Major Reconstructive Procedures Research Articles

Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders.

Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders. Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area. Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects. Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures. Therapeutic, IV.

Simulation of Reconstructive Microsurgery in Soft Embalmed Cadavers: A Teaching Module for Plastic Surgery Residents.

Background Cadaveric dissection courses-comprising flap harvesting techniques, vessel dissections, flap transfers to the defect, and microvascular anastomosis-would help residents gain confidence and master these difficult major reconstructive microsurgery procedures. Formalin embalmed bodies lack natural softness and many other features of a live body. Many soft embalming techniques have evolved to mimic live tissue and Theil technique is the most popular one among them. We explored alternate soft embalming options and started using Genelyn. Materials and Methods Over a span of 2 years (2019-2021), we have conducted three flap dissection workshops using soft-embalmed cadavers. Six soft-embalmed and two formalin-embalmed cadavers were used. Total number of participants was 80. Results Feedback of experience from the third course participants in the form of grades (1-5) for different criteria was obtained and evaluated. Confidence in the dissection of the various flaps and microsurgery is noticeable in all the participants. Conclusion Based on our experience, we propose that flap dissection and microsurgery training on soft-embalmed cadavers be included as a teaching module in the plastic surgery postgraduate curriculum.

Resection arthroplasty of the proximal humerus following chondrosarcoma removal and reconstructive failure: A case report with 22 year follow-up

Introduction: Proximal humeral reconstructive alternatives in orthopedic oncology are well described, but the literature regarding post-failure salvage is sparse. This report details a multiply failed humeral reconstruction that ultimately resulted in resection arthroplasty. Although initial tumor resection was treated with an intercalary reconstruction, this case is unique in that its sequelae are equally applicable to failures of proximal humeral reconstruction. Case presentation: We report a 61-year-old Caucasian woman with ultimate removal of a second proximal humeral reconstruction twenty-two years after initial grade I chondrosarcoma resection, leaving essentially a shoulder resection arthroplasty Conclusion: The patient’s acceptance of resection arthroplasty in this case suggests that not all failures of proximal humeral major reconstructive procedures need to be revised to another reconstruction. Resection arthroplasty is much less complex than revision surgery, requires little healing time, expedites recovery, minimizes subsequent further complications and allows for excellent pain relief. Resection arthroplasty may be a plausible approach after failed orthopedic oncology humeral reconstruction in carefully selected patients. Keywords: chondrosarcoma; resection arthroplasty; reconstruction; musculoskeletal tumor; intercalary allograft; proximal humerus; shoulder; shoulder arthroplasty

Complications and Management of Retained Double-J Stents in Children During the Coronavirus Disease-2019 Pandemic.

Double-J (DJ) stents were commonly used for internal drainage after major reconstructive procedures or in cases of obstruction and ureteral injuries. They should be removed or changed within the stipulated time; otherwise, they can lead to various complications such as stent occlusion, migration, breakage, encrustation, stone formation at either end of the stent, and entanglement of the two stents if bilateral stenting was done. The present study focuses on the complications and the management due to delay in the removal of the DJ stents due to the coronavirus disease-2019 pandemic. This is a cross-sectional study over a period of 9 months. Children <12 years were included in the study. The patients' demographic data, indication for DJ stenting, time gap between DJ stenting and removal, complication with delay in DJ stent removal, and its management were recorded. Indwelling duration for >4 months was considered a delay in removal. All patients were followed up for 3 months. A total of 10 patients were included in the study. Encrustation, proximal migration, distal migration, knotting of the stent, and entanglement of the bilateral stents in the bladder were observed. These complications were managed by various endourological procedures such as ureteroscopy, percutaneous nephroscopic, and cystoscopic removal. During follow-up, all patients were symptom-free. Prolonged indwelling stents can cause various complications. Endourological procedures are an essential armamentarium for a pediatric surgeon to manage these complications. Proper patient counseling regarding indwelling stents and maintaining stent registry and sending automatic messages and e-mails to patients may prevent these complications.

Stents in the Management of Stenotic and Occlusive Lesions in the Venous System.

