Mean Operative Time Research Articles

Tranexamic Acid for Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference. To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR. Meta-analysis; Level of evidence, 1. Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing TXA with a control in ARCR were included. Visualization, postoperative pain, operative time, pump pressures, and shoulder swelling were evaluated. A P value < .05 was deemed statistically significant. Six RCTs with 450 patients were included in this review. Overall, 5 studies evaluated intraoperative visualization, with 3 studies finding a significant difference in favor of TXA. With TXA, patients had a lower mean postoperative visual analog scale (VAS) score of 3.3, and with the control, patients had a mean VAS score of 4.1, which was statistically significant (P = .001). With TXA, the mean weighted operation time was 79.3 minutes, and with the control, the mean operation time was 88.8 minutes, which was statistically significant (P = .001). No study found any difference in intraoperative pump pressures or swelling. TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR.

The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation.

Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan. Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up. Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns). The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications. Level IV.

Navigated bedside implantation of external ventricular drains with mobile health guidance: technical note and case series

PurposeExternal ventricular drain (EVD) implantation is one of the fundamental procedures of emergency neurosurgery usually performed freehand at bedside or in the operating room using anatomical landmarks. However, this technique is frequently associated with malpositioning leading to complications or dysfunction. Here, we describe a novel navigated bedside EVD insertion technique, which is evaluated in a clinical case series with the aim of safety, accuracy, and efficiency in neurosurgical emergency settings.MethodsFrom 2021 to 2022, a mobile health–assisted navigation instrument (Thomale Guide, Christoph Miethke, Potsdam, Germany) was used alongside a battery-powered single-use drill (Phasor Health, Houston, USA) for bedside EVD placement in representative neurosurgical pathologies in emergency situations requiring ventricular cerebrospinal fluid (CSF) relief and intracranial pressure (ICP) monitoring.ResultsIn all 12 patients (8 female and 4 male), navigated bedside EVDs were placed around the foramen of Monro at the first ventriculostomy attempt. The most frequent indication was aneurysmal subarachnoid hemorrhage. Mean operating time was 25.8 ± 15.0 min. None of the EVDs had to be revised due to malpositioning or dysfunction. Two EVDs were converted into a ventriculoperitoneal shunt. Drainage volume was 41.3 ± 37.1 ml per day in mean. Mean length of stay of an EVD was 6.25 ± 2.8 days. Complications included one postoperative subdural hematoma and cerebrospinal fluid infection, respectively.ConclusionCombining a mobile health–assisted navigation instrument with a battery-powered drill and an appropriate ventricular catheter may enable and enhance safety, accuracy, and efficiency in bedside EVD implantation in various pathologies of emergency neurosurgery without adding relevant efforts.

Utility of three-dimensional printing in the surgical management of intra-articular distal humerus fractures: a systematic review and meta-analysis of randomized controlled trials.

Clinical outcomes after fixation of distal humerus intraarticular fractures are directly related to the quality of reduction. The use of three-dimensional (3D)-printed fracture models can benefit preoperative planning to ensure good reduction. This review aims to determine if surgery performed with 3D printing assistance are faster and result in fewer complications and improved clinical outcomes than conventional methods. We also outline the benefits and drawbacks of this novel technique in surgical management of distal humerus fractures. A systematic literature search was carried out in various electronic databases. Search results were screened based on title and abstract. Data from eligible studies were extracted into spreadsheets. Meta-analysis was performed using appropriate computer software. Three randomized controlled trials with 144 cases were included in the final analysis. The 3D-printed group had significantly shorter mean operating time (mean difference, 16.25 minutes; 95% confidence interval [CI], 12.74-19.76 minutes; P<0.001) and mean intraoperative blood loss (30.40 mL; 95% CI, 10.45-60.36 mL; P=0.005) compared with the conventional group. The 3D-printed group also tended to have fewer complications and a better likelihood of good or excellent outcomes as per the Mayo elbow performance score, but this did not reach statistical significance. Three-dimensional-printing-assisted surgery in distal humerus fractures has several benefits in reduced operating time and lower blood loss, indirectly decreasing other complications such as infection and anemia-related issues. Future good-quality studies are required to conclusively demonstrate the benefits of 3D printing in improving clinical outcomes. Level of evidence: I.

