Layer Closure Research Articles

A Protocol for Constructing a Rat Wound Model of Type 1 Diabetes

A single high dose of streptozotocin injection followed by full-thickness skin excision on the dorsum of rats is a common method for constructing animal models of type 1 diabetic wounds. However, improper manipulation can lead to model instability and high mortality in rats. Unfortunately, there are few existing guidelines on type 1 diabetic wound modeling, and they lack detail and do not present specific reference strategies. Therefore, this protocol details the complete procedure for constructing a type 1 diabetic wound model and analyzes the progression and angiogenic characteristics of the diabetic wounds. Type 1 diabetic wound modeling involves the following steps: preparation of the streptozotocin injection, induction of type 1 diabetes mellitus, and construction of the wound model. The wound area was measured on day 7 and day 14 after wounding, and the skin tissues of the rats were extracted for histopathological and immunofluorescence analysis. The results revealed that type 1 diabetes mellitus induced by 55 mg/kg streptozotocin was associated with lower mortality and a high success rate. The blood glucose levels were relatively stable after 5 weeks of induction. The diabetic wound healing rate was significantly lower than that of normal wounds on day 7 and day 14 (p < 0.05), but both could reach more than 90% on day 14. Compared with the normal group, the epidermal layer closure of diabetic wounds on day 14 was incomplete and had delayed re-epithelialization and significantly lower angiogenesis (p < 0.01). The type 1 diabetic wound model constructed based on this protocol has the characteristics of chronic wound healing, including poor closure, delayed re-epithelialization, and decreased angiogenesis compared to normal rat wounds.

Drain-free donor site in Deep Inferior Epigastric Perforator free flap: A single-surgeon experience

Donor-site seroma and wound dehiscence in Deep Inferior Epigastric Perforator (DIEP) free flaps can be problematic. The value of donor-site drains is debated, with alternative closure techniques demonstrating good outcomes. However, no literature exists on patient outcomes in which no drain or dead space reduction technique is used. The senior author of this paper has opted for a drain-free, simple layered closure without adjuncts since 2016. We evaluate the outcomes of this technique against the literature. A single-center, single-surgeon, prospective study of all DIEP flap breast reconstruction between January 2016 and March 2020, whereby the donor site was closed without drains or alternative dead space reduction measures. One hundred and thirty-eight patients with a mean age of 50.72±9.16 (range 26-73) underwent DIEP breast reconstruction (78% unilateral (n=107), 22% bilateral (n=31). The incidence of drain-free specific donor-site complications was 8.7%, with wound breakdown being the most common (9/138, 6.5%). However, only one patient required secondary closure. The average length of hospital stay was 4.2±1 days (range 2-9). Abdominal drains may serve as a psychological barrier for patients in expediting discharge and can be painful and cumbersome. This translates into significant cost implications. Evidence suggests that superior outcomes are achieved when dead space-reducing adjuncts rather than drains are used. However, our data suggest that DIEP donor sites can also be safely closed without these adjuncts, which may unnecessarily lengthen procedure time, consume more resources, and increase localized foreign body tissue reactions, without good indication.

Ultrasound Evaluation of Cesarean Uterine Scar Following Single Compared to Double Layer Closure

Ultrasound Evaluation of Cesarean Uterine Scar Following Single Compared to Double Layer Closure

Association between characteristics of previous cesarean delivery and pelvic adhesions: a case-controlled study.

To assess the correlation of previous cesarean delivery characteristics to pelvic adhesions in infertile patients. This Case-controlled study was conducted in the period from January 2018 to December 2020 at Tanta University. All patients (222) presenting with post-cesarean infertility who underwent diagnostic laparoscopy were included in the study. According to presence of adhesions during laparoscopy, two groups were allocated. Characteristics of previous cesarean delivery were assessed in patients with or without adhesions. There were significant differences between both groups regarding type of CS, shape of skin scar, parietal peritoneal closure, and postoperative complications of the prior CS between both groups. Independent predictors of adhesions were age [OR: 1.43 (1.15-1.77); p = 0.001], BMI [OR: 0.76 (0.61-0.95); p = 0.02], emergency CS [OR: 7.74 (1.61-37.19); p = 0.01], parietal peritoneal closure [OR: 0.06 (0.01-0.24); p = 0.001]. Post-cesarean adhesions were correlated to age, BMI, emergency CD, double layer closure, and closure of peritoneum and to postoperative complications. No correlation to duration of infertility or number of cesarean sections.

