Median Incision Research Articles

Right brachiocephalic artery reconstruction along with coronary artery bypass grafting

The presence of concomitant coronary artery and supraaortic diseases requires a management strategy for best neurological outcome. A combined operation for both innominate artery reconstruction and coronary artery bypass surgery through a single median sternotomy incision is feasible. We are presenting a concomitant repair for a 63 years old man with coronary artery disease and innominate artery occlusion at aortic arch origin.

Mixed Fixation and Interbody Fusion for Treatment Single-Segment Lower Lumbar Vertebral Disease: Midterm Follow-up Results.

To investigate the midterm outcomes of unilateral pedicle screws combined with contralateral gunsight-guided translaminar facet screw fixation and interbody fusion for treatment of single-segment lower lumbar vertebral disease. A total of 78 patients with various lower lumbar single-segment vertebral diseases were treated in our department from January 2008 to December 2011. There were 21 males and 57 females, with an average age of 52.5 years, including lumbar disc degeneration (28 cases), local recurrence of lumbar disc herniation (9 cases), huge lumbar disc herniation (11 cases), lumbar disc herniation with spinal stenosis (13 cases), and lumbar degenerative spondylolisthesis (degree I) (17 cases). All patients were treated by unilateral pedicle screws in the median incision combined with contralateral gunsight-guided translaminar facet screw fixation and interbody fusion. No wound infection or skin necrosis around incision was observed after operation. No leakage of cerebrospinal fluid or nerve injury occurred during and after operation. Excepting 4 cases, 74 cases were followed up for 18-60 months, averaged 33.5 months. All but one patient (98.6%) received interbody fusion. The intervertebral height of the indexed level was well restored and maintained. At final follow-up. During follow-up, there was no screw loosening or pedicle fracture observed. No apparent degeneration of adjacent segments. The mean Japanese Orthopaedic Association (JOA) scores was increased significantly from 12.79 ± 2.12 preoperatively to 25.8 ± 2.87 at the final follow-up. Unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion showed good mid-term outcomes in the treatment of single-segment lower lumbar vertebral disease, and can be used as an optimal choice for fixation and fusion of some single-segment lower lumbar vertebral diseases.

Sudden Thrombosis in Coronary Artery Bypass Grafting Surgery

Sudden Thrombosis in Coronary Artery Bypass Grafting Surgery

Fluorescence-Guided Surgery of Liver Metastasis in Orthotopic Nude-Mouse Models

We report here the development of fluorescence-guided surgery of liver metastasis. HT29 human colon cancer cells expressing green fluorescent protein (GFP) were initially injected in the spleen of nude mice. Three weeks later, established liver metastases were harvested and implanted on the left lobe of the liver in other nude mice in order to make an orthotopic liver metastasis model. Fourteen mice with a single liver metastasis were randomized into bright-light surgery (BLS) or fluorescence-guided surgery (FGS) groups. Seven mice were treated with BLS, seven were treated with FGS. Three weeks after implantation, the left lobe of the liver with a single metastasis was exposed through a median abdominal incision. BLS was performed under white light. FGS was performed using a hand-held portable fluorescence imaging system (Dino-Lite). Post-surgical residual tumor fluorescence was visualized with the OV100 Small Animal Imaging System. Residual tumor fluorescence after BLS was clearly visualized at high magnification with the OV100. In contrast, residual tumor fluorescence after FGS was not detected even at high magnification with the OV100. These results demonstrate the feasibility of FGS for liver metastasis.

