Lysis Of Adhesions Research Articles

Pelvic Nerves in Laparoscopy: A Review of Anatomy and Approach to Dissection

<h3>Study Objective</h3> Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. <h3>Design</h3> Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. <h3>Setting</h3> Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). <h3>Patients or Participants</h3> Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Laparoscopic Management of Tubo-Ovarian Abscess Refractory to Percutaneous Drainage

<h3>Study Objective</h3> To demonstrate the feasibility and safety of a laparoscopic approach to a case of tubo-ovarian abscess (TOA) refractory to percutaneous drainage and antibiotic therapy. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room with traditional laparoscopy. <h3>Patients or Participants</h3> 30-year-old female patient with refractory TOA. <h3>Interventions</h3> Laparoscopic lysis of adhesions, bilateral salpingectomy, right oophorectomy, wash out and drain placement. <h3>Measurements and Main Results</h3> The patient is a 30-year-old female who presented with a 16cm TOA, initially managed with parenteral antibiotics and percutaneous drainage. However, despite initial improvement, the abscess continued to re-accumulate, refractory to a total of three percutaneous drain placements over the course of 8 weeks. She was taken to the operating room for laparoscopic resection of the TOA. Four port sites were utilized, three 5mm ports and one 10mm port. Survey of the pelvis revealed dense adhesions, bilateral pyosalpinx, and residual large abscess encompassing the right ovary. Given the patient's prolonged pre-operative course and her consent for loss of future fertility, the decision was made to proceed with bilateral salpingectomy and right oophorectomy. The right adnexal structures were densely adherent to the pelvic side wall and cul de sac; therefore, retroperitoneal dissection was utilized to identify important landmarks including the medial umbilical ligament, uterine artery and ureter in order to safely remove the diseased tissue without injuring the surrounding vital structures. The pelvis was irrigated and a JP drain was placed. She was discharged home on the same day. She had an uncomplicated post-operative course. Final surgical pathology revealed chronic and active salpingitis as well as focal endometriosis. <h3>Conclusion</h3> Laparoscopy is a safe and feasible surgical approach to the management of tubo-ovarian abscess refractory to percutaneous drain placement. The surgeon should be adept and familiar with retroperitoneal dissection to ensure safety of surrounding structures in the setting of dense adhesive disease and inflammation.

Use of a Biologic Allograft to Treat Vesicovaginal Fistula in a Patient with Cervical Cancer.

<h3>Study Objective</h3> To demonstrate the robotic treatment of a vesicovaginal fistula that occurred after chemotherapy and radiation for cervical cancer with the help of a biologic allograft. <h3>Design</h3> Video demonstration. <h3>Setting</h3> Tertiary care center. <h3>Patients or Participants</h3> Forty-five-year-old post-menopausal female para three with a history of stage 3b squamous cell carcinoma of the cervix diagnosed in 2020 status-post treatment with cisplatin, pelvic external beam radiotherapy, and left nephrostomy tube placement for hydronephrosis. She subsequently developed a vesicovaginal fistula in early 2021, which was treated with total abdominal hysterectomy, bilateral salpingectomy, vesicovaginal fistula repair and bilateral ureteral stent placement. She was discharged with a foley catheter and the left nephrostomy tube still in place. She was subsequently seen at the Urogynecology office for leakage of urine. On exam, a two-three-centimeter persistent vesicovaginal fistula was noted. <h3>Interventions</h3> She underwent re-operation with robotic lysis of adhesions, vesicovaginal fistula repair, and placement of a biologic allograft. <h3>Measurements and Main Results</h3> Her post-operative course was uncomplicated. She was seen at three weeks post-operatively, and had intermittent leakage of urine, but was otherwise healing well. <h3>Conclusion</h3> Vesicovaginal fistula in the setting of gynecologic malignancy, especially following radiation, can be more complicated to treat and more prone to failure than other etiologies. Biologic allografts may be a viable alternative to autografts in these complicated cases given their favorable biochemical properties. Controlled trials should be performed to assess the benefit of using biologic allografts to enhance complicated vesicovaginal fistula repair, and possibly reduce the need for re-operation.