Association of Comorbidities and Functional Level With Mortality in Geriatric Bowel Perforation

IntroductionSpontaneous bowel perforation is associated with high morbidity and mortality. This entity remains understudied in the geriatric patient. We sought to use a national surgical sample to uncover independent predictors of mortality in elderly patients undergoing emergent operation for perforated bowel. MethodsUsing the American College of Surgeons National Surgical Quality Improvement database, years 2007 to 2017, all geriatric patients (age ≥65 y) who underwent emergency surgery and who had a postoperative diagnosis of bowel perforation were included. Univariate and multivariable analyses were used to identify independent predictors of 30-d mortality. ResultsA total of 8981 patients were included. The median (interquartile range) age was 75 y (69, 82), and 59.0% were female. Twenty-one percent of patients were partially or totally dependent, and 25.2% were admitted from sources other than home. Overall, 30-d mortality rate was 22.1%. Independent predictors of mortality included the following: age 70-79 y (odds ratio [OR]: 1.59, P < 0.001), age ≥80 y (OR: 3.23, P < 0.001), American Society of Anesthesiologists ≥3 (OR: 4.74, P < 0.001), admission from chronic care facility (OR: 1.61, P < 0.001), being partially or totally dependent (OR: 1.50, P < 0.001), chronic steroid use (OR: 1.36, P < 0.001), and preoperative septic shock (OR: 3.74, P < 0.001). Having immediate fascial closure was protective against mortality (immediate fascial closure only, OR: 0.55, P < 0.001; -immediate closure of all surgical site layers, OR: 0.44, P < 0.001). ConclusionsIn geriatric patients, functional status and chronic steroid therapy play an important role in determining survival following surgery for bowel perforation. These factors should be considered during preoperative counseling and decision-making.

“A COMPARATIVE STUDY OF SINGLE LAYER CLOSURE AND CONVENTIONAL LAYERED CLOSURE OF LAPROTOMY WOUNDS IN OUR INSTITUTE.”

Background: Many of the operations performed by the general surgeons take place within the abdomen and consequently incision and suturing of the abdominal layers are the commonest exercises in operative surgery. Abdominal closure is very important as regards to incision, technique of repair and use of newer suture material, and has created a great interest to surgeons. Recent data suggests that technical factors are crucial and can be manipulated by the surgeon. Different suture techniques are used for closure of laparotomy wounds and each has its strong proponents. But the ideal method of abdominal wound closure is modied frequently. Commonly followed methods of abdominal closure are conventional layered closure and single layer closure. Since 1973, different workers have carried out comparative studies of these two methods with encouraging results and single layer closure was found to have denite advantages over conventional closure as regards to operating time, cost, feasibility, ease and postoperative morbidity. The present study is taken up to evaluate the advantages of single layer closure in comparison with the conventional layered closure on the basis of operative time, healing time and postoperative morbidity such as wound infection, burst abdomen and incisional hernia. To compare the techniques of single layer closure and conve Objective: ntional layered closure of laparotomy wounds on the basis of operative time and post- operative complications. Prospective study of 100 patients who un Methods: derwent laparotomy in CU Shah Medical College and Hospital, Surendranagar, for abdominal surgical problems needing either emergency or elective surgery was carried out after taking approval from ethical committee. Out of these 100 patients, 50 patients underwent laparotomy wound closure by single layer closure technique and the rest 50 patients by conventional layered closure technique. Time taken for closure of laparotomy wound was noted and patients were followed up post-operatively for any wound complications like seroma, wound infection, wound gaping, burst abdomen and incisional hernia. The mean time taken for closure of laparotomy wounds by single layer closure technique was 19 Results: minutes and by conventional layered closure technique was 27 minutes. There was a difference of 8 minutes which was statistically signicant (p=0.001). In the postoperative period, in patients who underwent single layer closure, totally 9 patients (18%) had post operative complications. In those 3 patients (6%) had seroma, 3 patients (6%) had wound infection, 2 patients (4%) had wound gaping, 1 patient (2%) had burst abdomen and none had incisional hernia. In patients who underwent conventional layered closure, totally 15 patients (30%) had post operative complications. In those 5 patients (10%) had seroma, 4 patients (8%) had wound infection, 3 patients (6%) had wound gaping, 2 patients (4%) had burst abdomen and 1 patient (2%) had incisional hernia. Laparotomy wound closure with single layer closure technique i Conclusion: s better than the conventional layered closure technique in terms of decreased operative time and also decreased postoperative complication