Efficacy analysis of endovascular aneurysm repair and open surgery repair in patients with abdominal aortic aneurysm

Objective To analyze and compare the clinical efficacies of endovascular aneurysm repair (EVAR) and open surgery repair (OSR) in patients with abdominal aortic aneurysm (AAA). Methods The clinical data of 271 patients with AAA who received surgery at the First Hospital of China Medical University between January 2004 and December 2014 were retrospectively analyzed. Of the 271 patients, 153 patients undergoing EVAR were allocated into the EVAR group and 118 patients undergoing OSR into the OSR group, respectively. All the patients underwent a primary screening of preoperative ultrasonography and were diagnosed by three-dimensional computed tomography angiography (CTA), then urgent and severe patients were confirmed by abdominal enhanced CT. The procedures of EVAR: guide wire was inserted into the abdominal arota from femoral artery incision and branched stent was placed. The procedures of OSR: AAA was resected by median abdominal incision, thrombi and sclerosis plaques in endovascular wall were cleared, and end-to-end abdominal aortic anastomosis and end-to-side iliac aortic anastomosis were performed using Y-shaped blood vessel prosthesis. All the patients were followed up by telephone interview up to December 31, 2014. The operation situation, complications at postoperative day 30, short-term complications (between postoperative 3 months and 3 years), medium- and long-term complications (more than postoperative 3 years), mortality and survival rate were observed. Measurement data with normal distribution were presented as ±s and analyzed using the t test, and count data were analyzed using the chi-square test or Fisher exact probability. Survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log-rank test. Results All the patients were confirmed as with AAA by preoperative three-dimensional CTA. The operation time, volume of intraoperative blood loss, volume of intraoperative blood transfusion, time for out-off-bed activity, duration of hospital stay and hospital expenses were (179±64)minutes, (79±36)mL, 0, (5.7±3.1)days, (12±6)days, (179 018±65 796)yuan in the EVAR group and (205±40)minutes, (402±297)mL, (410±367)mL, (8.3±2.1)days, (18±11)days, (77 853±21 164)yuan in the OSR group, with significant differences between the 2 groups (t=-32.464, -51.719, -294.350, -11.833, -10.957, 2 778.748, P 0.05). The number of patients complicated with postoperative heart failure and I-shaped inner leakage were 0 and 8 in the EVAR group and 4 and 0 in the OSR group, with a significant difference between the 2 groups (P 0.05). The number of patients complicated with chest pain and abdominal distension were 0 and 0 in the EVAR group and 4 and 4 in the OSR group, with a significant difference between the 2 groups (P 0.05). The 3-, 5-, 10-year survival rates in the EVAR group and in the OSR group were 94.35%, 89.52%, 60.48% and 93.33%, 91.42%, 69.52%, respectively, showing no significant difference between the 2 groups (χ2=0.103, 0.239, 2.033, P>0.05). Conclusion EVAR has an advantage of micro-invasion in perioperative management, and both of EVAR and OSR are effective for the treatment of AAA with equivalent incidence of complications and long-term survival rate. Key words: Abdominal aortic aneurysm; Endovascular aneurysm repair; Open surgery; Efficacy

Efficiency of one-stage posterior median incision via costotransverse joint in treating thoracic spinal tuberculosis

Objective To assess the efficacy of one-stage posterior median incision via costotransverse joint in treating thoracic spinal tuberculosis. Methods Thirty three patients with tuberculosis of thoracic spine undergoing one-stage posterior thoracic spine debridement, bone grafting fusion and posterior instrumentation from July 2011 to October 2013 were included in the study.There were 18 males and 15 females. The age was from 17 to 39 years old with an average of 29.5. The course was from 5 to 11 months with an average of 7.3. The Cobb angle was from 19° to 42° with an average of 29.8°. There were 5 in upper thoracic spine, 17 in middle thoracic spine and 11 in lower thoracic spine. 6 were in Frankel scale grade C, 11 were in grade D and 16 were in grade E before surgery. Postoperative kyphosis correction, recovery of neurological function and bone fusion were observed. Results All the surgeries were completed successfully. The operation time was from 120 to 230 min with an average of 183. The blood loss during operation was from 480 to 700 ml with an average of 530. All 33 patients were followed-up for 12-36 months with an average of 22.7 months. The Cobb angle was from 8° to 15° with an average of 10.2°, the correction rate was 77%. The Frankel scale of 11 patients recovered from D to E, 2 recovered from C to D and 4 recovered from C to E. The postoperative kyphosis correction and Frankel scale were significantly improved, all patients had a 100% bone fusion rate and there were no internal fixation loosened or shift of graft bone at the last follow-up. ESR and CRP were returned to the normal range and the tuberculosis symptoms disappeared. Conclusions One-stage posterior median incision via costotransverse joint can complete surgery by the same position and the same incision in treating thoracic spinal tuberculosis with safety and good clinical efficacy. Key words: Tuberculosis, osteoarticular; Thoracic vertebrae; Curettage; Treatment outcome; Posterior median incision

Pleuropneumonectomy for a large thymoma with multiple pleural dissemination using median sternotomy followed by posterolateral thoracotomy.