An additional lysis procedure during arthrocentesis of the temporomandibular joint

BackgroundArthrocentesis of the temporomandibular joint (TMJ) is an easy, highly efficient, minimally invasive procedure for treating temporomandibular joint disorders (TMDs). However, in some cases of mouth opening limitation (MOL), routine arthrocentesis is ineffective due to severe fibrotic adhesion in the superior joint space of the TMJ. In this condition, mechanical lysis of the adhesions might be needed to resolve the MOL, as well as other symptoms, such as chronic pain. Currently, this can be achieved by arthroscopic surgery or open TMJ surgery. The objective of this study was to introduce and evaluate our trial of the adhesion lysis procedure during arthrocentesis of the TMJ using normal 18-gauge needles.ResultsIn this study, 40 patients with MOL due to disc derangement underwent conventional arthrocentesis at first and then physical detachment was conducted using the same needle. The change in maximum mouth opening (MMO) and the pain at the TMJ were recorded before, during, and after treatment according to our protocol. The mean increase in MMO after conventional arthrocentesis was 6.6 ± 4.2mm. The mean increase in MMO after the detachment procedure with the same needle was 4.2 ± 2.0 mm. The MMO in ten patients was significantly increased after the detachment procedure than after arthrocentesis alone. In all cases, the pain intensity in the TMJ significantly decreased over time, whereas the MMO increased over time. No adverse effect was observed in all joints during our observation periods.ConclusionWe confirmed that our simple lysis procedure with the same needle of the arthrocentesis of the TMJ could not only improve the MMO more than after a conventional arthrocentesis but also resolve severe adhesion of the joint space that was ineffective by conventional arthrocentesis. Although this additional lysis procedure is simple, it might reduce the number of cases of more invasive procedures such as arthroscopic surgery or open TMJ surgery.

Mycobacterium abscessus subsp. massiliense infection secondary to traumatic anterior cruciate ligament reconstruction surgery

Non-tuberculous Mycobacterium (NTM) infections following knee surgery are rarely reported in the literature. One month after arthroscopic lysis of adhesions from anterior cruciate ligament (ACL) reconstruction, a 67-year-old male patient presented with symptoms suggesting septic arthritis. Empiric antibiotics were initiated. Intraoperative cultures were positive for Mycobacterium abscessus. Organism-specific antimicrobial therapy with azithromycin, amikacin, and imipenem were started. Four months later the patient was switched to oral outpatient treatment with azithromycin, clofazimine and bedaquiline. Mycobacterium infections following ACL reconstruction are exceedingly rare in the United States. Successful management of Mycobacterium abscessus infection is exceptionally challenging for both orthopedists and infection disease specialists.

BRONCHOPLEURAL FISTULA POST LOBECTOMY: A RARE COMPLICATION WITH AN EVEN MORE UNUSUAL PRESENTATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The formation of a bronchopleural fistula (BPF) is a rare but known complication following major thoracic surgery. In a study by Nachira et al. looking at 835 patients in Italy who underwent major lung resection, 786 patients underwent lobectomy with 11 (1.3%) developing a BPF [1]. In other studies their incidence has been reported between 0.5-3% [2]. Here we present a case of an unusual presentation of this rare complication. CASE PRESENTATION: 73 y.o F former smoker was incidentally found to have right upper lobe (RUL) chondral myxoid tumor. She underwent bronchoscopy and video assisted thoracoscopy (VATS) with wedge resection of RUL and placement of chest tube without peri-operative complications. Later that day, rapid response was called as patient developed facial swelling, sensation of throat tightening and upper chest erythema with subcutaneous emphysema (SCE) (Figure 1). Initial thought was possible anaphylaxis from NSAIDs and treated as such. Patient later further deteriorated leading to intubation and transfer to the ICU. Second right-sided chest tube and skin holes placed on chest for relief of subcutaneous air. Patient was extubated next day. Due to persistent SCE (Figure 2) and need for respiratory support, patient received bilateral blow-holes and was downgraded to surgical floor after improvement. Symptoms again recurred requiring re-intubation. Blow-holes were extended and 3rd right-sided chest tube placed. She was taken for repeat VATS and found to have a BPF with adhesions. Lysis of adhesions was performed with RUL mediastinal drainage and mechanical pleural abrasion. The rest of patient's hospital course was uncomplicated with eventual removal of chest tubes and discharge. DISCUSSION: As discussed, our patient had a complicated post-operative course, complicated further by the unique presentation of her BPF. We found no previous literature or case reports illustrating similar presenting symptoms of BPFs. They typically present 1 - 12 weeks postoperatively [2]. Our patient did not fit this timeline and had a very atypical presentation which mimicked symptoms of an anaphylactoid reaction. Although diffuse subcutaneous emphysema has been a reported finding from BPFs [3], this was thought to be a normal result of recent surgical procedure. This uncommon presentation led to delay in appropriate management and extended hospital course for this patient. CONCLUSIONS: This case demonstrates a unique presentation of a potentially fatal complication of major thoracic surgeries. BPF formation may need to be considered in patients who present similarly in the future. REFERENCE #1: Nachira D, Chiappetta M, Fuso L, Varone F, Leli I, Congedo MT, Margaritora S, Granone P. Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre. ANZ J Surg.2018 Apr;88(4):322-326.doi: 10.1111/ans.13886. Epub 2017 Feb 1.PMID: 28147437. REFERENCE #2: Gaur P, Dunne R, Colson YL, Gill RR. Bronchopleural fistula and the role of contemporary imaging. J Thorac Cardiovasc Surg. 2014 Jul;148(1):341-7. doi: 10.1016/j.jtcvs.2013.11.009. Epub 2013 Dec 16. PMID: 24355543. REFERENCE #3: Anas Riehani, Olivia Wilcox, Wassim Mohammed Odeh, Michael Kehdi, and John Armstrong. Bronchopleural Fistula Presenting as diffuse Subcutaneous Emphysema. C46. PLEURAL DISEASE: CASE REPORTS II. May 1, 2017, A5647-A5647 DISCLOSURES: No relevant relationships by Inessa Bronshteyn, source=Web Response No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Ross Lavine, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response