Outcomes of Layered Closure and Adjunctive Adhesive Retention Suture Device Use Following Ankle Fracture Open Reduction and Internal Fixation: A Single Center, Retrospective Cohort Study

Introduction. Wound edge necrosis, dehiscence, infection, and need for reoperation can occur following ankle fracture ORIF. An assistive retention suture device has been developed to serve as an adjunct to skin closure to help mitigate the potential for wound dehiscence and subsequent complications. Objective. This single-center retrospective review compared early postoperative healing and functional outcomes following ankle fracture ORIF in 39 patients in which layered closure alone (n = 20) and layered closure with use of a DAC (n = 19) was performed. Results. Adjunctive assistive retention suture device use with layered closure following ankle fracture ORIF resulted in a 60% decrease in the time to healing, an 80% reduction in postoperative dehiscence, a 90% reduction in the need for reoperation, and a 53% reduction in the time in which use of an ambulatory assistive device, brace, or orthoses was required compared to layered closure alone. Conclusions. The results of this study suggest that use of this assistive retention suture device minimizes potential postoperative healing complications, decreases need for revisional surgery, and reduces time until return to activity.

Transmastoid titanium mesh assisted extra dural layered closure of tegmen defect: Case report in a 10 year old

The study aimed to describe our experience with a case of tegmen defect that was approached transmastoid and was closed extradurally with titanium mesh. This was a retrospective review of surgical steps with cross reference to the clinical and radiological data collected. Two-year follow-up of the patient showed successful closure of the defect. Transmastoid approach can be considered even in a moderately large-sized tegmen defect and can thus avoid craniotomy which is a procedure with far superior morbidity.

Dermal substitute reinforced single-layer closure of the palatal fistula

Postoperative palatal fistulas are common after surgery to correct a cleft palate. The repair is hindered by palatoplasty-related scar tissue, reduced vascularity, and restricted mobility of flaps. Surgical repair of fistulae is often effective, but recurrence is common. A 3.5-year-old boy presented with anterior palatal fistula. The presence of peri-fistulous scarring prevented two-layered closure. Nasal layer closure was achieved but not the oral layer. The dermal matrix was reinforced in a one-step procedure over the nasal layer and fixed in place using a gel foam. At 6 months, the fistula almost completely healed, with only a pinpoint track remaining that occasionally leaked into the nasal cavity. These results indicate that the application of dermal matrix is a promising technique to repair fistula with surrounding scarring, but larger, prospective trials are needed to confirm its potential benefits.

Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood.

Up to half of all children who have a tracheostomy will develop a persistent tracheo-cutaneous fistula (TCF) after decannulation. Surgical closure of the TCF is technically easy but post-operative complications can be immediate and life-threatening. These include air leak from the tracheal repair leading to massive surgical emphysema or pneumothorax. We reviewed our experience of TCF closure to try to identify potential risk factors for complications. Retrospective case record review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following development of a persistent TCF after decannulation of a tracheostomy. We identified 67 children. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%). Life-threatening air leak occurred in the immediate post-operative period in 2 children (3%). Respiratory distress occurred in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. Complications for TCF closure are unfortunately common and it is unclear from the available evidence how best to prevent them. Further research is required.

Cesarean scar defect risk following endometrial layer closure versus non-closure: A randomized controlled trial

Cesarean scar defect risk following endometrial layer closure versus non-closure: A randomized controlled trial

Use of a Pericranial Flap Technique for Deep Brain Stimulation Hardware Protection and Improved Cosmesis

ObjectivesDeep brain stimulation (DBS) has become an established neuromodulation therapy; however, surgical site complications such as hardware skin erosion remain an important risk and can predispose to infection, requiring explantation of the system. Nuances of surgical technique can affect wound healing, cosmetic outcome, comfort, and risk of infection. In this study, we describe our experience with a layered closure technique using a vascularized pericranial flap for improving cosmesis and protection of the implanted hardware against skin erosion and infection. Materials and MethodsWe retrospectively reviewed 636 individuals (746 lead implantations) who underwent DBS surgery by a single academic neurosurgeon between 2001 and 2020. A layered pericranial flap closure technique for the burr-hole and connector sites was instituted in 2015. We assessed the effects of a multimodal infection prevention approach that included the pericranial flap on hardware complication rates compared with the premultimodality cohort, and we report the nuances of the technique. ResultsIn our institutional experience, we found that implementation of a pericranial flap closure technique can enhance the subjective cosmetic result at the burr-hole cover site and increase patient comfort and satisfaction. In addition, we found a decrease in hardware infection rates in the current cohort with a multimodal infection prevention regimen that includes the pericranial-flap technique (n = 256, 2015–2020 period) to 1.2% (p = 0.006), from 6.9% in the earlier cohort (n = 490, 2001–2015 period). ConclusionsThe report highlights the potential of a pericranial-flap closure technique as a surgical adjunct to improve DBS surgical site healing and cosmesis and may, as part of a multimodal strategy, contribute to decreased risk of skin breakdown and hardware infection.