Occlusive disease of the iliac veins or major intrathoracic veins have traditionally been managed by conservative management or by major vascular reconstructive procedures. Over the past 15-20 years, these lesions have become amenable to management with venous stents. Lesions in the iliac venous system are typically due to thrombus secondary to deep vein thrombosis, and lesions in the superior vena cava are due to either malignant intrathoracic lesions, indwelling central venous catheters, pacemaker leads, or enlarged nodes due to granulomatous disease. The success rate for implantation is between 92% and 95% and associated implantation complications vary between 2% and 5%. Primary patency of iliac stents is 70-90% at three years. Venous stents have higher patency in the treatment of stenotic lesions compared to totally occlusive lesions. Primary patency of stents placed in the superior vena cava is also about 70-90% and generally lower in lesions due to malignancy likely related to life expectancy. Stents in the venous system are associated with few complications at the time of insertion and have excellent long-term patency.

1119 Readdressing Consent in Head &amp; Neck Free Flap Surgery: The Nottingham Experience

Abstract Aim The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process. Method 35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality. 8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge. Results Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%. Conclusions We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.

MP67-17 REPORT OF MORE THAN 25 YEARS OF SUSTAINED UROLOGICAL PHILANTHROPIC EFFORT IN INDIA BY GLOBAL UROLOGIST THROUGH “JEEV SEWA SANSTHAN” (JSS) &amp; IVUMED

You have accessJournal of UrologyGlobal Health/Humanitarian (MP67)1 Sep 2021MP67-17 REPORT OF MORE THAN 25 YEARS OF SUSTAINED UROLOGICAL PHILANTHROPIC EFFORT IN INDIA BY GLOBAL UROLOGIST THROUGH “JEEV SEWA SANSTHAN” (JSS) & IVUMED Gopal Badlani, Sakti Das, Raju Thomas, and Amar Singh Gopal BadlaniGopal Badlani More articles by this author , Sakti DasSakti Das More articles by this author , Raju ThomasRaju Thomas More articles by this author , and Amar SinghAmar Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002028.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a retrospective review of more than 25 years of experience in running volunteer mission trips in Northern India under the aegis of a non- profit philanthropic organization(JSS) based in Bhopal. India. The goals of these missions were centered on philanthropy and enhancing surgical education of local surgeons and U.S. residents. Structural organization of the effort was assessed. METHODS: From 1992 to 2019, mission trips were conducted annually, in rural and smaller cities within Northern India. The surgical missions were conducted under the guidance and leadership of a senior mentor. Residents from an ACGME accredited program participated. Data were collected for each of the mission trips. Pre and postoperative care to all patients in continuity was delivered by a team of trained local urologist. A scholarship, and logistical support for the traveling residents were provided by IVUmed. RESULTS: There were 96 Urology mission trips conducted from initial effort in 1992 to 2019 with an average of 3.4 trips annually. 50,363 patients were screened, with an average of 525 patients screened in each of these individual camps. A total of 10,946 surgical interventions were performed for an average of 114 cases in 4.5 days. The variety of procedures included 3,609 for benign prostatic outlet obstruction, 1,967 PCNL, 492 ureteroscopies and 542 bladder stone surgeries. Pediatric cases mainly included hypospadias repair & circumcisions. Complex cases included fistula repairs, urethroplasties, & anti incontinence procedures. Based on the setting, support, and clinical needs, major reconstructive procedure including continent urinary diversions. Over 90% of adult surgeries were performed under spinal. No intra operative death has been reported. CONCLUSIONS: Conclusions: These volunteer mission trips over 25 years have successfully helped foster philanthropy, education, and has also helped expose the ACGME residents to a global health care. It has served in enhancing education of local urologist and subsequently elevate care and clinical skill set. The coordination of IVUmed and JSS is a model for organization. The benefit of giving of yourself is not measurable. Acknowledgement: Drs Bhushan. Khashu; Shiban. Warikoo; Jitendra. Amlani; Pravin. Baldaniya; Darshan.Shah; Rohit.Ajmera; Pankaj. Patel; Sudhir.Lokwani; C.Dewani; Sameer.Joshi; IVU Scholars Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e516-e516 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gopal Badlani More articles by this author Sakti Das More articles by this author Raju Thomas More articles by this author Amar Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

Overview of Imaging Modalities in Evaluation of Bone Allograft Viability

The goal of this review is to assess the importance of various imaging modalities which can be used in assessing the viability and integrity of the bone allograft. As it is widely in use in majority of major and minor reconstructive procedures.