Arthroscopic Coracoid Transfer in the Lateral Decubitus Position is Safe and Effective at Short-Term Follow-Up

To report on operative and clinical outcomes in a series of shoulders treated with arthroscopic Latarjet performed in the lateral decubitus position. Patients with shoulders that underwent arthroscopic Latarjet in the lateral decubitus position were identified. Data were retrospectively collected, including patient demographics, operative times, intra- and postoperative complications, and clinical and functional outcomes. Descriptive statistics were performed. Eighteen shoulders in 17 patients were included in the study with a mean follow-up of 14 ± 12.1 months (range, 4-39 months). The mean operative time for all procedures was 132.2 ± 18.0 minutes, and the mean operative time for the first half of the cohort was significantly longer than that of the second half (141.6 ± 14.2 minutes vs 122.8 ± 17.0 minutes, P= .02). There were no intraoperative complications, and no patients required a conversion to open surgery. One patient experienced a recurrent dislocation after a traumatic event but was able to be treated nonoperatively. Preoperative and postoperative patient-reported outcome measures (PROMs) were able to be collected on 8 of 18 patients (44.4%). Although all PROMs demonstrated improvements postoperatively, only the Single Assessment Numeric Evaluation score and American Shoulder and Elbow Surgeons Shoulder Index displayed a statistically significant increase (P<.05). Five of 8 (62.5%) shoulders demonstrated bony fusion on postoperative computed tomography scan. Of those eligible, 100% of patients returned to sport or felt that they could return if they wanted to. The arthroscopic Latarjet is an effective procedure for managing glenohumeral instability and can safely be performed in the lateral decubitus position. Level IV, therapeutic case series.

Safety and effectiveness of laparoscopic adult groin hernia repair in Africa: a systematic review and meta-analysis.

Surgery is the recommended treatment of groin hernia, and laparoscopic approach is increasingly accepted due to lower risk of chronic pain. This systematic review aims to evaluate results of laparoscopic groin hernia repair (LGHR) in Africa. We performed a literature search of published studies using electronic databases. Included African articles reported at least one of outcomes after LGHR in adult population. Newcastle-Ottawa Scale was used for quality assessment. A quantitative meta-analysis was performed to estimate the pooled prevalence of the post-operative outcomes. We included 19 studies from 6 countries which totalized 2329 hernia cases. Mean age was 44.5years and male patients were predominant (sex-ratio 19.8). The mean operative time was 69.1min. The pooled prevalence of conversion to open procedure was 2.578% (95% IC: 1.209-4.443). The pooled prevalence of surgical site infection and Hematoma/Seroma was respectively 0.626% (95%IC: 0.332-1.071) and 4.617% (95% IC: 2.990-6.577). The pooled prevalence of recurrence and chronic pain was respectively 2.410% (95% IC: 1.334-3.792) and 3.180% (95% IC: 1.435-5.580). We found that total morbidity for TAPP procedure was higher than TEP procedure (p = 0.0006; OR 1.8443). These results confirm that LGHR is safe and feasible and would be recommended in our African context.

Karydakis operation for pilonidal sinus disease in overweight and obese patients. A study of the efficacy of the procedure in 136 patients.