S3693 Gallstone Ileus

Introduction: Gallstone ileus is an anatomical mechanical obstruction of the small bowel that is induced by a gallstone also known as gallstone ileus. The pathophysiology includes the migration of a gallstone out of the gallbladder, where the pressure of the stone can create a passage, such as a cholecystoenteric fistula, and can therefore result in SBO. Case Description/Methods: A 74-year-old female presented to the emergency department complaints of 3 day history of nausea, vomiting, left lower quadrant pain, bloating & flatus. Patients vomiting was un-relenting despite electrolytes and OTC medications. On presentation she had significant left upper quadrant tenderness and hypoactive bowel sounds. She had a low-grade temperature; with stable vitals. Labs & Imaging: AST 22 U/L, ALT 19 U/L, Total Bilirubin 0.5 mg/dL, ALP 134 U/L, WBC 12.46 10^3/uL. Image: CT of the abdomen/pelvis without contrast showed “mid to distal small bowel obstruction most likely secondary to gallstone ileus”. Management & post-surgery: IVFs, NPO and Anti-emetics. GI consulted and Surgery consulted. Laparoscopic assisted enterotomy and removal of 3.5 cm gallstone with primary repair of small bowel enterotomy lysis of adhesions. The dilation of the bowel significantly improved thereafter, and the patient tolerated the procedure well. Specimen analysis confirmed findings as gallstone. 3 months post-surgery patient has been doing well with no further complications or surgical interventions. Discussion: Less than 1% of intestinal obstruction are derived from this etiology[1]. A review of Gallstone ileus cases across the nation from 2004-2009 indicated that the incidence is only 0.095%[2]. The associated mortality rate is around 15-18%[3]. Cholesterol gallstone created a fistula allowing air to enter the biliary tree, classic presentation of Rigler’s triad: pneumobilia, small bowel obstruction, and a gallstone 5. This is more of an anatomical obstruction rather than an actual ileus. The surgical approach of the obstruction is the mainstay of the treatment: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure; and (3) enterolithotomy with cholecystectomy performed later 1. The biggest controversy in the past has been, if a biliary surgery be carried out at the same time or at a later stage. In this patient management with simple enterolithotomy was proven successful.Figure 1:: CT images of Gallstone Ileus and Gross Appearance of Gall stone

Platelet-Rich Plasma Augmentation of Meniscal Repair in the Setting of Anterior Cruciate Ligament Reconstruction

Background: The increasing incidence of anterior cruciate ligament (ACL) and meniscal injuries has led to strong interest in discovering new methods to enhance the biological healing response of these tissues. Platelet-rich plasma (PRP) contains various growth factors associated with a positive healing response, but few existing clinical studies are available to determine the risks and benefits of these therapies. Purpose: To determine the effects of intraoperative PRP on postoperative knee function and complications at 2 years after ACL reconstruction with meniscal repair. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective matched case-control study was conducted between 2013 and 2017 using a single surgeon database of 1014 patients undergoing primary ACL reconstruction with concomitant meniscal repair, resulting in 324 patients (162 PRP patients and 162 control patients) who met the study criteria. Patients were matched by age, sex, graft type, and meniscal injury. The Single Assessment Numeric Evaluation (SANE) was administered at 2 years, and injury surveillance was conducted. Secondary outcomes included the time to return to activity (months), self-reported knee function (International Knee Documentation Committee [IKDC] score), functional performance testing (knee range of motion, single-leg balance, single-leg hopping, agility testing), and postoperative complications (graft failure, infection, loss of motion [requiring repeat arthroscopy for lysis of adhesions], venous thrombosis, etc). Univariate models were used for between-group comparisons, and alpha was set at .05 for all analyses. Results: No differences were found in SANE knee function scores between the PRP and matched-control groups at 2 years (91.6 ± 11.2 vs 92.4 ± 10.6, respectively; P = .599). Additionally, no differences were reported between groups for self-reported function (IKDC score, 87.6 ± 13.3 vs 88.1 ± 12.6; P = .952), functional performance testing (P > .05), and timing of return to activity (7.8 ± 1.9 vs 8.0 ± 1.9 months; P = .765). The PRP group demonstrated a higher rate of postoperative knee motion loss compared with the control group (13.6% vs 4.6%; P < .001). No other differences were observed in postoperative complications (P > .05). Conclusion: The added use of intraoperative PRP did not improve self-reported knee function, functional performance, and timing of return to activity for patients undergoing ACL reconstruction with meniscal repair. Furthermore, the use of PRP may have negative consequences for regaining knee range of motion after surgery. On the basis of these data, surgeons should cautiously consider the application of PRP when planning surgery for intra-articular injuries of the knee. Registration: NCT03704376 (ClinicalTrials.gov identifier).