We present 2 cases of a large thymoma with invasion to the hilum of the lung and pleural dissemination. Case 1: a 47-year-old woman was diagnosed with a type B3 thymoma with abundant left pleural effusion and multiple pleural masses, Masaoka stage IVa. A radical resection was planned after chemical pleurodesis and systemic chemotherapy. The left main pulmonary artery and left upper and inferior veins were dissected and resected in the pericardium, while the left main bronchus was cut behind the pericardium through a median sternotomy. Next, the median incision was closed and a left posterolateral thoracotomy was made, thus allowing the pleuropneumonectomy to be safely performed. Case 2: a 47-year-old woman was diagnosed with a type B3 thymoma with lymph node swelling and multiple pleural masses, indicating Masaoka stage IVb. Following induction chemotherapy, a thymothymectomy combined with a right pleuropneumonectomy was performed under a median sternotomy followed by a right posterolateral thoracotomy. The left brachiocephalic vein (BCV) was reconstructed with a ringed polytetrafluoroethylene (PTFE) graft, followed by resection of the right BCV. Next, the right main pulmonary artery and right upper and inferior veins were resected in the pericardium, and the right main bronchus was cut behind the pericardium, followed by reconstruction of the right BCV. Finally, the median incision was closed and a right posterolateral thoracotomy was made, thus allowing performance of a safe pleuropneumonectomy. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination.Electronic supplementary materialThe online version of this article (doi:10.1186/s40792-015-0071-z) contains supplementary material, which is available to authorized users.

Critical analysis of experimental model for study of adhesions after incisional hernias induced in rats' and repair of abdominal wall with different biomaterials.

Background: Adhesions induced by biomaterials experimentally implanted in the abdominal cavity are basically studied by primary repair of different abdominal wall defects or by the correction of incisional hernias previously performed with no precise definition of the most appropriate model. Aim: To describe the adhesions which occur after the development of incisional hernias, before the prosthesis implantation, in an experimental model to study the changes induced by different meshes. Methods: Incisional hernias were performed in 10 rats with hernia orifices of standardized dimensions, obtained by the median incision of the abdominal wall and eversion of the defect edges. Ten days after the procedure adhesions of abdominal structures were found when hernias were repaired with different meshes. Results: The results showed hernia sac well defined in all rats ten days after the initial procedure. Adhesions of the greater omentum occurred in five animals of which two also showed adhesions of small bowel loops besides the omentum, and another two showed liver adhesions as well as the greater omentum, numbers with statistical significance by Student's t test (p<0.05). Conclusion: Although it reproduces the real clinical situation, the choice of experimental model of incisional hernia repair previously induced implies important adhesions, with possible repercussions in the evaluation of the second operation, when different implants of synthetic materials are used.

Abstract 5117: Fluorescence-guided surgery of liver metastasis in orthotopic nude-mouse models

Abstract We report here the development of fluorescence-guided surgery of liver metastasis. HT29 human colon cancer cells expressing green fluorescent protein (GFP) were initially injected in the spleen of nude mice. Three weeks later, established liver metastases were then harvested and implanted to the left lobe of the liver in other nude mice in order to make an orthotopic liver metastasis model. Eleven mice with a single liver metastasis were randomized into BLS or FGS groups. Three weeks after the implantation, the left lobe of the liver with a single metastasis was exposed through a median abdominal incision. BLS was performed under white light. FGS was performed using a hand-held portable fluorescence imaging system (Dino-Lite). Post-surgical residual tumor fluorescence was visualized with the OV100 Small Animal Imaging System. Five mice were treated with BLS, six were treated with FGS. Residual tumor fluorescence after BLS was clearly visualized at high magnification with the OV100. In contrast, residual tumor fluorescence after FGS was not detected even at high magnification with the OV100. Citation Format: Takashi Murakami, Yukihiko Hiroshima, Shinji Miwa, Yano Shuya, Makoto Toneri, Mako Yamamoto, Masashi Momiyama, Takashi Chishima, Kuniya Tanaka, Michael Bouvet, Satoshi Hasegawa, Itaru Endo, Robert M. Hoffman. Fluorescence-guided surgery of liver metastasis in orthotopic nude-mouse models. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5117. doi:10.1158/1538-7445.AM2015-5117