General Surgery Programs Afford Trainees Bound for Vascular Surgery Fellowships Increased Vascular Case Experience

Educators have recently begun to call into question the value of general surgery training prior to completion of a 2-year vascular surgery fellowship. We hypothesized that general surgery residents destined to enter vascular surgery fellowships have an enriched experience in vascular surgery compared to general surgery residents who enter other specialties. We obtained Accreditation Council for Graduate Medical Education case records of general surgery residents completing training in the years 2015-2018. We then stratified graduates into those who went on to enter a vascular surgery fellowship program (GSVS) versus those who went into other fields (GS). Case records were broken down into standard operative categories applied by the RRC for surgery/Accreditation Council for Graduate Medical Education. Each category was compared with a two-sided Student t-test. In addition, we examined experience with general surgery cases we deemed relevant to vascular surgery practice and those not directly relevant to vascular surgery. Between 2015 and 2018 there were 3242 graduates of general surgery programs who did not go on to vascular fellowships and 342 graduates who did enter vascular surgery fellowship programs. As shown in Table I, GSVS residents had significantly greater operative experience in every vascular surgery category than GS residents. Notably, they had twice the exposure to the major categories of aneurysm repair, cerebrovascular repair, and peripheral obstructive. In aggregate, GSVS residents completed 187.2 major vascular reconstructive procedures compared to 108.7 procedures for GS residents. Table II demonstrates the comparative experience in overall general surgery cases. Notably, GSVS residents had less exposure to a variety of cases of less direct relevance to vascular surgery including breast, esophagus, stomach, small intestine, large intestine, anorectal, biliary, spleen, hernia, endocrine, thoracic, complex laparoscopic and endoscopy cases. Conversely, GSVS residents had similar operative exposure to most cases of relevance to vascular surgery including skin and soft tissue, head and neck, abdominal–general, organ transplantation, and trauma. Total cases and major cases did not differ. It is unclear whether increased vascular exposure during general surgery training leads to vascular surgery as a career choice or if residents interested in vascular surgery are now afforded more opportunity to do vascular cases through increased training flexibility in general surgery programs. Regardless, general surgery training appears to offer an enriched vascular and relevant general surgery training experience to those candidates who go on to vascular fellowships. Ongoing analysis is necessary to determine the optimal content of general surgery training necessary for those trainees interested in vascular surgery.Table ICase TypeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)Mean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesP valueAneurysm repair5.1500.08605012.6700.569066.0000 Open infrarenal aneurysm repair0.8160.0240171.5200.100010.0000 Endo repair infrarenal aneurysm2.4150.0530236.8250.352039.0000Cerebrovascular9.6930.14207817.6780.8030104.00008.5150.13307515.0350.7160100.0000Periph obstructive18.0810.225012237.5441.3342182.0000 Aortofemoral bypass0.8610.0230121.7870.139028.0000 Femoral-popliteal bypass, vein2.2820.0450253.8300.183019.0000Infrapopliteal bypass, vein1.8780.0410264.1370.236026.0000Abdominal obstructive0.5130.016091.4330.102013.0000Upper extremity1.8010.0350243.0580.159026.0000Thrombolysis/mech thromb0.6480.0260331.5760.136020.0000Vascular trauma2.5240.0430233.6290.173021.0000Endovascular diagnostic6.8120.190011716.6931.0240132.0000 Arteriography4.8800.142010812.7630.7620104.0000Vascular access31.0680.333020145.5291.3742145.000016.0010.19408323.8360.808096.0000Amputations15.4140.188012021.7190.791196.0000 Amputation, below knee5.3990.0730357.6200.296040.0000 Amputation, above knee3.8090.0550285.9770.256033.0000Extra-anatomic bypass1.5700.0320162.8980.150016.0000Endovasc therapeutic0.2460.011070.7870.07508.0000Venous8.3740.14508414.1930.602069.0000Miscellaneous vascular6.0310.0830479.1870.416061.0000Total vascular108.7031.01613506187.1825.57550582.0000 Open table in a new tab Table IICase typeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)P valueMean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesSkin and soft tissue59.7790.424524158.3101.37114153.2867Head and neck22.8040.231011621.9590.692187.2570Breast64.1920.507127356.0791.3156153.0000Esophagus11.8580.1520719.6400.361035.0000Stomach39.0180.454229334.8771.1713216.0011Small intestine36.8960.256314334.5500.8927186.0118Large intestine141.2270.68842339132.0232.11039266.0000Anorectal33.3690.287120528.3710.732182.0000Abdomen-general43.6280.354316842.7751.3737296.5478Liver9.9820.1090589.4010.305035.0734Biliary126.2510.73330341118.4742.22642288.0010Pancreas10.3080.1400889.7810.421051.2445Spleen2.6990.0370162.2950.102013.0002Hernia130.7320.64231337118.8831.82546318.0000Endocrine33.4980.375529127.5500.9218107.0000Complex laparoscopica135.8971.36353528125.8683.44675275.0077Hand2.5070.10201772.4330.219026.7579Thoracic39.4350.469529834.7660.87315118.0000Pediatric26.3540.251112726.0120.782394.6735Genitourinary4.0870.0810623.8040.236046.2776Gynecology2.2400.11201491.6780.282085.1164Plastic23.8990.371124222.1350.8822115.0657Nervous system0.0440.005060.0500.02206.7998Orthopaedics1.3590.0720801.0960.181049.2505Organ transplant10.7330.211021910.2780.534058.4994Trauma29.0750.315216230.1671.0224143.2866Endoscopy138.2380.88926511121.0292.00865327.0000Ophthalmology0.0550.005050.0440.01101.3503aIncludes data for year 2017-2018 only. Open table in a new tab