V10-04 A BUCCAL MUCOSAL GRAFT SUB-CORONAL RESURFACING FOR TREATMENT OF RECURRENT PENILE ADHESIONS: THE BUCCAL BELT

You have accessJournal of UrologyLower Tract Reconstruction (V10)1 Sep 2021V10-04 A BUCCAL MUCOSAL GRAFT SUB-CORONAL RESURFACING FOR TREATMENT OF RECURRENT PENILE ADHESIONS: THE BUCCAL BELT Matthew Beamer, Javier Angulo, Leandro Capiel, Damian López-Alvarado, Erick Ramirez-Perez, Paksi Satyagraha, Daniel Zaccarini, and Dmitriy Nikolavsky Matthew BeamerMatthew Beamer More articles by this author , Javier AnguloJavier Angulo More articles by this author , Leandro CapielLeandro Capiel More articles by this author , Damian López-AlvaradoDamian López-Alvarado More articles by this author , Erick Ramirez-PerezErick Ramirez-Perez More articles by this author , Paksi SatyagrahaPaksi Satyagraha More articles by this author , Daniel ZaccariniDaniel Zaccarini More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002061.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recurrent penile adhesions often cause pain, post-coital bleeding, disfigurement and patient distress. Treatment options are limited and include topical steroids, lysis of adhesions and repeat circumcisions. Furthermore, adhesions are often associated with Lichen Sclerosus (LS) limiting the use of skin in any reconstruction. We present a novel surgical procedure using a sub-coronal buccal mucosal graft (BMG) resurfacing technique. METHODS: To perform the buccal belt procedure a sub-coronal segment of affected skin, approximately 1.5 cm in width, was circumferential excised. The circumference of the penile shaft was measured and an appropriately size buccal mucosal graft was harvested. The graft was placed sub-coronally and secured circumferentially with a proximal and distal anastomosis. Buck’s fascia was included in both the anastomosis and quilting sutures to allow for appropriate spread fixation of the graft. A vaseline gauze bolster was secured as a tie-over dressing. Patients were discharged with the bolster dressing and foley catheter. They were seen 7 days postoperatively for removal and then at 4-6 month intervals for follow-up. A retrospective, international multi-institutional review was conducted to include all patients treated with this technique. Surgical complications and evidence of recurrence were recorded. Patient-reported outcome measures including visual analog scale (VAS) and Global Response Assessment (GRA) questionnaires administered to measure functional and esthetic outcomes were also reviewed. RESULTS: Thirty-one men underwent the procedure across six institutions between 3/2014 and 9/2020. Mean age was 56.3 (32-77) and prior treatments included: topical agents 14 (45%) and circumcision 25 (81%). LS was seen in 23(74%) patients. Mean surgical time was 59 (25-95) minutes and mean hospital stay was 0.65(0-2) days. At the mean follow-up of 27 (4-79) months no patients developed recurrence. No patients reported painful erections. Mean VAS was 8.9 and 9.0 for esthetics and functional outcomes respectively. On GRA overall improvement was reported by all patients (61% +3; 25% +2; 14% +1). The majority saw improvement in esthetic appearance (46% +3; 39% +2; 7% +1; 4% 0; 4% -1) and improvement with post-coital bleeding (43% +3; 43% +2; 4% +1; 11% 0). Ninety-six percent would recommend the procedure to a friend. CONCLUSIONS: There are limited options for the treatment of recurrent penile adhesions, particularly in the setting of LS. A sub-coronal BMG resurfacing is feasible, with no recurrence and overall high satisfaction seen on an initial patient cohort. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e756-e756 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Beamer More articles by this author Javier Angulo More articles by this author Leandro Capiel More articles by this author Damian López-Alvarado More articles by this author Erick Ramirez-Perez More articles by this author Paksi Satyagraha More articles by this author Daniel Zaccarini More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement Loading ...