Sequelae of radiotherapy-induced coronary artery disease in breast reconstruction

Sir, Approximately 37% of breast cancer patients who undergo breast conserving surgery or are found to have positive lymph nodes receive adjuvant radiotherapy [1]. Known side-effects of radiotherapy include wound breakdown, scarring, and radiation-induced angiosarcoma [2]. Less commonly cardiovascular complications can occur secondary to unwanted indirect irradiation of the heart, including coronary artery disease, pericarditis, and cardiomyopathy [3]. Chemotherapy for breast cancer can also induce cardiotoxicity, mainly secondary to anthracycline chemotherapy, which can lead to irreversible heart failure [4]. Cardiotoxicity has also been described with fluorouracil (5-FU) as angina-like chest pain, with incidences ranging from 1 to 68 % in the literature; cardiac events occur generally within 5 days after first administration [4]. We present an interesting case of a 45-year-old lady who underwent left mastectomy for breast cancer. This was followed by non-anthracycline chemotherapy and adjuvant radiotherapy receiving a total of 40 Gy over a course of 3 weeks. Two years later, she underwent delayed left breast reconstruction with a pedicled extended latissimus dorsi (ELD) musculocutaneous flap with a 220 cc round textured implant. She completed 5 years of tamoxifen and breast follow-up without any complications and remained diseasefree. Seven years after completion of radiotherapy, she presented to the emergency department with syncopal episodes and a four week history of exertional angina. Although she thought this pain was implant-related, her blood results showed a positive troponin (peak of 75 ng/L) and ECG’s showed T wave inversion in all the anterior leads, indicating an acute myocardial infarction. Coronary angiogram revealed critical coronary disease involving the left anterior descending, left circumflex and right coronary arteries (i.e. triple vessel disease). Her general risk factors were that she was an ex-smoker (2 pack years) with a family history of coronary heart disease. The cardiologists believed that her left-sided breast radiotherapy was the main predisposing factor for such unique triple vessel disease in a young patient. She was referred for urgent coronary artery bypass graft (CABG). Though the preoperative CT showed that the medial margin of the left breast implant was near the mid-sternal line (Fig. 1), this was probably positional, as clinically it appeared aesthetically acceptable (Fig. 2a). The patient underwent an uncomplicated triple CABG, and the left breast implant was preserved as it had not encroached the median sternotomy incision. Her postoperative breast aesthetic appearance remained unchanged (Fig. 2b). This letter highlights an interesting case of radiotherapyinduced triple vessel coronary artery disease and subsequent acute myocardial infarction in a young woman, following left sided irradiation for breast cancer. Microscopically, endothelial injury may occur secondary to the formation of reactive oxygen species and the activation of lysosomal enzymes within intima and media. Radiation promotes the adhesion of endothelial cells and the release of VonWillebrand factor inducing a prothrombotic state. Overall, atherosclerosis is * Hazim Sadideen hazim.sadideen@doctors.org.uk

Management of erectile dysfunction in patients who failed prior vascular intervention

Management of erectile dysfunction in patients who failed prior vascular intervention