Objective: To test the efficacy of the Karydakis procedure in overweight and obese patients and to check the recurrence rates in our patients. Study Design: Multicenter Prospective study. Setting: Sughra Shafi Medical Complex Narowal. Period: May 2011 to July 2021. Material &amp; Methods: Total 146 patients were selected for this study a formal informed consent was taken. Ten patients were lost from follow up and excluded from study. Results: Out of remaining 136 patient 130 were male and only 6 were female. Mean age of the patient was 23 year and 5 months (range 16 years to 49 years). Thirty five patients had a single sinus in the midline, Seventy two had multiple sinuses in the midline, and 38 patients had lateral tract either on the right or on the left side in addition midline sinuses. Mean operating time was 39 minutes (range 23 – 70 minutes), mean blood loss was 26 ml (10 – 70ml) and mean hospital stay was 3 days (range 2- 7 days). There were a total of 21 (15 .05 %) complications. Seven(4.29) patients developed major wound infection requiring opening of the sutures and regular dressing till the wound became healthy to be closed by secondary suturing. Seven patients developed minor wound infection, 6 patients developed seroma and 3 patients had leakage of serous fluid from drain site for a couple of days. There were only 5 (3.67%) recurrences in mean follow up period of 23 months (range 11 months to 4 years). Two (1.47%) recurrence were observed in patient with BMI of below 35 and 3 recurrences (2.20%) were observed in patient with BMI of &gt;35. All of them occurred in obese patient who could not maintain their personal hygiene according to advice given to them. Majority of the patient were satisfied with the procedure. Conclusion: We concluded that Karydakis operation has good outcome in overweight and obese patients. It addresses the etiological factors of the disease, is less time consuming as compared to other flap operation, is not associated with wound scar in the midline, can be easily performed by surgeons in training, is associated with minimum complications, has minimum recurrence rate on short and long term follow up, avoid the painful prolong dressing regimen and well accepted by the patients.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up.

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Endoscopic Thyroidectomy for Large-Sized Goiters: Merits of the Axillo-Breast Approach with Gas Insufflation.

Several minimal access approaches to the thyroid gland have been widely applied; nevertheless, such approaches are still challenging when dealing with large-sized thyroid nodules or goiters. We hereby evaluated the outcomes and highlighted the merits of endoscopic axillo-breast hemithyroidectomy (EABH) for large-sized unilateral goiters. Patients underwent EABH for unilateral large thyroid nodules ≥6 cm in its greatest dimension or unilateral large goiter (≥60 ml sonographic volume) whatever the size of its contained nodules were identified from a prospectively maintained database. Their demographic data, clinicopathological profiles, and surgical and esthetic outcomes are reported and analyzed. Over a 2-year period, 33 patients matched the selection criteria. Their mean age was 34.75 ± 11.39 years. There were 30 women and 3 men. The majority of nodules were radiologically TIRADS3 and cytologically Bethesda 3. The mean sonographic dominant nodule greatest dimension was 5.29 ± 1.48 cm (range: 3-9.5 cm). The mean sonographic volume of the pathological lobe was 101.86 ± 54.45 ml (range: 60.11-236.88 ml). All cases were completed endoscopically with no conversion to open. The mean operative time was 110.76 ± 18.75 minutes. No significant postoperative complications were reported except for one case with temporary vocal cord paresis. Most (87.9%) of the patients were extremely satisfied with the procedure. EABH with our suggested key steps could be considered an effective valid approach for unilateral large goiters in trained hands and in patients desirous for cosmesis.

Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy.

Thoracic esophageal cancer resection through the neck approach has recently been reported as mediastinoscopic surgery. We present the first report of a new minimally invasive technique for thoracic esophageal cancer: robot-assisted transcervical esophagectomy with a bilateral cervical approach. Ten cases of robot-assisted bilateral transcervical esophagectomy performed at the National Cancer Center Hospital East, Japan, from February 2023 to August 2023 were reviewed. The short-term surgical outcomes were presented, and the feasibility and efficacy of this procedure were discussed. The mean operation time for the cervical procedure was 184.2 ± 23.6min. The total time for the whole procedure was 472.7 ± 28.4min, and total intraoperative blood loss was 162.2 ± 40.0ml. Among the 10 cases, one patient developed recurrent nerve paralysis, one patient developed pulmonary complications, and no patients developed postoperative pneumonia. The median postoperative hospital stay was 22 (range: 12-43) days. No patients developed severe postoperative surgical complications, which were graded as Clavien-Dindo ≥ III. The total number of surgically harvested mediastinal lymph nodes was 37.2 ± 11.2. Robot-assisted bilateral transcervical esophagectomy, a novel procedure for thoracic esophageal cancer, was safe and feasible. Using this procedure, the incidence of recurrent nerve palsy, which is a problem with transcervical esophagectomy and mediastinoscopic esophagectomy, is expected to decrease.