Role of Prophylactic Sartorius Flaps for Preventing Deep Space Infection in Lower Extremity Revascularization.

Groin infections in vascular surgery are common and compromise the goal of limb preservation. Strategies to prevent deep space infection(DSI) include incision orientation and muscle flaps. Literature evaluating prophylactic flaps preventing DSIis scarce. We aimed to compare prophylactic sartorius flaps to layered closure in preventing readmission for DSI, along with the effect of incision orientation. This was a retrospective study of vascular surgery patients at a single institution with femoral artery exposure from 2017-2021. Patients with active groin infections were excluded. Prophylactic sartoriusflaps were compared to those with layered closure regarding 30-day hospital readmission for DSI. Oblique versus vertical incisions wascompared regarding the primary outcome. Fifty-three patients received sartorius flaps, and 122 received layered closure. Seventy patients had oblique incisions, and 105 patients had vertical incisions. Sartorius flaps had a higher rate of previous groin surgery compared to layered closure (45.3% vs. 24.7%, p<0.01). Vertical incisions had a higher rate of previous groin surgery (38.1% vs. 20.0%, p<0.02), while oblique incisions had a higher rate of obesity (24.3% vs. 8.6%, p<0.01). There was a lower rate of DSI in sartorius flaps compared to layered closure (1.9% vs. 6.6%, p=2.80), although not statistically significant due to lack of power. There wasno difference in DSI in the oblique versus vertical incisions (4.3% and 5.7%, p=0.760). Patients with prophylactic sartorius flaps experienced fewer DSI, although further evaluation with increased sample size is required for adequate study power. We believe sartorius flaps are a simple solution to prevent groin complications.

Clinical application of single-layer annular vaginal flap in transvaginal repair for vesicovaginal fistula.

To compare the first-time success rate and prognosis of repairing vesicovaginal fistula (VVF) by transvaginal and transvesical approaches, and to highlight a modified transvaginal repair technique which only require single layer closure of an annular vaginal flap. Retrospective analysis of 57 consecutive patients who underwent VVF repair between 2007 and 2021. Fistula characteristics, operative factors, post-surgical complications and outcomes were analyzed. A total of 57 women with a median age of 50.4 (27-75) years were included. The history ranged from 7 daysto 8years, with an average of 20months. 56 cases (98.2%) of VVFswere caused by pelvic surgery, and only one resulted from difficult labour. 11 cases (19.3%) had a history of surgical repair failure.All 57 cases of surgery were smoothly completed. Among them, 17 patients underwent transvaginal repair, whereas 40 (70.2%) women had transvesicalrepair. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced postoperative hospital stay, less hospitalization cost and lower minor complication ratesthan transvesical group (p < 0.05). No serious complications occurred in the two groups. No cystostomy was performed in the transvaginal group, but 12 cases (30%) in the transvesical group. The average follow-up time was 18.5 (3-48) months. The first-time success rates of transvaginal and transvesical techniques were 82.3 and 75%, respectively. VVF repair with single layer closure of an annular vaginal flap is a technically feasible, simple and successful approach with significantly better operative parameters and lower complications rates.

7489 Conjunction of Cystoscopy and Robotic-Assisted Bladder Trigone Endometriosis Nodule Removal with Ureteral Preservation