Avoiding Infertility after Spinal Cord Injury by Hyperbaric Oxygenation Therapy

Introduction After a primary mechanical injury in the spinal cord, a cascade of inflammatory events is triggered leading to the degeneration and death of potentially viable neuronal tissue. Besides motor loss, the injured patients suffer from erectile and ejaculatory dysfunctions, and spermatogenesis deficiencies. The objective is to study the efficacy of hyperbaric therapy in the acute phase in rats with spinal cord injury (SCI) to recover spermatogenesis. Materials and Methods Experimental study approved by the ethics and research committee. Eighteen rats were submitted to T9 spinal cord trauma by a 25 g weight drop using the MASCIS Impactor. They were allocated randomly to the hyperbaric therapy (HBT) and control group. The rats submitted to HBT had 1 hour sessions daily at 2 atmospheres of oxygen for 7 days. Previous works by the authors of this study support the HBT protocol chosen. The control group had supportive treatment. Testicular biopsies were performed by median abdominal incision in all rats on the 1st and 28th day of study. The samples obtained were soaked in hypoosmotic solution to evaluate the concentration of sperm per mL, number of round cells per field, number of infectious cells per field (peroxidase-Endtz test), and sperm viability (HOS test). The data were analyzed using SPSS software v.20, described by mean and standard deviation, and compared using the Student t-test or Mann–Whitney U-test according to the parametricity of the variable. A p-value of &lt; 0.05 was considered significant. Results The mean concentration of sperm per mL did not change in the HBT ( p = 0.41) and control groups ( p = 0.74) over the 28 days of the study. The number of round cells and inflammatory cells per field was significantly greater in both groups on the 28th day. Sperm viability from day 1 to day 28 diminished two times more in the control ( p = 0.001) than in the HBT group ( p = 0.017) and sperm viability was significantly greater on day 28 in the HBT group as compared with the control group (86.67 ± 5.59% vs. 48.75 ± 21.83%) ( p &lt; 0.001). The other variables analyzed did not present a statistically significant difference between the groups. Conclusion The SCI promote spermatogenesis deficiencies that can be partially recovered by the HBT performed in the acute phase of SCI. Sperm viability was two times greater in the HBT group when compared with the control group 28 days after the injury.

Camptocormia and Dropped Head Syndrome Induced by Chemoradiotherapy for Base Tongue Carcinoma: A Case Report and Review of Literature

Introduction Camptocormia (bent spine syndrome) is an acquired postural disease characterized by forward flexion of the thoracolumbar spine. Camptocormia leads to lumbar kyphosis and increases during walking or standing. Management of Camptocormia is still a challenge and the literature on this topic is limited. There is no specific pharmacologic treatment for primary axial myopathy. Patients and Methods Our patient is a 68-year-old man, diagnosed in 2009 with a base tongue squamous cell carcinoma, surgically removed in September 2010. By May 2011, it was diagnosed with local recurrence, submitted to radiosensitive chemotherapy, and followed by radical radiotherapy 35 fractions of 70 Gy. Results After general anesthesia, and neuromonitoring a median incision was made from C3 to the sacrum, former instrumentation C3–T3 were tested, and no loosening or breakage was detected. Pedicle screws were inserted by free hand technic except C7 and T1 because the small space for rod connectors and T6, T10, L2, and L5 were osteotomies were performed total of 28 screws until S2 with sacropelvic fixation. In T6 and T10, Ponte osteotomies were made, and closing wedge pedicle subtraction in L2 and laminectomy of L3. Patient presented good outcome, receiving discharge at 7th postoperatory day, and initiated naturotherapy, fonotherapy, and physiotherapy, and nasoenteral catheter were maintained until 3 weeks and some swallowing improvement reported by the 6th week. In the follow-up, patient maintained satisfied with procedure and returned to work by 3rd month, screening showed no recurrence of the tumor or distant metastasis. Conclusion This is the first case described where dropped head syndrome and camptocormia occurred in the same patient because of radiosensibilizing chemotherapy for a nasopharyngeal carcinoma. We only found a single case report of a patient with dropped head syndrome associated with chemoradiotherapy for a nasopharyngeal carcinoma in a 59-year-old Japanese patient, described by Hashimoto (2012), treated without surgery who developed symptoms 2 years after chemoradiotherapy.

Mast Quadrant-assisted minimally invasive modified transforaminal lumbar interbody fusion: single incision versus double incision.