Laparoscopic polyglycolic acid spacer placement for locally recurrent rectal cancer.

Carbon ion radiotherapy (CIRT) has received attention for the treatment of locally recurrent rectal cancer. When the surrounding primary organs are close to the irradiation site, a spacer is required to ensure safe irradiation. This work describes a novel technique using a bioabsorbable polyglycolic acid spacer placed laparoscopically and presents a technical report with five case studies. The short-term surgical outcomes were as follows: mean operating time 235 min with blood loss of 38 mL. CIRT was planned, and the patients underwent irradiation within 2 months of surgery. No pelvic infections occurred, and all procedures were performed safely. Herein, were present a technical report with reference to a video of the surgical procedure.

(138) Evidence-based Strategies for Preventing Lower-limb Complications Secondary to Prolonged Use of the Dorsal Lithotomy Position

Abstract Introduction Patient positioning at the time of surgery plays a critical role in determining patient outcomes. Specific to patients undergoing genital gender-affirming surgery (gGAS), these patients are required to be placed in the lithotomy position to access the pelvis and perineum for their procedures. Lower-extremity injury due to prolonged surgical time in the lithotomy position can have significant post-operative morbidity affecting patient outcomes. This risk is increased in patients undergoing gGAS procedures due to high surgical complexity and especially long operative times as compared to other surgical procedures. Careful attention must be directed to the patient’s specific position intraoperatively due to significant risk of potential injury with prolonged surgeries. Prolonged stasis can cause injuries ranging from mild soft-tissue injuries which rapidly resolve, such as mild pressure injuries to bony prominences, to severe injuries including pressure ulcers, nerve injuries, rhabdomyolysis, and compartment syndrome. These complications can have lasting impact on the patient, with associated morbidity and mortality risk, and can also impact healthcare systems through additional dollars spent caring for patients who suffer these complications and their associated rehabilitation, and legal recourse on behalf of the patient who suffered these severe complications. Objective Our study aimed to describe our technique for preventing lower extremity injuries in the dorsal lithotomy position, and to evaluate our positioning-related post-operative complications and rates. Methods We describe our technique for lower-limb positioning in the dorsal lithotomy position, with an emphasis on injury prevention for patients undergoing gGAS. We assessed positioning-related outcomes and complications among patients undergoing gGAS for prolonged periods (&amp;gt;300 minutes) in the lithotomy position between January 2017 to March 2023. Results A total of 227 patients underwent 310 gGAS procedures were included in our study (156 masculinizing:154 feminizing gGAS procedures). Mean operative time was 495.5 minutes +/- 156.5 minutes (SD) (Range 300–1095 minutes) (Table 1a). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-operatively. No (0%) patients had major or chronic complications including chronic nerve injury, pressure ulcers, rhabdomyolysis or compartment syndrome (Table 1b). Our patient positioning employs the use of ½ inch foam placed to surround the lower extremity, ensuring that all at-risk areas of compression are adequately protected when placing the patient’s leg in the Allen stirrups whilst in the lithotomy position (Figure 1). In addition, a perioperative list is also utilized with regular leg checks every 2 hours with nursing documentation and also, ensuring patients are able to move their lower extremities without any pain post-operatively (Figure 2). Conclusions Our study is the first to describe and illustrate specific techniques, and outline strategies, for protecting the lower extremities to prevent injuries in patients undergoing prolonged surgical procedures in the lithotomy position. The low complication rates associated with our technique warrants attention to further refine this technique, and, to integrate these strategies into operating-room programs across diverse specialties. Disclosure No.

Can robotic gastric bypass be considered a valid alternative to laparoscopy? Our early experience and literature review.