Emergency surgery in the time of Coronavirus: the pandemic effect.

The COVID-19 epidemic became a challenge for Emergency Departments (ED) and a remarkable reduction in surgical emergencies has been widely noticed. The aim of the present study was to evaluate the impact of the pandemic period in the need of surgical emergencies. Between January 1, and May 31, 2020 all the consecutive general surgery emergencies performed by the Unit Hospital Emergency Surgery of the Careggi University (Florence, Italy) were prospectively recorded and compared to the same period of 2019. Demographic and clinical data were recorded and analyzed. The number of surgical procedures decreased only in the month of March 2020 (compared to 2019), while in April the total numer of emergency surgical procedures was similar. Only appendectomy, complicated hernia repair and colonic resection were significantly reduced (40%, 48% and 33% respectively). The number of small intestine excision, cholecystectomy and lysis of peritoneal adhesions remained stable throughout the entire period. No statistically significant differences were found considering age, sex, Emergency Surgery Score, mortality, ICU postoperative admission and time between admission and surgery, even when analyzed with multivariate analysis for every single surgical procedure, suggesting a comparable disease severity and comorbility patterns. Mortality in COVID patients was 25%, compared to 7% of no-covid patients. The COVID-19 pandemic has caused major changes in daily clinical practice, especially in areas such as Emergency. This has led to a temporary reduction and changes in the flow of patients to the emergency room, with implications also for emergency surgical activities.

PD32-03 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION. SURGICAL TECHNIQUE WITH 10 YEAR EXPERIENCE

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (PD32)1 Sep 2021PD32-03 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION. SURGICAL TECHNIQUE WITH 10 YEAR EXPERIENCE Cassandra Schuster, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002033.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy with uterus preservation (RASCP-UP) is a transabdominal approach to repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and preserves female sexual organs. Although hysterectomy may be performed at the time of POP repair, many women choose to preserve their uterus for reasons of sexuality, female identity, religion, maintenance of maximal vaginal length, and resistance to removal of a normal organ. METHODS: Data is collected from an IRB approved prospectively maintained database of robotic POP repair in an 836 bed tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port. Commercially available 4 x 24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate >10 cm anterior and posterior dissections of the vaginal walls. The anterior vaginal wall component is brought through the broad ligament and joined with the posteriorly placed component for attachment to the Anterior Longitudinal Ligament with GoreTex sutures. The mesh is then completely covered by peritoneum. All patients for RASCP-UP had Stage 4 prolapse with maximal anterior, posterior and apical descent with the cervix at the apex of the descent. All patients had normal PAP smears and pelvic ultrasounds. RESULTS: Between 2010 and 2021 a total of 351 patients underwent RASCP at the same institution. Of these, 54 presented with complete vaginal vault eversion requesting RASCP-UP. Mean age was 67.5 years and mean BMI 26.8. Cases were completed with robotic console time between 61 and 121 minutes and all patients discharged within 24-48 hours. At mean 60 month (12–124 month) follow-up, there were no mesh erosions, hernias, or reoperations for prolapse. There was one reoperation for hysterectomy at 6 year follow up for suspected endometrial carcinoma and one reoperation for small bowel obstruction in a patient with extensive lysis of adhesions. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence CONCLUSIONS: RASCP-UP is a reproducible, reliable procedure for patients with severe POP who desire uterus preservation. The surgery restores normal vaginal axis and length without placement of mesh material through vaginal mucosa. Long-term results show durable functional repair. Is the “unnecessary” removal of an otherwise normal uterus “necessary” for repair of POP? For a number of female patients, the answer appears to be no. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e545-e545 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Robert Carey More articles by this author Expand All Advertisement Loading ...

Robotic transthoracic diaphragmatic hernia repair.

Robotic transthoracic diaphragmatic hernia repair.

Robotic Ventral Hernia Repair: Lessons Learned From a 7-year Experience.