Background:The concept of minimally invasive techniques is to make every effort to reduce tissue damage. Certainly, reducing skin incision is an important part of these techniques. This study aimed to investigate the clinical feasibility of Mast Quadrant-assisted modified transforaminal lumbar interbody fusion (TLIF) with a small single posterior median incision.Methods:During the period of March 2011 to March 2012, 34 patients with single-segment degenerative lumbar disease underwent the minimally invasive modified TLIF assisted by Mast Quadrant with a small single posterior median incision (single incision group). The cases in this group were compared to 37 patients with single-segment degenerative lumbar disease in the double incision group. The perioperative conditions of patients in these two groups were statistically analyzed and compared. The Oswestry Disability Index (ODI) scores, Visual Analog Scale (VAS) scores, and sacrospinalis muscle damage evaluation indicators before operation and 3, 12 months postoperation were compared.Results:A total of 31 and 35 cases in the single incision and double incision groups, respectively, completed at least 12 months of systemic follow-up. The differences in perioperative conditions between the two groups were not statistically significant. The incision length of the single incision group was significantly shorter than that of the double incision group (P < 0.01). The ODI and VAS scores of patients in both groups improved significantly at 3 and 12 months postoperation. However, these two indicators at 3 and 12 months postoperation and the sacrospinalis muscle damage evaluation indicators at 3 months postoperation did not differ significantly between the two groups (P ≥ 0.05).Conclusions:Mast Quadrant-assisted modified TLIF with a small single posterior median incision has excellent clinical feasibility compared to minimally invasive TLIF with a double paramedian incision.

Circumferential anal giant condyloma acuminatum: a new surgical approach.

Perianal giant condyloma acuminatum is a rare clinical condition related to human papillomavirus infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion. The dermis was divided from the subcutaneous tissue. This way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures. Two months after surgery, no findings of anal stenosis or mucosal ectropion were reported. At the 1-year follow-up there was no recurrence of condylomatosis in any of the 3 cases. Our procedure seems simpler to perform when compared with other techniques and reduces hospital stay and complications such as anal stenosis and mucosal ectropion.

Application of vacuum assisted venous drainage in heart surgeries for newborns.

To explore the role of cardiopulmonary bypass (CPB) with vacuum assisted venous drainage(VAVD)in the management of newborns with congenital heart diseases. Total 15 newborns with congenital heart diseases (11 males and 4 females)underwent heart operations. Their age ranged from 2 days to 28 days [mean:(15.67 ± 2.22)days], and their body weight from 2.3 kg to 4.8 kg [mean: (3.75 ± 0.19)kg]. Sternal median incision was made to establish CPB,during which VAVD was applied for all the newborns. In these 15 newborns,the mean CPB time was from 50 minutes to 343 minutes [mean:(170.3 ± 26.6)minutes], and the mean aortic clamping time ranged from 20 minutes to 172 minutes [mean:(85.8 ± 14.6)minutes]. No macroscopic hematuria, inadequate drainage, or cannulation vena cava difficulty was observed during the procedures. All the newborns were successfully weaned from the machine. No neurological complication due to micro air embolus caused by negative pressure was noted. No vena cava infarction, thrombosis, or other complication was reported after the surgery, although one patient died after the surgery and another patient was discharged upon its family's own decision. VAVD is a safe, simple, and cost-effective technique. Appropriate negative pressure can the resistance during thinner venous intubation and thus speed up blood drainage,provide adequate perfusion flow,and reduce the pre-filling volume.