<h3>Study Objective</h3> Demonstrate tips for successful execution of robotic-assisted resection of large bladder trigone endometriosis nodule while preserving the ureters. <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic-tertiary-care hospital. <h3>Patients or Participants</h3> 36-year-old G0 with symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis. <h3>Interventions</h3> Cystoscopy was first performed, and large mid-trigonal endometriosis nodule was noted to be extending within millimeters of the ureteral orifices. Bilateral ureteral orifices were identified, and double-J ureteral stents were sequentially guided up to the kidneys. The robotic instruments were docked, and inspection of the pelvic space conducted. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Bilateral distal ureters were dissected out circumferentially and the dissection was carried distally. Flexible cystoscopy with Firefly technology was then utilized to define precise location and extent of the trigonal nodule in effort to minimize removal of uninvolved bladder tissue and preserve ureters. Using cystoscopic-guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. Bilateral ureters were preserved despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once resection was completed, running 3-0 V-loc sutures were utilized in 2-layer closure. <h3>Measurements and Main Results</h3> Patient was discharged in one-day with Foley catheter and ureteral stents with minimal pain. Cystogram at 10 days postop was negative for leak and Foley catheter was removed. <h3>Conclusion</h3> Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance offers the most precise and delicate dissection of large bladder trigone endometriosis nodules, thus providing optimal bladder trigone and ureteral preservation.

Laparoscopic Myomectomy for a Large Incarcerated Posterior Myoma

<h3>Study Objective</h3> To demonstrate a technique for laparoscopic myomectomy with a large posterior fibroid and incarcerated uterus. <h3>Design</h3> We present a stepwise narrated demonstration of our technique for posterior myomectomy. <h3>Setting</h3> Referral Center in Upstate NY. <h3>Patients or Participants</h3> A 35-year-old with large posterior fibroid desiring fertility sparing treatment. <h3>Interventions</h3> Bilateral retroperitoneal dissections are performed, demonstrating both lateral and anterior approaches for isolation of uterine blood supply. Hemostatic control is achieved with the use of rectal misoprostol, intrauterine vasopressin and temporary occlusion of the uterine blood supply. A high hysterotomy is made and the fibroid is dissected away from the pseudocapsule, eventually allowing displacement of the uterus out of the posterior cul-de-sac with a vaginal hand as the dissection continues, demonstrating an approach to hysterotomy when the ideal location is inaccessible. On completion of the myomectomy, a uterine manipulator is placed, and excess serosa is trimmed. The myometrium is repaired with a 3-layer closure followed by a single layer on the uterine serosa. <h3>Measurements and Main Results</h3> Successful laparoscopic myomectomy for a 669-gram fibroid with estimated blood loss of 100ml and benign pathology. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up ultrasound. <h3>Conclusion</h3> Laparoscopic myomectomies can be safely performed on large posterior uterine fibroids even in the setting of an incarcerated uterus. The above techniques can improve hemostasis, access to the fibroid and repair of atypical hysterotomy.

Laparoscopic Resection of Cesarean Scar Pregnancy at 11 Weeks Gestational Age

<h3>Study Objective</h3> To demonstrate a laparoscopic technique for resection of cesarean scar pregnancy (CSP) and revision of cesarean scar defect. <h3>Design</h3> We present a stepwise narrated demonstration of our technique of a resection of a CSP. <h3>Setting</h3> Referral Center in NY. <h3>Patients or Participants</h3> 33-year-old with cesarean scar pregnancy at 11 weeks gestational age, desiring fertility sparing treatment <h3>Interventions</h3> A retroperitoneal dissection is performed, and the uterine blood supply is isolated<b>.</b> Hemostatic control is achieved with the use of intrauterine vasopressin and temporary occlusion of the uterine blood supply. The bladder is carefully dissected from the lower uterine segment and cesarean scar pregnancy. Ultrasound guidance is used to assist in hysterotomy location for resection of the ectopic pregnancy. The myometrium is repaired with a 3-layer closure. Uterine ventrosuspension by plication of the round ligaments bilaterally results in anteversion of the previously sharply retroverted uterus, reducing tension on the repair. Hysteroscopy under laparoscopic visualization confirms repair of the scar defect. <h3>Measurements and Main Results</h3> Successful laparoscopic resection of a cesarean scar ectopic pregnancy and resection of scar defect with EBL of 250 mL. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up MRI with no residual cesarean scar defect and residual myometrial thickness of 1.6 cm. <h3>Conclusion</h3> Laparoscopic resection provides a means of addressing cesarean scar pregnancy at advanced gestational age while repairing the associated cesarean scar defect. Control of the uterine blood supply and mobilization of the bladder are critical aspects of the surgery. Intraoperative ultrasound and laparoscopic guided hysteroscopy can ensure full resection of the defect and achieve optimal repair. For the retroverted uterus, ventrosuspension may avoid tension on the repair to promote healing. For this patient, our technique resulted in no residual cesarean scar defect on follow-up imaging.