Robotic bariatric surgery serves as an alternative to laparoscopy. The technology provides the surgeon with an accurate three-dimensional view, allowing complex maneuvers while maintaining full control of the operating room. We report our experience with this innovative surgery compared with laparoscopy during Roux-en-Y gastric bypass to demonstrate its safety and feasibility. The aim of this study is to evaluate potential differences between the robotic and laparoscopic techniques. Our study retrospectively identified 153 consecutive obese patients who underwent either laparoscopic or robotic gastric bypass (RGB) procedures over a 2-year period at the Department of Medical and Surgical Sciences, University of Foggia. Data on demographics, operative time, conversion rate, length of hospital stay, and mortality were collected and compared between two groups of patients: 82 patients who underwent laparoscopic procedures and 71 who underwent robotic procedures. We analyzed 153 patients who underwent gastric bypass with a mean age of 42.58 years, of whom 74 were female; 71 were treated with a robotic approach and 82 with a laparoscopic approach. The mean operative time was 224.75 ± 10.4 min for RGB (including docking time) and 101.22 min for laparoscopic gastric bypass (LGB) (p < 0.05), which is statistically significant. The median length of stay was 4.1 days for the RGB group and 3.9 days for the LGB group (p = 0.89). There is only one conversion to laparoscopy in the RGB group. We observed only one case of postoperative complications, specifically one episode of endoluminal bleeding in the laparoscopic group, which was successfully managed with medical treatment. No mortality was observed in either group. The statistical analysis shows to support the robotic approach that had a lower incidence of complications but a longer operative duration. Based on our experience, the laparoscopic approach remains a technique with more haptic feedback than the robotic approach, making surgeons feel more confident.This study has been registered on ClinicalTrial.gov Protocol Registration and Results System with this ID: NCT05746936 for the Organization UFoggia (https://clinicaltrials.gov/ct2/show/NCT05746936).

(224) The Use of an Acellular Dermal Matrix for Peyronie’s Plaque Excision and Grafting

Abstract Introduction The optimal surgical approach for severe Peyronie’s disease (PD) and the ideal grafting material are debatable. Acellular dermal matrices (ADM), among other graft materials that have been reported in the literature, are ideal candidates for graft choice due to the ability to retain structural integrity during the healing process and low immunoreactivity levels. Their use remains novel and only a few small studies have described outcomes of ADM grafting for PD. Objective The current study reports on the largest cohort of patients in the literature undergoing PEG with ADM (FlexHD Pliable). Methods After IRB approval, we reviewed the medical records of all patients undergoing PEG with Flex HD Pliable at our institution between the period of 2014 to 2023. A total of 52 patients with PD underwent PEG with FlexHD Pliable graft, with or without simultaneous inflatable penile prosthesis (IPP) insertion. Preoperative urological assessment of plaque was undertaken using penile color duplex ultrasound (PNUS) and degree of angulation and calcifications were recorded. All patients underwent surgery by a single surgeon. Results Patient’s age was 59.1+/-8.4 (43 to 81) years old. Dorsal curvature was recorded in 46.2% of patients, 23% had lateral, 13.5% had ventral and 17.3 % of patients had a combined curvature. Average penile curvature was 61+/-16 degrees (range 30-90 degrees). Hourglass deformity was recorded in 29.4% of cases; plaque calcification was confirmed on PNUS. The mean time between onset of curvature and surgical treatment was 25±37.9 months (range: 1-204 months). 19.2% patients failed intralesional treatment with Xiaflex prior to surgery and 4% had prior surgical treatment. In 75% of cases, simultaneous IPP placement was performed and in 25% of cases we performed PEG with FlexHD Pliable grafting only. Mean operative time for PEG was 114±22 minutes and simultaneous IPP placement prolonged the average operative time to 147±38 minutes. The average defect size was 21±8.3 cm2 (range: 4-48 cm2). A complete curvature correction was achieved in 90.4% and 9.6% had an average residual curvature of 11.25 °±4.8° (range: 5 ° -15 °). Eight patients (15.4%) reported postsurgical complications. Among them, two patients (3.8%) with altered penile sensation. One patient reported absence of sensation at the tip in the right mid glans; a decreased sensation at the ventral part of the penile shaft was recorded in the second case. There was one case of reactive hydrocele following IPP placement (2%) and five patients (9.6%) developed hematomas: 2 subcapsular graft hematomas required needle aspiration under PNUS guidance, a left spermatic cord hematoma and two penile hematomas that resolved spontaneously. Recurrent curvature onset was recorded in 4 patients (7.7%), but only 2 (3.8%) required re-operation. None of the patients suffered from infection-related complications. Conclusions Our results demonstrate the largest experience with ADM grafting for PD in the literature. PEG with FlexHD Pliable is a safe alternative to other commercially available grafting materials with a low complication rate. In the absence of a gold standard treatment for PD grafting materials, FlexHD Pliable is a practical and valuable option for this surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Irrimax.