Mo1630 Length of Bowel Distal to a Diverting Ileostomy (DI) Does Not Influence the Risk of Dehydration After Ileal Pouch-Anal Anastomosis (IPAA)

S A T A b st ra ct s without adhesions (p = 0.60). In the multivariable analysis, factors independently decreasing the risk for having CPAP were higher age (OR 0.97; p 0.001) and BMI (OR 0.93; p 0.006), lower preoperative anxiety and depression symptom score (OR 0.32; p 0.045), and usage of a median incision (OR 0.52; p 0.006) (table 1). The presence of pain longer than three months (OR 3.99; p 0.000), preoperative usage of opioid analgesia (OR 3.54; p 0.001), a higher minimal NRS value on postoperative day 2 (OR 1.23; p 0.004) and severe adhesions underneath the incision (OR 1.63; p 0.040) showed to independently increase the risk for having abdominal pain 6 months after surgery. Conclusion 1 in 3 patients will have CPAP 6 months after elective abdominal surgery. The duration of preoperative pain, preoperative usage of opioid analgesia and the severity of acute postoperative pain and severe adhesions underneath the incision increase the risk for having CPAP 6 months after surgery. Older age and lower preoperative anxiety and depression symptom score showed to be protective for CPAP. These results can be used for improving patient counseling. Table 1 Multivariable logistic regression analysis for having chronic postoperative abdominal pain* (CPAP)

Combined surgical treatment of a pincer nail with chemical matricectomy, median nail incision, and splinting

Combined surgical treatment of a pincer nail with chemical matricectomy, median nail incision, and splinting

Minimally invasive transthoracic closure of ventricular septal defects without cardiopulmonary bypass under guidance of transepicardial echocardiography

Objective To introduce a new technique: minimally invasive transthoracic closure of ventricular septal defects (VSD) without cardiopulmonary bypass (CPB) under guidance of transepicardial echocardiography (TECE). Methods A total of 41 patients with VSD, 5 months to 6 years, averaging (15.1±18.5)months, underwent transthoracic device closure. The weight of these patients ranged from 5 to 26.0 kg with an average weight of (10.78 ± 6.87) kg. The diameter of their VSD ranged from 3 to 8.5 mm with an average of (5.2 ± 1.13) mm. After small median sternotomy incision, an appropriately sized VSD occluder was inserted into the left ventricle via VSD, then the occluder was released and the VSD was closed. TECE was used to monitor the whole procedure to guide the device positioning and evaluate the cursive effect instantly after operation. Results The procedure was successful in 38 patients. Three cases failed, including two cases whose guiding wire could not pass through VSD and one case whose occluder could not fix well. Three patients had tiny residual shunt after operation, two vanished during the follow-up period, and one case still had small amount residual shunt because of the occluders shifting. In 6 to 36 months follow-up, neither complete atrioventricular heart block nor aortic insufficiency was found in any patient. Conclusions The transthoracic closure of ventricular septal defects without cardiopulmonary bypass under guidance of transepicardial echocardiography is easy, safe, and efficient. Key words: Heart septal defects, ventricular/SU; Heart catheterization; Echocardiography/MT; Surgical procedures, minimally invasive/MT; Cardiac surgical procedures

Left ventricular apical diverticulum associated with double outlet right ventricle

Corresponding author: Muhammet Akyuz, M.D. Ege Universitesi Tip Fakultesi Kalp ve Damar Cerrahisi Anabilim Dali, 35100 Bornova, Izmir, Turkey. Tel: +90 232 388 11 15 e-mail: drmak100@gmail.com A six-year-old boy was admitted to our hospital for surgery for cardiac anomaly. The patient’s medical history included a right 5 mm sided modified Blalock-Taussig shunt through median sternotomy incision. Physical examination was normal, except a pulsatile mass localized in the epigastric area starting near inferior portion of the xiphoid process. Transthoracic echocardiography revealed double outlet right ventricle, subaortic ventricular septal defect, pulmonary stenosis, and patent right-sided shunt. An outpouching in the left ventricle apex which freely communicated with the left ventricle cavity through a narrow neck was observed. The diverticulum showed characteristics synchronous contractility with the left ventricle. The patient had normal left ventricular function without any evidence of thrombus in the left ventricular cavity or diverticulum. Cardiac computed tomography images revealed focal outpouching in the apical wall of the left ventricle, consistent with a congenital muscular diverticulum of the left ventricle apex (Figure 1). The patient was operated through re-median sternotomy incision and the apical diverticulum was visualized (Figure 2). After initiating cardiopulmonary bypass, Rastelli procedure was performed. At the end of the procedure, the left ventricular diverticulum was resected and primarily closed.