Isolated limb perfusion is an effective treatment modality for locally advanced Kaposi sarcoma of the extremities

IntroductionKaposi sarcoma (KS) is a rare soft tissue sarcoma. In case of locally advanced disease, mutilating surgery such as amputations or major reconstructive procedures are sometimes inevitable. The aim of this study was to evaluate the effectiveness of isolated limb perfusion (ILP) in patients with locally advanced KS of the extremities. Material and methodsAll patients who underwent ILP for KS between 1996 and 2018 at Erasmus MC, Rotterdam were identified. Clinical data was obtained from either a prospectively maintained database or retrospective assessment of patient files. ResultsA total of 14 primary ILP's were performed in 11 patients. Median follow-up from primary ILP was 30 months (range, 5–98). The overall response rate of primary ILP was 100%, with a complete response (CR) rate of 50%. Only minimal local toxicity (Wieberdink I-III) was observed. Local progressive disease occurred after eight primary ILP's (57%) with a median local progression free survival (PFS) of 18 months (95% confidence interval [CI]: 7.0–28.9). Subsequently, four (46%) patients received a total of 5 recurrent ILP's. After the recurrent ILP on the same leg, the overall response rate was 75% and a CR-rate of 50%. One patient needed amputation post-operatively resulting in a limb salvage rate of 91%. One (9%) patient developed metastases four months after ILP. ConclusionsILP is a highly effective treatment modality with very limited morbidity rates for patients with locally advanced KS of the extremity. ILP should be considered as a treatment modality for locally advanced KS of the extremities.

A Retrospective Audit of Major Head and Neck Reconstructive Procedures over a 3 year period at Royal Derby Hospital (RDH)

Introduction Head and Neck reconstruction has advanced significantly over the past ∼40 years. Free flaps and pedicled flaps are now routinely used to restore the defect left after head and neck ablative surgery often due to malignancies. Immediate or early reconstruction of head & neck defects is ideal due to the aesthetic, physiological and functional consequences that major resections can bear. Our unit undertake a wide range of flaps depending on the specific conditions.

A Retrospective Survey of Pediatric Urethral Stricture in Isfahan, Iran

BackgroundIn order to ensure maximum recovery, stenosis management of the narrow and fragile tissue of urethra in children should be based on ingenious preserving of adequate urethral caliber.ObjectivesOwing to advancements in pediatric surgery that lead to improving the quality and quantity of life in recent years, it is necessary to evaluate urethral strictures and its management. With this respect, we studied the management of children with urethral strictures in two tertiary hospitals in Isfahan, Iran.MethodsAfter obtaining ethical committee clearance (code number 396454), a retrospective search of the hospital information system was carried out for urethral stricture in children aged up to 15 years from 2008 to 2018. We studied all children who underwent the management for urethral strictures associated with recorded data (ICD-10; n = 35.9). Data were analyzed by SPSS and age, as a continuous variable, was expressed as mean ± standard deviation (SD). A P value of < 0.05 was considered statistically significant.ResultsFor over a period of 10 years, there were 383 children, including 348 boys and 35 girls, with the mean ± SD age of 5.5 ± 3.4 years old. The management strategies for boys with the disease of urethra ranked as: dilation of urethra (n = 99), urethral meatotomy (n = 82), urethral meatoplasty (n = 75), urethrotomy (n = 7) and unspecified management (n = 85). In girls, the ranked values corresponded to dilation of urethra (n = 14), diagnostic ureteroscopy (n = 7), and unspecified management (n = 12). There was a significant difference associated with age in each subgroup. Statistical analysis based on the Kruskal-Wallis test showed a significant difference between the variables (P < 0.0001). The minimum age for urethrotomy in the population studied was 4 years old.ConclusionsIn pediatric, surgical treatment is an optimistic surrogate transaction to take the majority of cases with urethral strictures. As a result, in order to decrease complications such as incontinence, impotency, and surgical risks associated with major reconstructive procedures, proper repair at the appropriate time is recommended.