Robotic-Assisted Laparoscopic Treatment of Diaphragmatic Endometriosis

<h3>Study Objective</h3> To demonstrate the surgical technique used for a robotic-assisted diaphragm endometriosis treatment. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in the semi-gynecological position, left lateral decubitus and proclivity. Robotic side docking set for upper abdomen using da Vinci Si platform. <h3>Patients or Participants</h3> A 34-year-old woman reports dysmenorrhea and pain in her right shoulder during menstruation for 5 years, ceased after combined oral contraceptive use. When she stopped the contraceptive, symptoms recurred. On MRI, hematic foci were identified in the right subphrenic space, suggesting endometrial implants. <h3>Interventions</h3> A 12 mm incision is performed in the umbilicus for endoscope port. Other two 8mm robotic ports and a 5 mm accessory laparoscopic trocar were placed. Patient's cart side docking enters obliquely through patient's left shoulder. Inspection shows superficial and deep typical endometriotic lesions on right diaphragmatic surface, falciform ligament is sectioned for better liver mobilization. Most superficial lesions are removed before accessing thoracic cavity. For deeper lesions, the diaphragm is opened, showing pleural involvement of endometriosis. No pulmonary lesions were identified. Diaphragm is repaired carried out by a double-layered barbed suture. Before first layer closure, a laparoscopic suction tip is introduced into the thoracic cavity and the aspiration of the pneumothorax is done concomitantly with the forced Valsalva maneuver. <h3>Measurements and Main Results</h3> Patient was discharged in the second postoperative day, showing great evolution in respiratory physical therapy and normal chest X-ray. Painful shoulder symptoms have completely resolved. <h3>Conclusion</h3> Diaphragm endometriosis has been gaining more attention in the practice of gynecologist surgeons. Robotic system improves access to the subdiaphragmatic space due to the articulated instrument movements and 3D high-definition static vision. Excision of diaphragmatic lesions is a standardized feasible procedure that allows complete treatment and good clinical results.

Robotic Assisted Laparoscopic Excision of a Placenta Percreta

<h3>Study Objective</h3> To illustrate the steps of a robotic-assisted laparoscopic excision of a placenta percreta. <h3>Design</h3> Placenta accreta spectrum (PAS) is a group of disorders characterized by various degrees of placental invasion through the myometrium and uterine serosa. Incidence has increased in recent years following the increase in cesarean deliveries. Risk factors include previous uterine surgeries, multiple cesarean deliveries and the presence of placenta previa. Ultrasound is the primary diagnostic modality. Most PAS cases are diagnosed in the second trimester, and guidelines for early recognition are sparse. A cesarean hysterectomy is the mainstay of management. This video shows an alternative, fertility-sparing treatment for PAS when diagnosed early. <h3>Setting</h3> The video displays a patient in the operating room in the supine position, with Trendelenburg positioning and a bedside assist for robotic-assisted laparoscopy. <h3>Patients or Participants</h3> We present a case of a 32-year-old G5P1121 with a history of one prior cesarean section and a dilation and curettage who was had early imaging concerning for CS scar ectopic and placenta accreta spectrum. <h3>Interventions</h3> The patient was counseled on termination of pregnancy and given her desire for fertility, counseled on attempted resection of invading pregnancy with uterine repair. <h3>Measurements and Main Results</h3> Key surgical steps illustrated include the following: 1. Lysis of adhesions and separation of bladder 2. Identification of the borders of the pregnancy 3. Injection of vasopressin 4. Laparoscopic guided suction dilation and curettage 5. Dissection invading pregnancy 6. Circumferential resection of the invading pregnancy 7. Full thickness myometrial closure in multiple layers <h3>Conclusion</h3> Early diagnosis of placenta accreta spectrum provides options for alternative fertility-sparing treatment.

2 Layered Closure by Buccal Fat Pad and Collagen Sheath in Severe OSMF: A Case Report

Oral Submucous fibrosis is a disease common among developing countries of South-east Asia. The condition was first demonstrated by Schwartz in 1952, and Pindborg et al have done extensive research to explain the pathophysiology of the disease. This potentially malignant condition once initiated cannot be reversed completely and the long standing cases suffer from altered nutrition status, poor intraoral hygiene and disarticulation. Hence, this disease should be dealt with radical surgical intervention and reconstruction with the appropriate method to prevent recurrence and increase the quality of life for the patients. Keywords: Oral Submucous fibrosis, Potentially malignant condition, Reconstruction