To describe the outcomes of RVHR with varying prosthetic reinforcement techniques. As a recent addition to minimally invasive hernia repair, more data is needed to establish the long-term benefits of RVHR and to identify potential predictors of adverse outcomes. Patients who underwent RVHR over a 7-year period were evaluated. Robotic intraperitoneal onlay mesh (rIPOM), transabdominal preperitoneal (rTAPP), Rives-Stoppa (rRS), and transversus abdominis release (rTAR) techniques were compared. The main outcomes were 90-day FFC, and 5-year FFR, depicted through Kaplan-Meier curves stratified by repair type and date. A total of 644 RVHRs were analyzed; 197 rIPOM, 156 rTAPP, 153 rRS, and 138 rTAR. There was a gradual transition from intraperitoneal to extraperitoneal mesh placement across the study period. Although rTAPP had the highest 90-day FFC (89.5%) it also had the lowest 5-year FFR (93.3%). Conversely, although rTAR demonstrated the lowest FFC (71%), it had the highest FFR (100%). Coronary artery disease, lysis of adhesions, incisional hernia, and skin-to-skin time (10 minutes. increment) were significant predictors of 90-day complications. Incisional hernia was the sole predictor of 5-year recurrence. This study provides an in-depth perspective of the largest series of RVHR. Based on this experience, rTAPP is no longer recommended due to its limited applicability and high recurrence rate. Both rIPOM and rRS offer encouraging short- and long-term outcomes, while rTAR is associated with the highest perioperative morbidity. Longer follow-up is needed to assess rTAR durability, despite a promising recurrence profile.

Surgical Management of Medial Discoid Meniscus in Pediatric and Adolescent Patients.

Medial discoid meniscus (MDM) is an exceedingly rare anatomic abnormality that presents similarly to other meniscal pathologies. Symptomatic MDM is typically managed arthroscopically with mixed short-term and long-term outcomes, although the existing knowledge about MDM is limited. The purpose of this study was to describe the presentation and surgical treatment of MDM in pediatric and adolescent patients. Medical records of 12 knees with MDM in 8 pediatric and adolescent patients treated between 1991 and 2016 were reviewed retrospectively for patient characteristics, clinical manifestations, radiographic findings, operative techniques, and surgical outcomes. Of the 446 knees diagnosed arthroscopically with discoid menisci, lateral discoid meniscus was noted in 434 knees (97.3%) and MDM was present in 12 knees (2.7%). The MDM series included 8 patients of mean age 13.8 years (range: 7.8 to 19.8), of which 5 were males (63%), and 4 (50%) had bilateral involvement. Of the 11 knees with available clinical records, all cases presented symptomatically (pain, mechanical symptoms); 10 (91%) had concurrent physical exam findings. On intraoperative examination, discoid morphologies were described as complete in 4/8 knees (50%) or incomplete in 4/8 (50%), with associated instability in 6/12 (50%). Meniscal tears were reported in 9 cases (75%)-primarily, horizontal cleavage tears. Saucerization was performed in 11 knees (92%), with medial meniscal repair in 7 (58%), when indicated. Retear of the medial meniscus occurred in 4/11 knees (36%) at a mean of 25.8 months postoperation; 2 knees required revisions. One knee developed arthrofibrosis and underwent arthroscopic lysis of adhesions. MDM is a rare diagnosis, representing 3% of all discoid menisci, with a nonspecific clinical manifestation. Operative management of symptomatic MDM typically involves saucerization and meniscal repair, when indicated, for concurrent tears. Symptom resolution is common short-term, but long-term outcomes include recurrent meniscal tears. Subsequent observational studies are important to evaluate long-term outcomes, such as arthritic changes, with the advancement of arthroscopic techniques for meniscal preservation. Level IV-retrospective case series.

Immediate Pain Relief at Time of Corticosteroid Injection for Idiopathic Adhesive Capsulitis as a Predictor of Eventual Outcomes.

Background:Corticosteroid injection and physical therapy remain the mainstay of treatment for idiopathic adhesive capsulitis of the shoulder; however, a certain percentage of patients will not improve using these interventions and will require manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA).Purpose:To evaluate whether the immediate pain reduction after fluoroscopic-guided, mixed anesthetic-corticosteroid injection for idiopathic adhesive capsulitis is related to the eventual need for LOA/MUA or a repeat glenohumeral steroid injection.Study Design:Case-control study; Level of evidence, 3.Methods:This single-institution study involved patients undergoing fluoroscopic glenohumeral corticosteroid injection for a diagnosis of idiopathic adhesive capsulitis between 2010 and 2017. Included were patients with a minimum of 1-year postinjection follow-up and visual analog scale (VAS) pain scores from immediately before and after the injection. The primary analysis was the relationship between patients with an immediate change in VAS score after injection and those who underwent LOA/MUA. A repeat glenohumeral injection was also evaluated as an outcome. Receiver operator characteristic curves and a multivariate binomial logistic regression analysis were performed.Results:Overall, 739 shoulders in 728 patients (mean age, 52.6 years; 68% women) were included, of which 38 (5.1%) underwent LOA/MUA and 209 (28%) underwent repeat injections. The immediate change in the VAS score was not significantly associated with the eventual need for LOA/MUA. Preinjection VAS and immediate postinjection VAS scores were not significant predictors of eventual LOA/MUA or subsequent injection. For all 3 predictors, the area under the receiver operator characteristic curve classified them as extremely poor discriminators.Conclusion:The immediate pain response to a fluoroscopic-guided glenohumeral injection for idiopathic shoulder adhesive capsulitis was not predictive of the eventual need for LOA/MUA or subsequent injection. Patients can be counseled that even if their initial pain response to an injection is poor, they still have an excellent chance of avoiding surgery, as the overall rate of LOA/MUA was low (5.1%).