A Contemporary Analysis of Pediatric Urology Surgical Volume at a Tertiary Care Center

ObjectiveTo describe the annual volume of pediatric urology cases in an academic, tertiary care setting. MethodsA retrospective review was performed of all patients operated on by 4 pediatric urologists (total of 2.5 full-time equivalents) at an academic, tertiary care center with a free-standing children's hospital from 2016 to 2017 (24 months). Basic case information was collected from operative reports. Descriptive statistics are reported using nonparametric methods. “Uncommon” was defined a priori as occurring <10% of the time. ResultsDuring the entire study period, 2718 patients underwent 4580 procedures. This equated to 1088 patients and 1832 procedures per full-time equivalent. Median age at surgery was 3.2 years (IQR 0.8-10) and 757 (16.5%) of patients were female. Most procedures were elective (4406, 96.2%) and did not require postoperative admission (3842, 83.9%). Urgent and emergent cases were uncommon (174, 3.8%). Most cases were classified as general pediatric urology (3894, 85%) with 319 (7%) classified as major reconstruction, 275 (6%) as laparoscopy/endourology and 92 (2%) as oncology. The most common cases involved the groin/scrotum (1415, 30.9%), prepuce (809, 17.7%), phallus (802, 17.5%), and endoscopy (652, 14.2%). All other case types were uncommon. ConclusionThis description of an academic pediatric urology practice at a tertiary care center with a free-standing children's hospital noted a high volume of elective, outpatient procedures that are largely general pediatric urology. Uncommon cases include urgent/emergent interventions, major reconstruction, laparoscopy/endourology, and oncology procedures.

The effect of admission to intensive care unit on outcomes and complication rates after head and neck reconstruction

The study objectiveis to evaluate the utilisation and effectiveness of intensive care unit (ICU) in the postoperative period as to its potential benefits to the head and neck reconstruction services.Materials and methods. This is a retrospective study on 143 consecutive patients who underwent 144 major head and neck microvascular reconstructive procedures performed by a single surgeon, that focused on perioperative management and on the relation between admission to ICU and complications/outcomes.Results.Thirty-four (23.6 %) patients were admitted to ICU during the early postoperative period. Admission to ICU was not associated with lower incidence of complications compared to direct admission to the Head and Neck ward: 29.4 % vs 27.3 % (p = 0.807709).Conclusion.Routinely early postoperative admission to ICU seems not to improve outcomes and/or reduce complications, and, as a consequence, ICU admission should be restricted to selected patients only.

Minimally invasive approaches to craniosynostosis.

Craniosynostosis (CS) is defined as the premature fusion of one or more calvarial sutures. This carries several consequences, including abnormal/asymmetric cranial vault development, increased intracranial pressure, compromised neurocognitive development, and craniofacial deformity. Definitive management is surgical with the goal of protecting cerebral development by re-establishing normal cranial vault expansion and correcting cosmetic deformity. In today's practice, CS surgery has advanced radically from simple craniectomies to major cranial vault reconstructive (CVR) procedures. More recently there has been considerable interest in endoscopic assisted surgery (EAS). Theoretical benefits include decreased operative time, morbidity, blood loss, postoperative pain, cost and faster recovery times. In this focused review, we summarize the current body of literature reporting clinical outcomes in EAS and review the data comparing EAS and CVR.

