use of minimally invasive surgical techniques ın pediatric patients with partial anomalous pulmonary venous return

Aim The use of minimally invasive procedures in low-risk congenital heart surgeries has been increasing recently. Compared to traditional median sternotomy, minimally invasive techniques offer better cosmetic results and provide more satisfaction to both the patient and their parents. Partial anomalous pulmonary venous return (PAPVR) can be safely repaired using these techniques. Material and Metods The perioperative data of right- sided PAPVR patients who were operated on using minimally invasive approaches in our clinic between March 2019 and January 2023 were reviewed retrospectively. The perioperative data of the patients' including , type of surgery , cardiopulmonary bypass time, cross-clamp time, postoperative cardiac rhythm, total operation time, total drainage, total intensive care unit time, and total hospital stay time were obtained. The results were compared with the data in the current literature. Results During the study period, 14 patients underwent surgical repair. Five (36%) of them were female and nine (64%) were male. Patients undergoing right infraaxillary vertical thoracotomy (RIAVT) and right anterolateral thoracotomy (RALT) had mean ages of 48±26.6 and 42±18.2 month, respectively. High venosum type atrial septal defect (ASD) was detected in 12 (85.7%) of the patients. The most frequently used surgical treatment was the double patch technique which was used in 12 patients (85.7%). This was followed by single patch repair with one patient (7.1 %). The Warden procedure was used in one patient (7.1%) who was operated on with the RIAVT technique. Patients’ cross-clamp, cardiopulmonary bypass (CPB), and total operation times were comparable to those reported in the medical literature. Conclusion RIAVT and RALT are two of the oftenly used minimally invasive surgical techniques in congenital heart surgery. After gaining sufficient experience, both of these methods can be safely applied to PAPVR repair.

Adoption, Outcomes, and Healthcare Professionals’ Perceptions of Minimally Invasive Surgical Techniques in Neonatology and Pediatric Surgery: A Clinical Study

ABSTRACT Background: Minimally invasive surgical techniques have revolutionized neonatology and pediatric surgery by offering less traumatic procedures with reduced recovery times and improved outcomes. However, healthcare professionals’ perceptions regarding these techniques and their adoption rates remain varied and warrant investigation. Materials and Methods: A clinical study was conducted to assess the adoption, outcomes, and healthcare professionals’ perceptions of minimally invasive surgical techniques in neonatology and pediatric surgery. Data was collected through surveys distributed among healthcare professionals involved in neonatal and pediatric surgical care across multiple institutions. Adoption rates were quantified, outcomes were assessed through a comparative analysis of surgical success and complication rates, and healthcare professionals’ perceptions were evaluated using Likert scale-based questions. Results: The adoption rate of minimally invasive surgical techniques in neonatology and pediatric surgery was found to be 75%, indicating a significant acceptance within the medical community. Comparative analysis revealed that minimally invasive procedures yielded lower complication rates (arbitrary value: 20%) and shorter hospital stays (arbitrary value: 30%) compared to traditional open surgeries. Healthcare professionals’ perceptions indicated a high level of satisfaction and confidence in the efficacy and safety of minimally invasive techniques. Conclusion: Minimally invasive surgical techniques have been widely adopted in neonatology and pediatric surgery, demonstrating superior outcomes in terms of reduced complication rates and shorter hospital stays. Healthcare professionals’ positive perceptions highlight the potential for further integration and advancement of these techniques in clinical practice, ultimately benefiting pediatric patients.

Imaging of Minimally Invasive Surgical Techniques in Epilepsy: What the Radiologist Needs to Know

Imaging plays an increasingly important role in the preoperative evaluation, surgical guidance, and follow-up of patients with epilepsy, particularly with adoption of minimally invasive techniques in epilepsy surgery. These techniques offer increased precision, reduced surgical morbidity, and comparable outcomes. For radiologists, it is important to be familiar with these emerging techniques to understand their expected imaging appearance and potential complications. This review covers the role of imaging within a multidisciplinary approach to minimally invasive epilepsy surgery.Learning Objective: To identify the expected imaging appearance and potential complications of minimally invasive surgical techniques for epilepsy.

Assessing the Fractional Curve for Proper Management of Adult Degenerative Scoliosis.

Adult degenerative scoliosis (ADS) is a coronal plane deformity often accompanied by sagittal plane malalignment. Surgical correction may involve the major and/or distally-located fractional curves (FCs). Correction of the FC has been increasingly recognized as key to ameliorating radicular pain localized to the FC levels. The present study aims to summarize the literature on the rationale for FC correction in ADS. Three databases were systematically reviewed to identify all primary studies reporting the rationale for correcting the FC in ADS. Articles were included if they were English full-text studies with primary data from ADS ( ≥ 18 years old) patients. Seventy-four articles were identified, of which 12 were included after full-text review. Findings suggest FC correction with long-segment fusion terminating at L5 increases the risk of distal junctional degeneration as compared to constructs instrumenting the sacrum. Additionally, circumferential fusion offers greater FC correction, lower reoperation risk, and shorter construct length. Minimally invasive surgery (MIS) techniques may offer effective radiographic correction and improve leg pain associated with foraminal stenosis on the FC concavity, though experiences are limited. Open surgery may be necessary to achieve adequate correction of severe, highly rigid deformities. Current data support major curve correction in ASD where the FC concavity and truncal shift are concordant, suggesting that the FC contributes to the patient's overall deformity. Circumferential fusion and the use of kickstand rods can improve correction and enhance the stability and durability of long constructs. Last, MIS techniques show promise for milder deformities but require further investigation.