“Extra-anatomical Pedicle Rerouting” An alternative technique to obtain new recipient vessels for microsurgical reconstruction in unfavorable clinical situations

BackgroundLack of adequate recipient vessels in certain anatomically unfavorable locations or in complex clinical situations still represents a limit for a successful microsurgical transfer. To address such complex cases, advanced microsurgical techniques should be applied. In this paper, the authors describe their experience with the Extra-anatomical Pedicle Rerouting (EPR) technique, an alternative approach that was used in selected cases throughout the body to obtain healthy recipient vessels for microsurgical reconstruction in unfavorable clinical situations where suitable recipient vessels were difficult to find. Patients and Methods15 patients with defects of variable etiology (oncological resection, trauma, previous surgeries) located in the trunk, upper and lower extremities received EPR free flap reconstruction at our Institution. Operative data, post-operative course and complications were recorded. Clinical and photographical follow-up were also documented. ResultsA total of 15 flaps (6 ALT, 6 LD/TDAP, 3 DIEP) were transferred adopting the EPR technique for oncological (11) and post-traumatic (4) defects. The rerouted vessels according to the different clinical scenarios were the thoraco-acromial, posterior circumflex humeral, thoracodorsal, deep inferior epigastric, lateral circumflex femoral, anterior tibial and medial sural pedicles. Mean length of the rerouted vascular conduits was 6.53cm. Mean operative time was 420minutes. No major complications were registered. Minor wound dehiscence was observed and managed conservatively in 3 patients. ConclusionsThe EPR technique proved to be expendable in a reliable and reproducible manner in different regions of the body as an alternative solution to obtain healthy recipient vessels in anatomically and surgically unfavorable clinical situations.

The impact of coexisting Hashimoto's thyroiditis on the feasibility of endoscopic thyroidectomy in papillary thyroid carcinoma

Objective：The safety of endoscopic thyroidectomy in patients with Hashimoto's thyroiditis (HT) is a matter of concern. This study aimed to assess the effect of concomitant HT on the feasibility of endoscopic thyroidectomy in patients with papillary thyroid carcinoma (PTC). MethodsThis study is an observational, retrospective study. All patients were histopathologically diagnosed with HT. The study group consisted of 44 patients (40 %) with PTC who also had HT, whereas the remaining 66 patients (60%) without HT were assigned to the control group. The number of dissected lymph nodes, mean operation time, thyroid volume, blood loss, TSH level, and postoperative complications were recorded and statistically analysed. ResultsOne patient underwent conversion to open thyroidectomy because of recurrent laryngeal nerve (RLN) transection. Another patient required reoperation owing to postoperative haemorrhage. Statistically significant differences were observed in mean operation time (105.4 ± 10.7 vs 98.2 ± 7.4 min, P = 0.0001),mean thyroid lobe volume (12.2 ± 5.8 vs 9.6 ± 3.5 mL [mL], P = 0.0041), TSH level(4.1 ± 1.5 mIU/L vs 3.4 ± 0.9 mIU/L, P ＝ 0.0028), and the number of dissected lymph nodes between groups (4.1 ± 1.5 vs 3.4 ± 0.9,P = 0.0028). The estimated mean blood loss (31.5 ± 6.8 vs 29.5 ± 3.9 mL, P = 0.0529) and rate of complications (15.9% vs 10.6%, P = 0.4136) did not show statistically significant differences between groups. ConclusionThe coexistence of PTC and HT increases the operation time and difficulties in endoscopic thyroidectomy but does not affect postoperative outcomes. Endoscopic thyroidectomy can be safely performed with acceptable complication rates.