The scope of minimally invasive techniques in spinal infections

The primary goals for treating infectious spinal conditions are to make an accurate diagnosis, isolate the causative organism, and prescribe effective antibiotic therapy based on the culture reports. A positive culture is extremely important for successful treatment and prevention of further morbidity. Surgically collected samples have shown to have a greater chance of demonstrating growth of organism on culture as compared to computed tomography-guided fine-needle samples. Surgical drainage and/or reconstruction with/or without fixation is usually indicated when there is no or poor response to antibiotic therapy, systemic toxicity with evidence of large collections, progressive spinal deformity, or instability or neurological impairment. However, the incidence of perioperative morbidity is particularly increased in elderly patients or in those with a poor general condition. With improved instrumentation and techniques in minimally invasive spine surgery, spinal infections can be successfully treated by minimally invasive debridement followed by pharmacological treatment, without causing any destabilization to spine. Where major reconstruction and fixation procedures are deemed mandatory, various MIS techniques can be utilized to decrease the surgery related morbidity and allow for faster rehabilitation. These procedures are associated with steep learning curve. With the advent of intraoperative navigation, the exposure to radiations can be significantly reduced.

Healing ulcers and preventing their recurrences in the diabetic foot.

Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.

Multi-institutional Experience in Laparoendoscopic Single-site Surgery (LESS): For Major Extirpative and Reconstructive Procedures in Pediatric Urology

To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P < .05). LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety.

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

Gastrocnemius recession: a Panacea for What Ails the foot and ankle: commentary on an article by Deborah A. Nawoczenski, PT, PhD, et al.: "isolated gastrocnemius recession for achilles tendinopathy: strength and functional outcomes".

Commentary In recent years, there seems to be a trend toward performing large numbers of gastrocnemius recessions for a variety of pathological conditions of the foot and ankle. Whether it be as part of a complex flat or cavus foot reconstruction or to improve dorsiflexion, to offload forefoot pressures when treating diabetic ulcers, or, in the case of this paper, to decrease tension across the Achilles to treat tendinopathy, there is no doubt that the gastrocnemius recession has emerged as a vital tool in the armamentarium of the foot and ankle surgeon. While there are several case series that demonstrate promising results with regard to pain relief after gastrocnemius recession for Achilles tendinopathy1,2, the literature has not been as defined regarding the effect on plantar-flexion strength postoperatively3,4. Some of these limitations include small sample size, retrospective study designs with no preoperative strength-testing for comparison, and gastrocnemius recession procedures performed in conjunction with other major reconstructive procedures, making it difficult to determine what effect the recession would have in isolation. The present study does an admirable job of quantifying the pain relief, strength, and function following a gastrocnemius recession. The results are very encouraging with regard to reducing pain and improving patient-reported satisfaction. The results of strength-testing and self-reported sports function may be a little less promising; however, this comes as no surprise. We believe that this procedure is so effective because by lengthening the gastrocnemius, the muscle is weakened. In the case of tendinopathy, this muscle-weakening reduces the stress across the degenerative portion of the tendon, and with other pathological processes, it reduces the deforming force of the gastrocnemius-soleus complex. The decrease in calf circumference postoperatively seems to support this assumption. The authors also addressed the small sample size, but they did not separate the cases with insertional and midsubstance disease. We believe that it may be beneficial to look at these entities separately, as they are distinct clinical problems that may respond differently to an isolated recession. This current study certainly supports the use of gastrocnemius recession to relieve pain associated with Achilles tendinopathy. However, patients should be counseled that they might still have difficulty with high-impact and sporting activities postoperatively. These authors should be commended for this analysis of outcomes following a gastrocnemius recession for the treatment of Achilles tendinopathy, yet we should exercise some caution when interpreting their results. As they point out in the discussion section, it is difficult to interpret the strength data, as they did not have preoperative isokinetic strength measures, and it is possible that the patients with tendinopathy were stronger than the patients in the control group preoperatively. As the clinical indications for performing gastrocnemius recession continue to expand, it will be important to continue to look critically at the subjective and objective outcome data. Myotendinous recession has been used successfully to treat spasticity and contractures in the pediatric population as well as to increase motion by reducing the contractile force of the spastic muscle. We feel that the gastrocnemius recession is no different. Perhaps the perceived improvement in strength may come from removing both the pain and the inhibition that it causes by correcting the underlying pathological process, whether it be a painful foot deformity, ankle arthritis, or, in this study, tendinopathy. Nonetheless, gastrocnemius recession is here to stay, and we will continue to incorporate this procedure into our clinical practice, relying on its ability to weaken the gastrocnemius muscle to achieve the desired clinical result.