Comparison of tibial fracture plate length, placement, and fibular integrity effects on plate integrity through finite element analysis

Minimally invasive plate osteosynthesis is the most commonly used minimally invasive surgery technique for tibial fractures, possibly involving single or dual plate methods. Herein, we performed a finite element analysis to investigate plate strength according to the plate type, length, and presence of a fibula by constructing a three-dimensional tibia model. A thickness of 20 mm was cut 50 mm distal from the lateral plateau, and the ligaments were created. Plates were modeled with lengths of 150, 200, and 250 mm and mounted to the tibia. Screws were arranged to avoid overlapping in the dual plating. The von-Mises stress applied to the plates was measured by applying a load of 1 body weight. Dual plates showed the least stress with low displacement, followed by medial and lateral plates. As the plate length increased, the average stress gradually decreased, increasing plate safety. The difference in the influence of the fibula depending on the presence of proximal fibula osteotomy showed that the average stress increased by 35% following proximal fibula osteotomy in the D1(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Non Proximal fibula osteotomy) and D1P(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Proximal fibula osteotomy) models, confirming the necessity of the fibula model. There is no consensus guideline for treatment of this kind of fracture case. A single fracture plate can decrease the risk of skin damage, ligament damage, and wound infection, but because of its design, it cannot provide sufficient stability and satisfactory reduction of the condylar fragment, especially in cases of comminution or coronal fracture. So, these results will help clinicians make an informed choice on which plate to use in patients with tibial fractures.

(084) PERSISTENT GENITAL AROUSAL DISORDER/GENITO-PELVIC DYSESTHESIA (PGAD/GPD) SECONDARY TO TARLOV CYST-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent, unwanted genital arousal and/or other dysesthesia, including burning, itch and/or pain in the genito-pelvic area such as clitoris, vulva, perineal region and/or peri-anal region (pudendal nerve), umbilicus, urethra, bladder, vagina, and/or rectum (pelvic nerve) and also including the lower extremity buttock, thigh, calf, foot (sciatic nerve). Patients with PGAD/GPD are significantly bothered/distressed, and catastrophization and suicidal ideation are common. In 2012 Komisaruk reported that PGAD/GPD could result from Tarlov cyst-induced sacral radiculopathy. We developed a multidisciplinary step-care management algorithm with specialists in sexual medicine, spine surgery, sex therapy, physical therapy, and neurophysiology to diagnose and treat Tarlov cyst-induced sacral radiculopathy. Objective To utilize a multidisciplinary step-care management algorithm to identify PGAD/GPD patients with Tarlov cyst-induced sacral radiculopathy who could benefit from Tarlov cyst spine surgery and to evaluate long-term safety and efficacy of the surgery. Methods Clinical data were collected on PGAD/GPD patients who underwent Tarlov cyst spine surgery between 2016 and 2020 with at least 1-year follow-up. The management algorithm used to identify and treat Tarlov cyst-induced sacral radiculopathy involves: detailed psychosocial assessment and medical history; non-invasive diagnostic assessments for sacral radiculopathy; sacral MRI with Tarlov cyst protocol; targeted diagnostic caudal epidural injection; and if appropriate, Tarlov cyst spine surgery using minimally invasive surgery techniques. Treatment outcome was based on the validated Patient Global Impression of Improvement (PGI-I) measured at regular intervals post-operatively. Results Ten patients (8 women, 2 men), mean age 40 years (range 19-66), met inclusion criteria. Patients were discharged the same day or following morning post-operatively. No serious complications occurred. Follow-up was &amp;gt;12 months (range 13-22 months). Seven (70%) patients reported post-operative clinical improvement on PGI-I at last follow up: two patients reported “very much better”, three patients reported “much better” and two patients reported “little better”. Two patients had no improvement. Only one patient was much worse, however we believe that the PGI-I score of 6 reflected the worsening of the PGAD/GPD condition and not specifically the result of the surgical procedure. Conclusions Distressing PGAD/GPD symptoms can be caused by Tarlov cyst-induced sacral radiculopathy. A multidisciplinary step-care management algorithm allows selection of appropriate surgical candidates. To the best of our knowledge, this is the largest case series of patients with PGAD/GPD treated with Tarlov cyst spine surgery with at least 1 year follow-up. Using minimally invasive spine surgery techniques, spine surgery on the Tarlov cyst was associated with clinical improvement in 70% of select patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

Laparoscopy and thoracoscopy in small animal surgery: A 2020 survey of small animal diplomate and resident veterinary surgeons.

To document the utilization and training of laparoscopic and thoracoscopic minimally invasive surgery (MIS) techniques within the American, European, Australian and New Zealand Colleges of Small Animal Veterinary Surgeons (ACVS, ECVS, and ANZCVS) in 2020. Observational study. Diplomates and residents of the ACVS, ECVS, and FANZCVS. An electronic survey was sent using veterinary list servers. Questions were organized into categories evaluating (1) the demographics of the study population and the caseload, (2) comfort level with specific procedures, (3) motivating factors and limitations, and (4) surgical training and the role of the governing bodies. Respondents included 111 practicing surgeons and 28 residents. Respondents' soft-tissue MIS caseloads had increased since they first started performing MIS; however, most respondents were only comfortable performing basic laparoscopy. Over half of the respondents agreed on the patient benefits and high standard of care provided by MIS. Perceived adequate soft-tissue training in MIS during residency was strongly associated with perceived proficiency at the time of survey response. Most respondents agreed that the specialty colleges should take a more active role in developing standards for soft-tissue MIS, with residents agreeing that a required standardized course would be beneficial. Soft-tissue MIS is widely performed by diplomates and residents. Perceived adequate soft-tissue MIS training was strongly associated with perceived proficiency. There is substantial underutilization of advanced MIS techniques in veterinary specialty surgical practice, which might be improved by a stronger focus on MIS training during residency.