Long-term Efficacy of Percutaneous Epidural Neurolysis of Adhesions in Chronic Lumbar Radicular Pain: 10 Year Follow-up of a Randomized Controlled Trial

No long-term follow-up data exist in any treatment for chronic radicular pain occurring with disc pathology and after failed back surgery. A previous randomized controlled trial (RCT) has proven efficacy in short-term follow-up as an evidence-based effective therapeutic option. Long term data is needed to determine the efficacy and cost- effectiveness of minimal invasive procedures. The present study reports 10 year follow-up results from the randomized trial. A prospective, randomized, placebo-controlled, interventional clinical trial. A power calculation was based on a previous feasibility trial. University medical centers. After a 4 year enrollment phase, 381 patients with chronic radicular pain persisting beyond 4 months, who failed conservative treatments, were screened. Ninety patients were enrolled. Patients were randomly assigned to receive percutaneous epidural lysis of adhesions or placebo with concealed allocation in permuted blocks of 4 to 8 patients each, and stratified by treatment center. The primary outcomes were a mean change of the Oswestry Disability Index (ODI) scores and Visual Analog Scale (VAS), one and 10 years after intervention. For each rating scale an analysis of variance with the within-patient factor time (baseline, one year follow-up, 10 year follow-up) and the between-patient factor treatment (lysis, placebo) was used. Homogeneity was shown at baseline between the groups. The ODI and VAS scores were significantly better one and 10 years in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 9.6 ± 9.3 after one year and to 11.7 ± 14.2 after 10 years. The placebo group also improved from 55.4 ± 11.5 to 30.7 ± 14.2 after one year and to 24.8 ± 12.0 after 10 years. The VAS improved from 6.7 ± 1.1 to 1.2 ± 1.1 after one year and to 1.5 ± 1.4 after 10 years in the lysis group and from 6.7 ± 1.1 to 2.8 ± 1.5 after one year and to 2.9 ± 1.3 after 10 years after placebo intervention. The statistical difference of the ODI and VAS between the treatment and control groups remain significant up to 10 years. No treatment-related severe adverse effects occurred within the 10 years, but minor transient neurological effects were seen directly after the intervention. The long-term effects of single treatment components cannot be specified as no imaging examination was performed at 10 year follow-up. A large variety of unanalyzed noninvasive treatments were done within the 10 years. Some patients did not clearly remember the intervention after 10 years. Uncontrolled effects such as higher inhomogeneity of biometric properties, concomitant therapies, pain tolerance level, or just social effects could occur, but were not analyzed in the trial. This is the first 10 year follow-up report of a placebo-controlled RCT showing efficacy of the minimally invasive percutaneous adhesiolysis procedure for patients with chronic lumbosacral radicular pain. No alternative evidence-based treatment modality with 10 year follow-up is available to be recommended. This procedure should be considered as the first treatment option for patients with chronic lumbosacral radicular pain.

The Relationship of Staged, Bilateral Arthroscopic Primary Rotator Cuff Repair Timing and Postoperative Complications

Background: Although previous studies have reported acceptable clinical outcomes after simultaneous, single-stage bilateral and staged bilateral rotator cuff repair (RCR), few studies have been adequately powered to compare postoperative complication rates at various time intervals between procedures. Purpose: To examine the relationship between the timing of bilateral arthroscopic RCR and complications. Study Design: Descriptive epidemiology study. Methods: Patients from the Medicare data set within the PearlDiver database who underwent bilateral RCR between 2005 and 2014 were identified. These patients were then stratified by time between surgeries into cohorts: (1) single stage, (2) <3 months, (3) 3 to 6 months, (4) 6 to 9 months, (5) 9 months to 1 year, and (6) 1 to 2 years. Surgical and medical complications of these cohorts were compared with those of a control cohort of patients who underwent bilateral RCR >2 years apart using a regression analysis. Results: A total of 11,079 patients who underwent bilateral RCR were identified. Patients who underwent single-stage bilateral arthroscopic RCR experienced higher rates of revision RCR (odds ratio [OR], 2.1; P < .0001), reverse total shoulder arthroplasty (RTSA) (OR, 2.47; P < .0001), and postoperative infection (OR, 2.18; P = .007) in addition to higher rates of venous thromboembolism (VTE) (OR, 1.78; P = .031) and emergency department visits (OR, 1.51; P = .002) compared with the control group. Patients who underwent bilateral RCR with a <3-month interval had higher rates of revision surgery (OR, 1.56; P = .003), RTSA (OR, 1.89; P = .002), and lysis of adhesions (OR, 2.31; P < .0001) in addition to increased rates of VTE (OR, 1.92; P = .015) and emergency department visits (OR, 1.62; P < .0001) compared with the control group. There were no differences in any surgical or medical complications when surgeries were staged by ≥3 months compared with controls. Conclusion: Patients with Medicare undergoing single-stage and staged bilateral RCR who had the second repair within 3 months had significantly higher rates of multiple medical and surgical complications compared with patients waiting >2 years between procedures.