Outcomes of ultraminipercutaneous nephrolithotomy in infants: our experiences at a single center in an endemic region.

In this study, we aimed to contribute to the literature by sharing the perioperative and postoperative outcomes of infants (0-24months) who underwent ultra-mini percutaneous nephrolithotomy (PNL) for kidney stones in our clinic. Infants under 24months old with kidney stones of 2cm and larger, who applied to our clinic between January 2018 and May 2023, were included in the study. The patients' demographic and clinical characteristics were obtained from the medical records. The collected data were analyzed retrospectively. A total of 26 patients were included in the study. The mean age of the patients was 17.3±3.90 (12-24) months. The mean operation time was 50.7±6.43min. The mean stone size was 2.66±0.59cm. Stone-free was achieved in 23 patients (88.5%). In one patient (3.8%) with residual fragments, SWL was performed, and in two patients (7.7%), RIRS was performed to achieve stone-free. Postoperatively, fever was observed in 3 patients (11.5%). There were no patients requiring blood transfusion. In experienced centers, ultra-mini-PNL performed by experienced surgeons is an effective and reliable treatment option for infants under 24months of age with kidney stones larger than 2cm. It provides high-stone clearance rates and low complication rates.

A Relative Value Unit–Based Model for Targeted Nipple–Areola Complex Neurotization in Gender-Affirming Mastectomy

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple–areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2–111.5) without neurotization and 154.2 minutes (95% CI, 139.9–168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

Efficacy and safety of piecemeal submucosal tunneling endoscopic resection for giant esophageal leiomyoma

Background and AimsGiant esophageal leiomyoma usually requires a thoracotomy or thoracoscopic surgery, which is more invasive than an endoscopic treatment. The purpose of this study is to evaluate the efficacy and safety of piecemeal submucosal tunneling endoscopic resection (P-STER) for giant leiomyoma originating from the muscularis propria (MP) layer of the esophagus. MethodsThis is a retrospective study. Patients with giant esophageal leiomyoma (transverse diameter ≥ 3 cm) who underwent P-STER were enrolled from November 2012 to May 2023. Clinical data and results were investigated. ResultsA total of 16 patients were enrolled for analysis. The lesion mean transverse diameter and longitudinal diameter were 4.22 ± 1.20 cm and 6.20 ± 1.57 cm, respectively. Our mean operation time was 195.38 ± 84.99 min. The mean number of piecemeal resected was 4.31 ± 2.36. An adverse event noted was an esophageal fistula that occurred in one case (6.25%) and was treated conservatively. The mean length of hospital stay was around 11.81 ± 7.30 days. The mean total hospitalization cost was U.S. dollars (USD) $5976.50 ± 2866.39. No recurrence or metastasis was found during the follow-up period. ConclusionsP-STER can be an effective and safe treatment for giant leiomyoma originating from the MP layer of the esophagus.

A New Method in Transcanal Medial Grafting Type-I Cartilage Tympanoplasty.

To determine the surgical results of a modified technique for the tympanic membrane (TM) perforation repair and to compare this new technique with the traditional methods. An interventional study. Place and Duration of the Study: Department of Otolaryngology, Medicana International Hospital, Samsun, Turkiye, from June 2019 till June 2021. The study was conducted with 24 patients who underwent cartilage tympanoplasty. Pure-tone audiometry (PTA), preoperative and postoperative air and bone conduction hearing levels were determined. The mean values of air and bone conduction and air-bone gap (ABG) were recorded. Postoperatively, 23 grafts were intact, and one was perforated, perforation secondary to otomycosis in the first month postoperatively. Eight patients had previous unsuccessful tympanoplasty history. These patients' tympanic grafts were intact with this technique. Surgical success rate was 96.0%. Postoperative hearing gain was 12,8 dB. Functional success rate was 88.0%. Mean surgery time was 30 minutes. Patients easily continued their lives in one-week time after the surgery. The new modified cartilage tympanoplasty method had high surgical success, and good audiometric results were obtained. Type-I cartilage, Tympanoplasty, Transcanal medial grafting, Tympanomeatal flap elevation.