23 Repeat minimally invasive abdominal sacrocolpopexy for recurrent prolapse

The objective of this video is to demonstrate techniques for minimally invasive abdominal sacrocolpopexy for recurrent pelvic organ prolapse after prior sacrocolpopexy. Sacrocolpopexy is considered by many to be the gold standard for repair of apical pelvic organ prolapse. Although rates of surgical failure and repeat surgery are low, prolapse recurrence can occur after sacrocolpopexy. In this video, we review recurrence rates of prolapse after minimally invasive abdominal sacrocolpopexy (MI-SCP), discuss two cases of prolapse recurrence following MI-SCP and subsequent surgical repair of recurrence with repeat MI-SCP, and present clinical tips and tricks for repeat MI-SCP. Through both cases, we illustrate three key principles for approaching a repeat MI-SCP: assessment of prior surgical repair and identification of cause of anatomic failure, re-establishment of normal anatomy via lysis of adhesions, and resection of prior mesh and/or attachment of new mesh. The use of robotic assistance for dissection is also demonstrated. Despite the high durability of sacrocolpopexy, prolapse recurrence can still occur over time. Appropriate cases of prolapse recurrence can be managed in a minimally invasive manner with repeat MI-SCP.

45 Risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy

The objective of this study was to identify patient-specific risk factors for lower urinary tract (LUT) injury with laparoscopic sacrocolpopexy (LSCP). This is an age-matched case-control study including patients who underwent LSCP from 2014-2017 in a high volume Urogynecology practice. Patients were excluded if they had abnormal urinary tract anatomy. Risk factors such as race, body mass index (BMI), preoperative pelvic organ prolapse quantification (POP-Q) stage, prior abdominal and/or vaginal surgery, and concurrent procedures were analyzed. Groups were compared using Student’s t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate odds ratios, and all regression models were conditioned on the matching variable. The model for adjusted odds ratios included all potential risk factors. The prevalence of LUT injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 LSCP procedures). These 18 cases were age-matched to 72 controls. History of prior hysterectomy (unadjusted OR 162.41; CI 3.21, 8227; P= 0.011; adjusted OR 19.94, CI 2.48, 160.38; P= 0.005) and lysis of adhesions (unadjusted OR 5.15; CI 0.50, 52.76; P= 0.168; adjusted OR 4.94, CI 1.05, 23.19; P= 0.043) were associated with an increased risk of LUT injury. Concurrent posterior colporrhaphy appeared to have a protective association with LUT injury (unadjusted OR 0.78, CI 0.02, 27.67; P= 0.892; adjusted OR 0.32; CI 0.11, 0.88; P= 0.028). Race, BMI, POP-Q stage, prior abdominal and/or vaginal surgery, as well as concurrent bilateral salpingo-oophorectomy, mid-urethral sling placement, and anterior colporrhaphy were not associated with an increased risk of LUT injury. The prevalence of LUT injury with LSCP is rare, occurring in 2.4% of patients. History of prior hysterectomy significantly increased LUT injury risk. Concurrent lysis of adhesions increased the risk of LUT injury, while posterior colporrhaphy showed a protective effect. Although these two procedures may impact LUT injury risk, the associations are less clear due to the rarity of cases and baseline differences between groups. Based on our findings, the clinician can individualize surgical counseling based on patient-specific risk factors. This may also aid in setting appropriate postoperative patient expectations, including discussion as necessary regarding potential for prolonged catheterization or additional procedures and/or postoperative imaging in the case of LUT injury.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

16 Robotically-assisted lysis of adhesions & suction d&c for management of c-section scar ectopic pregnancy

16 Robotically-assisted lysis of adhesions & suction d&c for management of c-section scar ectopic pregnancy